Prevalence of iron deficiency in the United States

Erythrocyte incorporation of iron by infants: iron bioavailability from a low-iron infant formula and an evaluation of the usefulness of correcting erythrocyte incorporation values, using a reference dose or plasma ferritin concentrations

Bioavailability of iron (Fe) from a low-Fe infant formula was determined by erythrocyte incorporation of58Fe 14 d after administration in ten healthy, non-Fe-deficient infants. Two feeding protocols were compared, with each infant acting as his/her own control. At 140 and 154 d of age, infants were fed 1000 g of58Fe-labelled formula (1·44 mg total Fe/1000 g) as six feeds over 24 h (Protocol A) or as two feeds/day on three consecutive days (Protocol B). A water solution with57Fe and ascorbic acid was given separately as a reference dose in both study protocols. Erythrocyte incorporation of58Fe and57Fe was determined by thermal ionisation mass spectrometry. Geometric mean58Fe incorporation was 7·6 % (range 3·3–13·5 %) with Protocol A as compared to 10·6 % (range 6·7–18·6 %) with Protocol B (P=0·05); pairedttest. Inter-individual variability of58Fe was not reduced by correcting for the incorporation of57Fe from the reference dose, or by correcting for plasma ferritin concentration. Fractional erythrocyte incorporation of Fe from low-Fe infant formula was in the same range as our earlier published data on erythrocyte incorporation of Fe from human milk extrinsically labelled with58Fe (). The methodological evaluations included in this study clearly indicate the importance of using standardised study protocols when evaluating Fe bioavailability in infants. Corrections of erythrocyte incorporation data based on plasma ferritin or erythrocyte incorporation of Fe from a reference dose were not found to be useful.

Children with autism: effect of iron supplementation on sleep and ferritin

To determine if there is a relationship between low serum ferritin and sleep disturbance in children with autism spectrum disorder, an 8-week open-label treatment trial with oral iron supplementation was conducted as a pilot study. At baseline and posttreatment visits, parents completed a Sleep Disturbance Scale for Children and a Food Record. Blood samples were obtained. Thirty-three children completed the study. Seventy-seven percent had restless sleep at baseline, which improved significantly with iron therapy, suggesting a relationship between sleep disturbance and iron deficiency in children with autism spectrum disorder. Sixty-nine percent of preschoolers and 35% of school-aged children had insufficient dietary iron intake. Mean ferritin increased significantly (16 microg/L to 29 microg/L), as did mean corpuscular volume and hemoglobin, suggesting that low ferritin in this patient group resulted from insufficient iron intake. Similar prevalence of low ferritin at school age as preschool age indicates that children with autism spectrum disorder require ongoing screening for iron deficiency.

A comparison between improvers and non-improvers among children with anemia enrolled in the WIC program

OBJECTIVES

To investigate differences between children ages one to five enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in the state of Texas whose anemia status improved and those whose anemia status did not improve.

METHODS

The study involved administration of a survey to a randomly selected stratified sample of parents and guardians of WIC children residing in the eleven public health regions in Texas. Subjects volunteered to complete the survey during a scheduled WIC appointment. A total of 459 usable surveys were completed. Fifty-one percent of the surveys were completed by parents/guardians of children classified as anemia improvers and 49% were completed by parents/guardians of children classified as anemia non-improvers.

RESULTS AND CONCLUSIONS

A majority of the respondents were the child's parent (97%). Most of the children were Hispanic/Latino (77%). More non-improvers than improvers were of young age (p < 0.01), had a parent/guardian who was 18-30 years of age (p < 0.01), lived in a household with four or more other children (p = 0.05) and were from households with a very low income (p = 0.03). Compared to improvers, non-improvers ate fewer snacks (p = 0.01) and a greater percentage never consumed dried fruits (p < 0.01). Knowledge level of the parents/guardians was similar for the two groups. A high percentage of parents/guardians of non-improvers incorrectly believed that their child's condition had improved. WIC staff and other public health educators can utilize these findings to identify those children with anemia who are at higher risk for non-improvement.

