Less-tight versus tight control of hypertension in pregnancy.

BACKGROUND: The effects of less-tight versus tight control of hypertension on pregnancy complications are unclear. METHODS: We performed an open, international, multicenter trial involving women at 14 weeks 0 days to 33 weeks 6 days of gestation who had nonproteinuric preexisting or gestational hypertension, office diastolic blood pressure of 90 to 105 mm Hg (or 85 to 105 mm Hg if the woman was taking antihypertensive medications), and a live fetus. Women were randomly assigned to less-tight control (target diastolic blood pressure, 100 mm Hg) or tight control (target diastolic blood pressure, 85 mm Hg). The composite primary outcome was pregnancy loss or high-level neonatal care for more than 48 hours during the first 28 postnatal days. The secondary outcome was serious maternal complications occurring up to 6 weeks post partum or until hospital discharge, whichever was later. RESULTS: Included in the analysis were 987 women; 74.6% had preexisting hypertension. The primary-outcome rates were similar among 493 women assigned to less-tight control and 488 women assigned to tight control (31.4% and 30.7%, respectively; adjusted odds ratio, 1.02; 95% confidence interval [CI], 0.77 to 1.35), as were the rates of serious maternal complications (3.7% and 2.0%, respectively; adjusted odds ratio, 1.74; 95% CI, 0.79 to 3.84), despite a mean diastolic blood pressure that was higher in the less-tight-control group by 4.6 mm Hg (95% CI, 3.7 to 5.4). Severe hypertension (≥160/110 mm Hg) developed in 40.6% of the women in the less-tight-control group and 27.5% of the women in the tight-control group (P<0.001). CONCLUSIONS: We found no significant between-group differences in the risk of pregnancy loss, high-level neonatal care, or overall maternal complications, although less-tight control was associated with a significantly higher frequency of severe maternal hypertension. (Funded by the Canadian Institutes of Health Research; CHIPS Current Controlled Trials number, ISRCTN71416914; ClinicalTrials.gov number, NCT01192412.).

New perspectives on the regulation of iron absorption via cellular zinc concentrations in humans.

Iron deficiency is the most prevalent nutritional deficiency, affecting more than 30% of the total world's population. It is a major public health problem in many countries around the world. Over the years various methods have been used with an effort to try and control iron-deficiency anemia. However, there has only been a marginal reduction in the global prevalence of anemia. Why is this so? Iron and zinc are essential trace elements for humans. These metals influence the transport and absorption of one another across the enterocytes and hepatocytes, due to similar ionic properties. This paper describes the structure and roles of major iron and zinc transport proteins, clarifies iron-zinc interactions at these sites, and provides a model for the mechanism of these interactions both at the local and systemic level. This review provides evidence that much of the massive extent of iron deficiency anemia in the world may be due to an underlying deficiency of zinc. It explains the reasons for predominance of cellular zinc status in determination of iron/zinc interactions and for the first time thoroughly explains mechanisms by which zinc brings about these changes.

Fetal Treatment 2017: The Evolution of Fetal Therapy Centers - A Joint Opinion from the International Fetal Medicine and Surgical Society (IFMSS) and the North American Fetal Therapy Network (NAFTNet).

More than 3 decades ago, a small group of physicians and other practitioners active in what they called "fetal treatment" authored an opinion piece outlining the current status and future challenges anticipated in the field. Many advances in maternal, neonatal, and perinatal care and diagnostic and therapeutic modalities have been made in the intervening years, yet a thoughtful reassessment of the basic tenets put forth in 1982 has not been published. The present effort will aim to provide a framework for contemporary redefinition of the field of fetal treatment, with a brief discussion of the necessary minimum expertise and systems base for the provision of different types of interventions for both the mother and fetus. Our goal will be to present an opinion that encourages the advancement of thoughtful practice, ensuring that current and future patients have realistic access to centers with a range of fetal therapies with appropriate expertise, experience, and subspecialty and institutional support while remaining focused on excellence in care, collaborative scientific discovery, and maternal autonomy and safety.

Can adverse maternal and perinatal outcomes be predicted when blood pressure becomes elevated? Secondary analyses from the CHIPS (Control of Hypertension In Pregnancy Study) randomized controlled trial.

INTRODUCTION: For women with chronic or gestational hypertension in CHIPS (Control of Hypertension In Pregnancy Study, NCT01192412), we aimed to examine whether clinical predictors collected at randomization could predict adverse outcomes. MATERIAL AND METHODS: This was a planned, secondary analysis of data from the 987 women in the CHIPS Trial. Logistic regression was used to examine the impact of 19 candidate predictors on the probability of adverse perinatal (pregnancy loss or high level neonatal care for >48 h, or birthweight <10th percentile) or maternal outcomes (severe hypertension, preeclampsia, or delivery at <34 or <37 weeks). A model containing all candidate predictors was used to start the stepwise regression process based on goodness of fit as measured by the Akaike information criterion. For face validity, these variables were forced into the model: treatment group ("less tight" or "tight" control), antihypertensive type at randomization, and blood pressure within 1 week before randomization. Continuous variables were represented continuously or dichotomized based on the smaller p-value in univariate analyses. An area-under-the-receiver-operating-curve (AUC ROC) of ≥0.70 was taken to reflect a potentially useful model. RESULTS: Point estimates for AUC ROC were <0.70 for all but severe hypertension (0.70, 95% CI 0.67-0.74) and delivery at <34 weeks (0.71, 95% CI 0.66-0.75). Therefore, no model warranted further assessment of performance. CONCLUSIONS: CHIPS data suggest that when women with chronic hypertension develop an elevated blood pressure in pregnancy, or formerly normotensive women develop new gestational hypertension, maternal and current pregnancy clinical characteristics cannot predict adverse outcomes in the index pregnancy.

Supplemental dietary inulin of variable chain lengths alters intestinal bacterial populations in young pigs.

Previously, we showed that supplementation of diets with short-chain inulin (P95), long-chain inulin (HP), and a 50:50 mixture of both (Synergy 1) improved body iron status and altered expression of the genes involved in iron homeostasis and inflammation in young pigs. However, the effects of these 3 types of inulin on intestinal bacteria remain unknown. Applying terminal restriction fragment length polymorphism analysis, we determined the abundances of luminal and adherent bacterial populations from 6 segments of the small and large intestines of pigs (n = 4 for each group) fed an iron-deficient basal diet (BD) or the BD supplemented with 4% of P95, Synergy 1, or HP for 5 wk. Compared with BD, all 3 types of inulin enhanced (P < 0.05) the abundance of beneficial bifidobacteria and lactobacilli in the microbiota adherent to intestinal mucus of various gut segments of pigs. These changes were seen as proximal as in the jejunum with P95 but did not appear until the distal ileum or cecum with HP. Similar effects of inulin on bacterial populations in the lumen contents were found. Meanwhile, all 3 types of inulin suppressed the less desirable bacteria Clostridium spp. and members of the Enterobacteriaceae in the lumen and mucosa of various gut segments. Our findings suggest that the ability of dietary inulin to alter intestinal bacterial populations may partially account for its iron bioavailability-promoting effect and possibly other health benefits.

Biofortified black beans in a maize and bean diet provide more bioavailable iron to piglets than standard black beans.