Iron status of inner-city African-American infants

The iron status of African-American infants continues to be subject to debate. We characterized the iron status of 198 9-month-old inner-city infants (94% fed iron-fortified formula) using a comprehensive panel of measures and assessing lead and inflammation markers. The proportion with iron deficiency was calculated based on three approaches (> or = 2 abnormal iron measures with or without anemia for MCV model--NHANES II, ferritin model--NHANES III, or Sweden/Honduras study) and a promising new measure-body iron, calculated from ferritin and transferrin receptor (TfR). There were no sex differences for any iron measure. Hb < 110 g/l was observed in 25%; Hb < or = 105 g/l in 10.1%. Free erythrocyte protoporphyrin (FEP) values were elevated without elevated lead concentrations or an inflammatory response: mean FEP = 86.6 microg/dl red blood cells [75.5 micromol/mol heme]; 52.3% were > 80 microg/dl (1.42 micromol/l), almost half of which were accompanied by a second abnormal iron measure. The estimated prevalence of iron deficiency was 14.4, 5.3, and 2.5% for the MCV model, ferritin model, and Sweden/Honduras cutoffs, respectively, and 4.1% for body iron < 0 mg/kg. Regulation of iron storage is immature at < 1 year of age, making estimates of iron deficiency that depend on ferritin, including body iron, suspect in this age period. Thus, the "true" prevalence of iron deficiency could not be established with confidence due to major differences in the results, depending on the guidelines used. Functional indicators of poor iron status in young infants are urgently needed.

Folate deficiency is associated with nutritional anaemia in Lebanese women of childbearing age

OBJECTIVE

The objective of this study was to identify the determinants of anaemia in Lebanese women of childbearing age attending health centres in Lebanon.

DESIGN

Cross-sectional study carried out between May and December 2003. Anthropometric measurements as well as sociodemographic, health and dietary intake data were collected using a questionnaire. Haemoglobin (Hb), plasma ferritin, plasma folate and vitamin B12 were assessed using standard laboratory methods.

SETTING

Governmental health centres in Lebanon.

SUBJECTS

Four hundred and seventy non-pregnant Lebanese women aged 15-45 years.

RESULTS

Anaemia (Hb <12 g dl(-1)) and iron deficiency (ferritin <15 microg l(-1)) were prevalent in 16.0 and 27.2% of the study sample, respectively. Of the total sample, 7.7% had iron-deficiency anaemia. The percentage of women with either Hb or ferritin deficiency or both was 35.6%. Plasma folate and vitamin B12 deficiency was reported in 25.1 and 39.4%, respectively, and 12.6% of the women had both folate and vitamin B12 deficiencies. Of the anaemic group, 48.0% of the women had iron deficiency. The intake of iron was lower in iron-deficient than in non-deficient women and a positive relationship was shown between folate intake and its corresponding serum levels. Regression analysis showed that ferritin, plasma folate and family history of anaemia were significant determinants of the anaemia in the sample of women.

CONCLUSIONS

Anaemia not related to iron deficiency was partly explained by plasma folate deficiency. Measures to control folate and iron deficiency should be considered.

The prevalence of anaemia depends on the definition: an example from the Aboriginal Birth Cohort Study

OBJECTIVE

The cutoffs defining anaemia based on haemoglobin and haematocrit recommended by the World Health Organization (WHO) and the United States (US) are different. We compared the prevalences resulting from these definitions and explored the reasons for the variation observed.

DESIGN

A cross-sectional survey within a cohort study of children recruited at birth at Royal Darwin Hospital.

SETTING

Subjects were interviewed in their homes or other convenient location and had a blood sample drawn.

SUBJECTS

Five hundred and seventeen Australian Aboriginal children aged 9-13 years inclusive.

RESULTS

Depending on the criterion used, the prevalence of anaemia in the total group ranged between 6% (95% confidence interval: 4.1-8.4%) and 24.4% (20.7-28.3). Using the WHO criteria, girls aged 12-13 years were identified as a target group, having a two- to-six fold higher prevalence than the other groups. When compared to the US criteria, boys aged 12-13 years had the highest prevalence of anaemia, although this was not significant. Simulations show that the WHO cutoffs are based on inconsistent centiles of the age-sex haemoglobin and haematocrit distributions, and that this largely explains the discrepant results.

CONCLUSIONS

This variability in definition could lead to inappropriate identification of target groups for intervention programmes.