Our objective was to compare the capacities of biofortified and standard black beans (Phaseolus vulgaris L.) to deliver iron (Fe) for hemoglobin (Hb) synthesis. Two lines of black beans, one standard and the other biofortified (high) in Fe (71 and 106 microg Fe/g, respectively), were used. Maize-based diets containing the beans were formulated to meet the nutrient requirements for swine except for Fe (Fe concentrations in the 2 diets were 42.9 +/- 1.2 and 54.6 +/- 0.9 mg/kg). At birth, pigs were injected with 50 mg of Fe as Fe dextran. At age 28 d, pigs were allocated to the experimental diets (n = 10). They were fed 2 times per day for 5 wk and given free access to water at all times. Body weights and Hb concentrations were measured weekly. Hb repletion efficiencies (means +/- SEM) did not differ between groups and, after 5 wk, were 20.8 +/- 2.1% for the standard Fe group and 20.9 +/- 2.1% for the high Fe group. Final total body Hb Fe contents did not differ between the standard [539 +/- 39 mg (9.7 +/- 0.7 micromol)] and high Fe [592 +/- 28 mg (10.6 +/- 0.5 micromol)] bean groups (P = 0.15). The increase in total body Hb Fe over the 5-wk feeding period was greater in the high Fe bean group [429 +/- 24 mg (7.7 +/- 0.4 micromol)] than in the standard Fe bean group [361 +/- 23 mg (6.4 +/- 0.4 micromol)] (P = 0.034). We conclude that the biofortified beans are a promising vehicle for increasing intakes of bioavailable Fe in human populations that consume beans as a dietary staple.

Supplemental dietary inulin influences expression of iron and inflammation related genes in young pigs.

We have previously shown improved hemoglobin (Hb) repletion efficiency by supplementing a 50:50 mixture of short (P95) and long-chain (HP) inulin (Synergy 1, BENEO-Orafti) into a corn-soybean meal-basal diet (BD) for young pigs. In this study, weanling pigs (5 or 6 wk old) were fed the BD or the BD + 4% of P95, HP, or Synergy 1 (50:50 mixtures of HP and P95) for 5-7 wk. Blood Hb concentrations of pigs were measured weekly and digesta samples were collected at the end of the trial. In a replicate experiment, total RNA was isolated from the liver and mucosa of duodenum, ileum, cecum, and colon of all pigs at the end of the trial. Relative mRNA expression of 27 genes, including iron and inflammation-related genes, was quantified using real-time quantitative-PCR. Although all 3 types of inulin resulted in similar improvements (P < 0.05) in blood Hb concentration and liver ferritin protein amount, neither type of inulin was detectable in the digesta of cecum or colon. Supplemental inulin enhanced the expression of iron-storing protein genes but decreased that of inflammation-related genes. Such effects were more pronounced (P < 0.05) in the mucosa of the lower than the upper gut and were seen on 7 genes in liver. In conclusion, all 3 types of inulin shared similar efficacy and possibly similar modes of action in improving dietary iron utilization by young pigs. Suppressing inflammation-induced genes that can negatively influence iron metabolism might help explain the benefit of inulin.

Effects of ascorbic acid, phytic acid and tannic acid on iron bioavailability from reconstituted ferritin measured by an in vitro digestion-Caco-2 cell model.

The effects of ascorbic acid (AA), phytate and tannic acid (TA) on Fe bioavailability from Fe supplied as reconstituted ferritin were compared with FeSO4 using an in vitro digestion-Caco-2 cell model. Horse spleen apoferritin was chemically reconstituted into an animal-type ferritin (HSF) and a plant-type ferritin (P-HSF) according to the typical ratios of Fe:P found in these molecules. In the presence of AA (Fe:AA molar ratio of 1:20), significantly more Fe was absorbed from FeSO4 (about 303 %), HSF (about 454 %) and P-HSF (about 371 %) when compared with ferrous sulfate or ferritin without AA. Phytic acid (PA; Fe:PA molar ratio of 1:20) significantly reduced Fe bioavailability from FeSO4 (about 86 %), HSF (about 82 %) and P-HSF (about 93 %) relative to FeSO4 and the ferritin controls. Treatment with TA (Fe:TA molar ratio of 1:1) significantly decreased Fe bioavailability (about 97 %) from both FeSO4 and the ferritin samples. AA was able to partially reverse the negative effect of PA (Fe:PA:AA molar ratio of 1:20:20) on Fe bioavailability but did not reverse the inhibiting effect of TA (Fe:TA:AA molar ratio of 1:1:20) on Fe bioavailability from ferritin and FeSO4. Overall, there were no significant differences in bioavailable Fe between P-HSF, HSF or FeSO4. Furthermore, the addition of AA (a known promoter) or the inhibitors, PA and TA, or both, did not result in significant differences in bioavailable Fe from ferritin relative to FeSO4. The results suggest that Fe in the reconstituted ferritin molecule is easily released during in vitro digestion and interacts with known promoters and inhibitors.