The health of homeless children revisited

To the extent that representative data are available for specific health conditions (eg, under-immunization, asthma prevalence), the authors' data suggest that the gap between the health status of homeless children and housed children in minority, low-income families is narrowing. Studies of the health status of homeless children allow a window into the health status of medically underserved children whose needs may not be readily documented because of their lack of access to the health care system. Although prevalence rates of most of the health conditions discussed in this article exceeded national norms, they were generally consistent with rates characteristic of health disparities based on race-ethnicity and income. It must be emphasized that in most instances, children were seen for their first pediatric visit within weeks of entering the homeless shelter system. The health conditions identified were often present before the child and family became homeless. The high prevalence of asthma among homeless children should therefore be a matter of concern to health providers and payors, because the authors' data strongly suggest that this is not confined to children in homeless shelters as a special population. Similarly, childhood obesity predates homelessness (or at least the episode of homelessness during which health care was provided) and as such the authors' data may indicate the extent of this problem more generally among medically underserved children in the communities of origin. These conditions seem to be exacerbated by the specific conditions associated with homeless shelter life. Asthma care, assuming it was previously available, is disrupted when housing is lost, and shelter conditions may have multiple asthma triggers. Nutrition often suffers as a result of inadequate access to nutritious food and cooking facilities in shelters, as indicated by the high rate of iron-deficiency anemia among very young children. It is clear that homeless children in shelters require enhanced access to primary and specialist care. Shelter placement necessarily disrupts prior health care relationships (if any), while simultaneously placing additional stress on the child's physical and emotional well being. A medical home model is strongly recommended to allow for continuous, culturally competent care. Developmental and mental health problems are also more prevalent among homeless children. These conditions may jeopardize life successes. The overcrowding associated with homeless shelters and the housing conditions that frequently precede episodes of homelessness are associated with the higher prevalence of otitis media found among young children. This in turn is associated with developmental delay. Also contributing to the developmental risk associated with homelessness is exposure to DV, which is also frequently an antecedent of homelessness. Developmental surveillance for young, homeless children, monitoring of school attendance and academic performance, and assessment of mental status for homeless adolescents are recommended to facilitate early identification of problems and delivery of necessary interventions. For young children, providers of health care to the homeless should be well networked into the Early Intervention and Preschool Special Education programs in their locality. Given the multiplicity of needs for homeless families, which of course includes help finding affordable housing, health care providers serving this population should also develop linkages with community agencies, including those that can help parents develop the skills necessary for economic self-sufficiency and long-term ability to sustain independent housing.

Child food insecurity and iron deficiency anemia in low-income infants and toddlers in the United States

OBJECTIVE

Examine the association between child-level food insecurity and iron status in young children utilizing community-based data from the Children's Sentinel Nutrition Assessment Program (C-SNAP).

METHODS

A cross-sectional sample of caregivers of children < or =36 months of age utilizing emergency department (ED) services were interviewed between 6/96-5/01. Caregiver interviews, which included questions on child-level food security, were linked to a primary clinic database containing hemoglobin, red blood cell distribution width, mean corpuscular volume, free erythrocyte protoporphyrin and lead values. Children a priori at-risk for anemia: birthweight < or =2500 g, with HIV/AIDS, sickle cell disease, or lead values > or =10.0 ug/dL, and children < or =6 months of age were excluded from the analysis. Only laboratory tests 365 days prior or 90 days after interview were examined. Iron status was classified in four mutually exclusive categories: 1) Iron Sufficient-No Anemia (ISNA), 2) Anemia (without iron deficiency), 3) Iron Deficient-No Anemia (IDNA), 4) Iron Deficient with Anemia (IDA).

RESULTS

626 ED interviews linked to laboratory data met the inclusion criteria. Food insecure children were significantly more likely to have IDA compared to food secure children [Adjusted Odds Ratio = 2.4, 95% CI (1.1-5.2), p = 0.02]. There was no association between child food insecurity and anemia without iron deficiency or iron deficiency without anemia.

CONCLUSION

These findings suggest an association between child level food insecurity and iron deficiency anemia, a clinically important health indicator with known negative cognitive, behavioral and health consequences. Cuts in spending on food assistance programs that address children's food insecurity may lead to adverse health consequences.

Prevalence of anemia among healthy women in 2 metropolitan areas of Japan

Anemia is common among young women, and iron deficiency is one of the leading causes. In Europe and the US, the iron fortification of flour increased oral iron intake and decreased anemia prevalence from 30% to 10%. The National Nutrition Survey in Japan revealed that anemia prevalence among young Japanese women is increasing; however, no nationwide preventive policy has been aimed at iron deficiency anemia. The endpoint of this study was the estimation of anemia prevalence among healthy Japanese woman, based on a large sample size. We collected data from the consecutive check-up examination records of apparently healthy women (n = 13,147). We defined hemoglobin lower than 12 g/dL as anemia, hemoglobin lower than 10 g/dL as severe anemia, and a mean corpuscular volume lower than 80 fl as microcytic anemia. Of the 13,147 persons, anemia was identified in 2331 (17.3 %), and severe and microcytic anemia in 438 (3.3 %) and 700 (5.2 %), respectively. Among women younger than 50 years, anemia was identified in 22.3 %, and 25.2 % of them had severe anemia. In conclusion, the prevalence of anemia and severe anemia among young women is high in Japan. Some action needs to be considered to improve women's quality of life.

Sleep disorders in women: clinical evidence and treatment strategies

Sleep disorders are more prevalent in women than in men. Sex hormones modulate sleep-wake behaviors and mood and may contribute to heightened risk across the life cycle of women. Sleep disorders may have a unique expression in women, emerging throughout their reproductive life cycle. These conditions require careful treatment strategy to manage medical, hormonal, and behavioral contributing factors to poor sleep efficiency and impaired quality of life. This review focuses on clinical evidence for sleep disorders in women and discusses existing evidence of risk factors and treatment options for insomnia and sleep-disordered breathing in women.

Serum transferrin receptor in children: usefulness for determinating the nature of anemia in infection

OBJECTIVES

To know the variations of serum transferrin receptor (sTfR) and its indices depending on the status of body iron and the presence of infection in children, to evaluate their usefulness for recognizing the nature of anemia in infection, and to know the role of erythropoietic activity in these conditions.

DESIGN AND METHODS

Three hundred and sixty-eight children between 1 and 10 years were included: 206 healthy children; 60 iron deficient anemic children (IDA); 102 with anemia and infectious disease, 58 of them meeting criteria for IDA. We measured hemoglobin, red cell indices, reticulocytes, transferrin saturation, serum ferritin, erythrocyte protoporphyrin, serum erythropoietin, and sTfR. Statistic method: ANOVA test, multiple linear regression, and ROC curve.

RESULTS

sTfR, sTfR/ferritin ratio, and sTfR-logferritin index values were found to increase significantly in IDA children. These values were significantly lower in infectious anemia than iron deficiency states. Serum erythropoietin only was elevated significantly in iron deficiency states. In children without infection, mean corpuscular hemoglobin, erythrocyte protoporphirin, erythropoietin logarithm, and total-iron-binding-capacity logarithm predicted 81% of sTfR variability. sTfR and its indices showed a very high sensitivity and specificity for recognizing iron deficiency states. In children with IDA and infection sensitivity for sTfR/ferritin ratio was low (area under the curve: 0.71; 95% confidence interval: 0.64-0.88). For discriminating the nature of anemia in infection the cut-off point obtained for sTfR, sTfR/ferritin ratio, and sTfR-F index were 3, 70, and 1.8, respectively, and their sensitivity and specificity were also very high.

CONCLUSIONS

sTfR, sTfR/ferritin ratio, and sTfR-F index are useful parameters for recognizing iron deficiency and the nature of anemia in infection. In IDA+infection, sTfR/ferritin ratio should not be recommended in the diagnosis of iron deficiency. In iron deficiency, erythropoietic activity has a secondary role as predictor factor of sTfR levels.

Iron deficiency in infancy: applying a physiologic framework for prediction

BACKGROUND

Infants aged 6-24 mo are at high risk of iron deficiency. Numerous studies worldwide have sought to identify predictors of iron deficiency in this age group.

OBJECTIVE

The objectives of the study were to apply a physiologic model to identify risk factors for iron deficiency and to consider those risk factors under different conditions of iron supplementation. We predicted that factors related to iron status at birth (lower gestational age and lower birth weight), postnatal needs for iron (more rapid growth), and bioavailable iron (more cow milk) would be major risk factors.

DESIGN

The physiologic framework was assessed in 1657 Chilean infants (aged 12 mo) with birth weights >or=3 kg who were randomly assigned at age 6 mo to high or low iron supplementation or no added iron. Based on venous blood, the analysis used mean corpuscular volume and concentrations of hemoglobin, free erythrocyte protoporphyrin, and ferritin. Logistic regression models were used to identify predictors of iron deficiency anemia and iron deficiency without anemia.