Relationships between faecal phytate and mineral excretion depend on dietary phytate and age.

We investigated the adverse effect of phytate on mineral absorption and the effect of dietary phytate and age on the relationship between faecal phytate and faecal mineral excretion. Fourteen young women (aged 19-24 years) and fourteen elderly women (64-75 years) were studied for two metabolic periods (MP). In MP1, the subjects consumed a controlled high-phytate (HP) diet for 10 d; in MP2, they were on a low-phytate (LP) diet for 10 d. In each period, diet samples and complete faecal samples for 5 d were collected to analyse phytate and mineral contents. Mineral concentrations in diet and faeces were measured by inductively coupled plasma-atomic emission spectrometry. Linear regression analysis was used to examine the associations between faecal phytate and mineral excretion. The degradation rate of dietary phytate was about 77% for young women, which was significantly lower than that of elderly women (86%) (P < 0.05). Faecal phytate excretion was positively correlated with mineral excretion (Ca, P, Fe and Zn) in both the HP and LP diet groups in young women (P < 0.05). The linear relationship tended to be greater during the LP diet period compared with the HP diet period in young women. However, no association was found between phytate excretion and mineral excretion in elderly women. In summary, undegraded dietary phytate (10-20%) had a negative effect on mineral absorption in young women, and the relationship between faecal phytate and mineral excretion was affected by both dietary phytate and age.

Management of non-severe pregnancy hypertension - A summary of the CHIPS Trial (Control of Hypertension in Pregnancy Study) research publications.

The international CHIPS Trial (Control of Hypertension In Pregnancy Study) enrolled 987 women with chronic (75%) or gestational (25%) hypertension. Pre-eclampsia developed in 48%; women remained on their allocated BP control and delivered an average of two weeks later. 'Less tight' control (target diastolic BP 100 mmHg) achieved BP that was 6/5mmHg higher (p < 0.001) than 'tight' control (target diastolic 85 mmHg, BP achieved 133/85 mmHg). 'Less tight' (vs. 'tight') control resulted in similar adverse perinatal outcomes (31.5% vs. 30.7%; p = 0.84) that balanced birthweight < 10th percentile (16.1% vs. 19.8%; p = 0.14) against preterm birth (35.6% vs. 31.5%; p = 0.18). 12-month follow-up revealed no compelling evidence for developmental programming of child growth. However, 'less tight' (vs. 'tight') control resulted in more severe maternal hypertension (40.6% vs. 27.5%; p < 0.001), and more women with platelets < 100 × 109/L (4.3% vs. 1.6%; p = 0.02) or symptomatic elevated liver enzymes (4.3% vs. 1.8%; p = 0.03), with no difference in serious maternal complications (3.7% vs. 2.0%; p = 0.17). Labetalol was the drug of choice. Methyldopa did not result in inferior outcomes. Post-hoc, severe hypertension, independent of pre-eclampsia, was associated with heightened increased risk of adverse outcomes, and in 'less tight' control, of serious maternal complications. At no gestational age at initiation of BP control was 'less tight' superior to 'tight'. Women in both groups were equally satisfied with care. 'Less tight' control tended to be more expensive by CAD$6000 (p =0.07) based on neonatal care costs. Collectively, CHIPS publications have provided evidence that women with non-severe pregnancy hypertension should receive 'tight' BP control achieved by a simple algorithm.

Iron bioavailability from maize and beans: a comparison of human measurements with Caco-2 cell and algorithm predictions.

BACKGROUND: An in vitro digestion and Caco-2 cell model may predict iron bioavailability to humans; however, direct comparisons are lacking. OBJECTIVE: The objective was to test the differences in iron bioavailability between 2 maize varieties and 2 bean varieties (white beans and colored beans) by comparing human, Caco-2, and algorithm results. DESIGN: Two randomized, 2 x 2 factorial experiments compared women's iron absorption from 2 maize varieties (ACR and TZB; n = 26) and 2 bean varieties (great northern and pinto; n = 13), each fed with and without ascorbic acid (AA) from orange juice. Nonheme iron bioavailability was determined from 2-wk retention of extrinsic radioiron tracers and was compared with Caco-2 cell and algorithm results from identical meals. RESULTS: Without AA supplementation, women absorbed only about 2% of the iron from the maize or bean meals. The results were unaffected by the variety of either maize or beans. Adding AA (15-20 molar ratios of AA:iron) roughly tripled the iron absorption (P < 0.0001) from all test meals. Although the Caco-2 model predicted a slightly improved bioavailability of iron from ACR maize than from TZB maize (P < 0.05), it accurately predicted relative iron absorption from the maize meals. However, the Caco-2 model inaccurately predicted both a considerable difference between bean varieties (P < 0.0001) and a strong interaction between bean varieties and enhancement by AA (P < 0.0001). The algorithm method was more qualitatively than quantitatively useful and requires further development to accurately predict the influence of polyphenols on iron absorption. CONCLUSIONS: Caco-2 predictions confirmed human iron absorption results for maize meals but not for bean meals, and algorithm predictions were only qualitatively predictive.

Screening of iron bioavailability patterns in eight bean (Phaseolus vulgaris L.) genotypes using the Caco-2 cell in vitro model.

The common bean ( Phaseolus vulgaris) is an important staple plant food in the diets of people of Latin America, East Africa,and other regions of the developing world. It is also a major source of dietary iron. The primary goal of this research was to use an in vitro digestion/Caco-2 model to study iron bioavailability in eight genotypes (three Mesoamerican and five Andean) that represent the diversity of grain types in this crop. Complementing this goal, we measured the distribution of both iron and phytate in different bean grain tissues (cotyledon, seed coats, and embryos). Seed coats were confirmed to be the exclusive tissue containing polyphenols. The removal of the seed coat and associated polyphenols improved Caco-2 iron bioavailability, and significant differences were observed between genotypes. The addition of ascorbate enhanced iron bioavailability and exposed additional differences in Fe availability among the genotypes. These results indicate that iron accumulation and in vitro iron bioavailability vary among bean genotypes and that polyphenols had greater inhibitory effects on Caco-2 iron bioavailability as compared to phytate.

Moving toward a more physiological model: application of mucin to refine the in vitro digestion/Caco-2 cell culture system.

The objective of this study was to determine if a combination of commercially available mucin and an 8 microm microporous membrane insert can be used to replace the 15 kDa molecular weight cutoff (MWCO) dialysis membrane used in an established in vitro digestion/Caco-2 cell culture system. Although the current model with the 15 kDa membrane correlates well with human studies, use of mucin may improve the system as the mucus layer is suspected to play a physiological role in Fe absorption. Use of mucin may also enable more complete assessment of iron bioavailability from large molecular weight forms of Fe such as heme and ferritin Fe. A range of foods or Fe (i.e., FeCl(3) +/- ascorbic acid, cooked beef, red bean, white bean, soybean, horse spleen ferritin and plant-type ferritin) were subjected to in vitro digestion. In the presence of mucin, significantly more Fe was taken up from the heme Fe (86%) and ferritin (91%) samples and significantly less Fe was taken up from the white bean samples ( approximately 70%) relative to the 15 kDa membrane. The results indicated that the forms of iron interact with mucin. The mucus layer has a significant effect on Fe uptake. Further refinement and characterization of the mucin method is needed before it can be deemed to be a suitable replacement for the dialysis membrane.