RESULTS

The prevalence of iron deficiency (>or=2 abnormal iron measures) was 34.9% at age 12 mo. Of 186 infants with hemoglobin concentrations <110 g/L, 158 (84.9%) were iron deficient. The only consistent (and the strongest) predictor of iron deficiency or iron deficiency anemia was lower 6-mo hemoglobin. Factors related to poorer iron status at birth (lower birth weight, shorter gestation though full-term, or both) were predictors in the no-added-iron and high-iron groups. Otherwise, predictors varied by iron supplementation.

CONCLUSION

Variations in predictors of iron deficiency or iron deficiency anemia according to iron supplementation suggest that direct comparisons across studies are tenuous at best without data on early iron status and certainty that specific conditions are comparable.

Molecular and clinical aspects of iron homeostasis: From anemia to hemochromatosis

The discovery in recent years of a plethora of new genes whose products are implicated in iron homeostasis has led to rapid expansion of our knowledge in the field of iron metabolism and its underlying complex regulation in both health and disease. Abnormalities of iron metabolism are among the most common disorders encountered in practical medicine and may have significant negative impact on physical condition and life expectancy. Basic insights into the principles of iron homeostasis and the pathophysiological and clinical consequences of iron overload, iron deficiency and misdistribution are thus of crucial importance in modern medicine. This review summarizes our current understanding of human iron metabolism and focuses on the clinically relevant features of hereditary and secondary hemochromatosis, iron deficiency anemia, anemia of chronic disease and anemia of critical illness. The interconnections between iron metabolism and immunity are also addressed, in as much as they may affect the risk and course of infections and malignancies.

The relationship between depression and serum ferritin level

OBJECTIVE

This study looks at the association of depression and serum ferritin level.

DESIGN

Case-control study.

SETTING

University hospital.

SUBJECTS

Two hundred and five female medical students of Free University of Medical Sciences in Tehran were selected for the study (mean age; 24.5+/-1.6 years). Of these, 13 subjects were excluded and finally 192 subjects took part in the study.

INTERVENTIONS

A questionnaire was filled in by each participant for the diagnosis of depression to be made. Based on the Beck score, the students were grouped as depressed and healthy (67 depressed students and 125 healthy controls). The participants were evaluated in terms of hemoglobin (Hgb) level, serum ferritin, ESR (erythrocyte sedimentation rate), CRP (C-reactive protein), folic acid, vitamin B12 and Hgb simultaneously.

RESULTS

The prevalence of depression in the study population was 34.7%. The mean ferritin level in students with depression was significantly lower than the healthy ones (P<0.001). By changing the status from normal ferritin level to low ferritin level, odds of depression was increased by 1.92 (P<0.05).

CONCLUSION

The study implies a possible association between depression and decreased ferritin level before the occurrence of anemia.

SPONSORSHIP

Free University of Medical Sciences.

Brain Manganese Accumulation is Inversely Related to γ-Amino Butyric Acid Uptake in Male and Female Rats

Iron (Fe) is an essential trace metal involved in numerous cellular processes. Iron deficiency (ID) is reported as the most prevalent nutritional problem worldwide. Increasing evidence suggests that ID is associated with altered neurotransmitter metabolism and a risk factor for manganese (Mn) neurotoxicity. Though recent studies have established differences in which the female brain responds to ID-related neurochemical alterations versus the male brain, little is known about the interactions of dietary ID, Mn exposure, and sex on gamma-amino butyric acid (GABA). Male and female Sprague-Dawley rats were randomly divided into four dietary treatment groups: control (CN), control/Mn supplemented, ID, and ID/Mn supplemented. After 6 weeks of treatment, both ID diets caused a highly significant decrease in Fe concentrations across all brain regions compared to CN in both sexes. Both ID and Mn supplementation led to significant accumulation of Mn across all brain regions in both sexes. There was no main effect of sex on Fe or Mn accumulation. Striatal synaptosomes were utilized to examine the effect of dietary intervention on (3)H-GABA uptake. At 4 weeks, there was a significant correlation between Fe concentration and (3)H-GABA uptake in male rats (p < 0.05). At 6 weeks, there was a significant inverse correlation between Mn concentration and (3)H-GABA uptake in male and female rats and a postitive correlation between Fe concentration and (3)H-GABA uptake in female rats (p < 0.05). In conclusion, ID-associated Mn accumulation is similar in both sexes, with Mn levels affecting GABA uptake in both sexes in a comparable fashion.