Kaempferol in red and pinto bean seed (Phaseolus vulgaris L.) coats inhibits iron bioavailability using an in vitro digestion/human Caco-2 cell model.

Four different colored beans (white, red, pinto, and black beans) were investigated for factors affecting iron bioavailability using an in vitro digestion/human Caco-2 cell model. Iron bioavailability from whole beans, dehulled beans, and their hulls was determined. The results show that white beans contained higher levels of bioavailable iron compared to red, pinto, and black beans. These differences in bioavailable iron were not due to bean-iron and bean-phytate concentrations. Flavonoids in the colored bean hulls were found to be contributing to the low bioavailability of iron in the non-white colored beans. White bean hulls contained no detectable flavonoids but did contain an unknown factor that may promote iron bioavailability. The flavonoids, kaempferol and astragalin (kaempferol-3-O-glucoside), were identified in red and pinto bean hulls via HPLC and MS. Some unidentified anthocyanins were also detected in the black bean hulls but not in the other colored bean hulls. Kaempferol, but not astragalin, was shown to inhibit iron bioavailability. Treating in vitro bean digests with 40, 100, 200, 300, 400, 500, and 1000 microM kaempferol significantly inhibited iron bioavailability (e.g., 15.5% at 40 microM and 62.8% at 1000 microM) in a concentration-dependent fashion. Thus, seed coat kaempferol was identified as a potent inhibitory factor affecting iron bioavailability in the red and pinto beans studied. Results comparing the inhibitory effects of kaempferol, quercitrin, and astragalin on iron bioavailability suggest that the 3',4'-dihydroxy group on the B-ring in flavonoids contributes to the lower iron bioavailability.

Women's views and postpartum follow-up in the CHIPS Trial (Control of Hypertension in Pregnancy Study).

OBJECTIVE: To compare women's views about blood pressure (BP) control in CHIPS (Control of Hypertension In Pregnancy Study) (NCT01192412). DESIGN: Quantitative and qualitative analysis of questionnaire responses. SETTING: International randomised trial (94 sites, 15 countries). POPULATION/SAMPLE: 911 (92.9%) women randomised to 'tight' (target diastolic blood pressure, 85mmHg) or 'less tight' (target diastolic blood pressure, 100mmHg) who completed questionnaires. METHODS: A questionnaire was administered at ∼6-12 weeks postpartum regarding post-discharge morbidity and views about trial participation. Questionnaires were administered by the site co-ordinator, and contact was made by phone, home or clinic visit; rarely, data was collected from medical records. Quantitative analyses were Chi-square or Fisher's exact test for categorical variables, mixed effects multinomial logistic regression to adjust for confounders, and p<0.001 for statistical significance. NVivo software was used for thematic analysis of women's views. MAIN OUTCOME MEASURES: Satisfaction, measured as willingness to have the same treatment in another pregnancy or recommend that treatment to a friend. RESULTS: Among the 533 women in 'tight' (N=265) vs. 'less tight' (N=268) control who provided comments for qualitative analysis, women in 'tight' (vs. 'less tight') control made fewer positive comments about the amount of medication taken (5 vs. 28 women, respectively) and intensity of BP monitoring (7 vs. 17, respectively). However, this did not translate into less willingness to either have the same treatment in another pregnancy (434, 95.8% vs. 423, 92.4%, respectively; p=0.14) or recommend that treatment to a friend (435, 96.0% and 428, 93.4%, respectively; p=0.17). Importantly, although satisfaction remained high among women with an adverse outcome, those in 'tight' control who suffered an adverse outcome (vs. those who did not) were not consistently less satisfied, whereas this was not the case among women in 'less tight' control among whom satisfaction was consistently lower for the CHIPS primary outcome (p<0.001), severe hypertension (p≤0.01), and pre-eclampsia (p<0.001). CONCLUSIONS: Women in 'tight' (vs. 'less tight') control were equally satisfied with their care, and more so in the face of adverse perinatal or maternal outcomes.

The CHIPS Randomized Controlled Trial (Control of Hypertension in Pregnancy Study): Is Severe Hypertension Just an Elevated Blood Pressure?

To determine whether clinical outcomes differed by occurrence of severe hypertension in the international CHIPS trial (Control of Hypertension in Pregnancy Study), adjusting for the interventions of "less tight" (target diastolic blood pressure [dBP] 100 mm Hg) versus "tight" control (target dBP 85 mm Hg). In this post-hoc analysis of CHIPS data from 987 women with nonsevere nonproteinuric preexisting or gestational hypertension, mixed effects logistic regression was used to compare the following outcomes according to occurrence of severe hypertension, adjusting for allocated group and the influence of baseline factors: CHIPS primary (perinatal loss or high-level neonatal care for >48 hours) and secondary outcomes (serious maternal complications), birth weight <10th percentile, preeclampsia, delivery at <34 or <37 weeks, platelets <100×109/L, elevated liver enzymes with symptoms, maternal length of stay ≥10 days, and maternal readmission before 6 weeks postpartum. Three hundred and thirty-four (34.1%) women in CHIPS developed severe hypertension that was associated with all outcomes examined except for maternal readmission (P=0.20): CHIPS primary outcome, birth weight <10th percentile, preeclampsia, preterm delivery, elevated liver enzymes (all P<0.001), platelets <100×109/L (P=0.006), and prolonged hospital stay (P=0.03). The association between severe hypertension and serious maternal complications was seen only in less tight control (P=0.02). Adjustment for preeclampsia (464, 47.3%) did not negate the relationship between severe hypertension and the CHIPS primary outcome (P<0.001), birth weight <10th percentile (P=0.005), delivery at <37 (P<0.001) or <34 weeks (P<0.001), or elevated liver enzymes with symptoms (P=0.02). Severe hypertension is a risk marker for adverse maternal and perinatal outcomes, independent of BP control or preeclampsia co-occurrence. CLINICAL TRIAL REGISTRATION: URL: http://pre-empt.cfri.ca/. Unique identifier: ISRCTN 71416914. URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01192412.

The Cost Implications of Less Tight Versus Tight Control of Hypertension in Pregnancy (CHIPS Trial).

UNLABELLED: The CHIPS randomized controlled trial (Control of Hypertension in Pregnancy Study) found no difference in the primary perinatal or secondary maternal outcomes between planned "less tight" (target diastolic 100 mm Hg) and "tight" (target diastolic 85 mm Hg) blood pressure management strategies among women with chronic or gestational hypertension. This study examined which of these management strategies is more or less costly from a third-party payer perspective. A total of 981 women with singleton pregnancies and nonsevere, nonproteinuric chronic or gestational hypertension were randomized at 14 to 33 weeks to less tight or tight control. Resources used were collected from 94 centers in 15 countries and costed as if the trial took place in each of 3 Canadian provinces as a cost-sensitivity analysis. Eleven hospital ward and 24 health service costs were obtained from a similar trial and provincial government health insurance schedules of medical benefits. The mean total cost per woman-infant dyad was higher in less tight versus tight control, but the difference in mean total cost (DM) was not statistically significant in any province: Ontario ($30 191.62 versus $24 469.06; DM $5723, 95% confidence interval, -$296 to $12 272; P=0.0725); British Columbia ($30 593.69 versus $24 776.51; DM $5817; 95% confidence interval, -$385 to $12 349; P=0.0725); or Alberta ($31 510.72 versus $25 510.49; DM $6000.23; 95% confidence interval, -$154 to $12 781; P=0.0637). Tight control may benefit women without increasing risk to neonates (as shown in the main CHIPS trial), without additional (and possibly lower) cost to the healthcare system. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01192412.