Prevalence of iron deficiency and iron deficiency anemia among three populations of female military personnel in the US Army

BACKGROUND

Iron deficiency is the most prevalent micronutrient deficiency disease in the world and occurs in young women in the United States. Female military personnel represent a unique population faced with intense physical and cognitive demands.

OBJECTIVE

The objective of this study was to determine the prevalence of iron deficiency and iron deficiency anemia among three populations of female military personnel in the US Army.

METHODS

Iron status was assessed in 1216 volunteers. Volunteers were recruited from three groups: immediately following initial entry to the Army (IET), immediately following basic combat training (AIT), or following at least six months of permanent assignment (PP). Iron deficiency was determined using a three variable model, including cut-off values for serum ferritin, transferrin saturation, and red cell distribution width (RDW). Iron deficiency anemia was categorized by iron deficiency and a hemoglobin (Hgb) value of <12 g/dL.

RESULTS

The prevalence of iron deficiency was greater in women in the AIT group (32.8%) than in the IET and PP groups (13.4 and 9.6%, respectively). The prevalence of iron deficiency anemia was greater in the AIT group (20.9%) than in the IET and PP groups (5.8 and 4.8%, respectively). Furthermore, the prevalence of iron deficiency anemia was greater in Hispanic (21.9%) and African-American military personnel (22.9%) than in Caucasian military personnel (10.5%).

CONCLUSIONS

These data indicate that female military personnel experience diminished iron status following training, and that iron nutriture is an important issue facing females in the military.

Health-Related Quality of Life Among Japanese Women With Iron-Deficiency Anemia

Iron-deficiency anemia (IDA) is a common disease in females of childbearing age. Although iron supplementation quickly improves laboratory-measured parameters, its effect on health-related quality of life is unknown. Here, we conducted a prospective follow-up study to evaluate health-related quality of life in pre-menopausal women diagnosed with IDA. A convenience sample of 92 patients who visited Tokai University Hospital and three other affiliated hospitals were asked to fill out the Medical Outcome Study 36-item short-form health survey (SF-36) during the course of treatment (baseline, and 1 and 3 months after the start of treatment). At baseline, vitality and general health scores were significantly lower than the Japanese national norms. After the start of therapy, however, a significant improvement was seen in all domain scores except role emotional (RE), and at 3 months all eight scores were comparable to or greater than the national norms. In particular, physical functioning and vitality scores of patients with a lower hemoglobin level ( < 9.0 g/dl) at baseline showed a dramatic improvement. Iron supplementation in IDA patients improves not only hemoglobin levels, but also physical function, vitality, and general health perception.

Measurement of reticulocyte hemoglobin content to diagnose iron deficiency in Saudi children

Iron deficiency and iron deficiency anemia are common conditions in children, especially in developing countries. It is often difficult for the pediatrician to know which indices should be used in the diagnosis of these conditions in children. Reticulocyte hemoglobin (Hb) content (CHr) has been shown to be an accurate indicator of anemia, however whether its use suits the situation in developing countries or not is unclear. The aim of this study was to evaluate the value and effectiveness of using CHr as a method to diagnose iron deficiency and iron deficiency anemia in Saudi children. The samples for the study were collected from 305 children suspected to have anemia. Complete blood count, transferrin saturation (Tfsat), ferritin, circulating transferrin receptor (TfR) and CHr were measured. Three groups were defined, iron deficiency (Tfsat <20%, Hb >11 g/dL; n=120), iron deficiency anemia (Tfsat <20%, Hb <11 g/dL; (n=73) and controls (Tfsat >20%; n=112). The anemic group had significantly lower macrocytic anemia (MCV), mean corpuscular hemoglobin (MCH) and CHr. All of the variables in the anemia group were significantly lower than those of the control group except for the ferritin level. Compared to the control group, the iron deficiency group also showed significantly lower values except for transferrin receptor and the ferritin levels. CHr levels of <26 pg correlated well with anemic states. CHr together with a complete blood count may provide an alternative to the traditional hematologic or biochemical panel for the diagnosis of iron deficiency and iron deficiency anemia in young children and is cost-effective in developing countries. A CHr cut-off level of 26 pg is considered to be a reasonable indicator of anemic states.