Meat and ascorbic acid can promote Fe availability from Fe-phytate but not from Fe-tannic acid complexes.

This study utilized an in vitro digestion/Caco-2 cell model to determine the levels of ascorbic acid (AA) and "meat factor" needed to promote Fe absorption from Fe complexed with phytic acid (PA) or tannic acid (TA). AA reversed the inhibition of Fe absorption by PA beginning at a molar ratio of 1:20:1 (Fe:PA:AA) but essentially had no effect on the Fe complexed with TA. Fish also reversed the inhibition of Fe uptake by PA but not by TA. TA and fish decreased total Fe solubility. Iron in the presence of PA was highly soluble. AA, but not fish, increased the percentage of soluble Fe as Fe2+ in the presence of both inhibitors. The results indicate that monoferric phytate is a form of Fe that can be available for absorption in the presence of uptake promoters. In contrast, a TA-Fe complex is much less soluble and unavailable in the presence of promoters.

Potential for improving bioavailable zinc in wheat grain (Triticum species) through plant breeding.

A "whole-body" radioassay procedure was used to assess retention and absorption by rats of Zn in mature kernels of whole grain wheat harvested from 28 genotypes (Triticum spp.) grown in nutrient solution supplied with 2 microM ZnSO4 radiolabeled with 65Zn. Grain-Zn concentration differed among genotypes and ranged from 33 to 149 microg g(-1) of dry weight (DW); similarly, grain-Fe concentration varied approximately 4-fold, from 80 to 368 microg g(-1) of DW. Concentrations of Zn and Fe in the grain were positively correlated. Therefore, selecting genotypes high in grain-Zn also tends to increase grain-Fe concentration. Concentrations of myo-inositolhexaphosphate (phytate) in the wheat grain varied from 8.6 to 26.1 micromol g(-1) of DW. Grain intrinsically labeled with 65Zn was incorporated into test meals fed to Zn-depleted rats. All rats readily ate the test meals, so that Zn intake varied directly with grain-Zn concentration. As determined by the percentage of 65Zn absorbed from the test meal, the bioavailability to rats of Zn in the wheat genotypes ranged from about 60 to 82%. The amount of bioavailable Zn (micrograms) in the grain was positively correlated to the amount of Zn accumulated in the grain. There was a significant negative correlation between grain-phytate levels and percentage of Zn absorbed from the wheat grain, but the effect was not large. These results demonstrate that concentrations of Zn in whole-wheat grain, as well as amounts of bioavailable Zn in the grain, can be increased significantly by using traditional plant-breeding programs to select genotypes with high grain-Zn levels. Increasing the amount of Zn in wheat grain through plant-breeding contrivances may contribute significantly to improving the Zn status of individuals dependent on whole grain wheat as a staple food.

Agriculture: the real nexus for enhancing bioavailable micronutrients in food crops.

Human existence requires that agriculture provide at least 50 nutrients (e.g., vitamins, minerals, trace elements, amino acids, essential fatty acids) in amounts needed to meet metabolic demands during all seasons. If national food systems do not meet these demands, mortality and morbidity rates increase, worker productivity declines, livelihoods are diminished and societies suffer. Today, many food systems within the developing world cannot meet the nutritional needs of the societies they support mostly due to farming systems that cannot produce enough micronutrients to meet human needs throughout the year. Nutrition transitions are also occurring in many rapidly developing countries that are causing chronic disease (e.g., cancer, heart disease, stroke, diabetes, and osteoporosis) rates to increase substantially. These global developments point to the need to explicitly link agricultural technologies to human health. This paper reviews some ways in which agriculture can contribute significantly to reducing micronutrient malnutrition globally. It concludes that it is imperative that close linkages be forged between the agriculture, nutrition and health arenas in order to find sustainable solutions to micronutrient malnutrition with agriculture becoming the primary intervention tool to use in this fight.