A prospective study of same day bi-directional endoscopy in the evaluation of patients with occult gastrointestinal bleeding

OBJECTIVE

Previous studies show conflicting results in the diagnostic yield of oesophagogastroduodenoscopy (OGD) and colonoscopy (bi-directional) in identifying potential bleeding sources (PBS) in patients investigated for occult gastrointestinal bleeding (OGIB). The aims of this study were to evaluate the diagnostic yield of bi-directional endoscopy in patients presenting with OGIB and to assess the factors predictive of a positive yield.

MATERIAL AND METHODS

Patients with OGIB referred to the gastroenterology unit were prospectively included in the study. Colonoscopy was immediately followed by OGD. Predetermined criteria for the diagnosis of a PBS were used. Potential clinical factors predictive of positive yield were assessed.

RESULTS

Of the 219 patients (mean age 65 years, 34% M), 110 (50%) had at least one PBS. Colonoscopy revealed 87 PBS in 73 patients (33%), the most common being adenoma. OGD detected 49 PBS in 48 patients (22%), gastric ulcer being the most common. Of the patients with PBS at OGD, 23% also had a PBS at colonoscopy, including 3 patients with colonic cancers. Patients presenting with either a positive faecal occult blood test (FOBT) or iron-deficiency anaemia (IDA) only had a significantly lower yield for PBS than patients with combined positive FOBT and IDA. The percentages of patients with a PBS increased substantially with age.

CONCLUSIONS

A PBS was found in only 50% of the patients. Colonoscopy had a slightly higher diagnostic yield, and as expected, resulted in a significantly higher cancer detection rate than OGD. In older patients, colonoscopy should be done irrespective of the findings at OGD. Gastrointestinal-specific symptoms and the use of ASA/NSAIDs were not predictive in finding or localizing PBS.

The prevalence of anemia in adolescents: a study from Turkey

A cross-sectional method was used to study a group of 400 high school students in Kocaeli, Turkey, aged 14 to 16 years, identified among 17,812 high school students. Students from 10 high schools were selected using a random sampling method. Whole blood counts were performed as a screening test for anemia. Serum ferritin levels and, when necessary, hemoglobin electrophoresis were determined for anemic students. Iron medication was prescribed for iron deficiency and genetic counseling was given to adolescents with thalassemia trait. Out of 338 participating students (mean age, 14.72+/-0.71 y), anemia (hemoglobin <12 g/dL for girls and <13 g/dL for boys) was detected in 17/174 girls (9.7%) and 6/164 boys (3.6%). Iron deficiency anemia was detected in 20/23 (86.9%) of anemic children [15/17 (88.2%) girls and 4/6 (66.6%) boys]. Of 23 students with anemia 2 had beta-thalassemia trait and 2 had both iron deficiency, and beta-thalassemia trait. Etiology of anemia could not be defined in 1 student. The prevalence of adolescent anemia in Kocaeli is almost equal to that in developed countries.

The diagnosis and treatment of iron deficiency and its potential relationship to hair loss

Iron deficiency is the world's most common nutritional deficiency and is associated with developmental delay, impaired behavior, diminished intellectual performance, and decreased resistance to infection. In premenopausal women, the most common causes of iron deficiency anemia are menstrual blood loss and pregnancy. In men and postmenopausal women, the most common causes of iron deficiency anemia are gastrointestinal blood loss and malabsorption. Hemoglobin concentration can be used to screen for iron deficiency, whereas serum ferritin concentration can be used to confirm iron deficiency. However, the serum ferritin concentration may be elevated in patients with infectious, inflammatory, and neoplastic conditions. Other tests may be needed, such as erythrocyte zinc protoporphyrin concentration, transferrin concentration, serum iron concentration, and transferrin saturation. The cause of iron deficiency must be identified. If the patient is male, postmenopausal female, or has risk factors for blood loss, then the patient should be evaluated for sources of blood loss, especially gastrointestinal (eg, colon cancer). Several studies have examined the relationship between iron deficiency and hair loss. Almost all have addressed women exclusively and have focused on noncicatricial hair loss. Some suggest that iron deficiency may be related to alopecia areata, androgenetic alopecia, telogen effluvium, and diffuse hair loss, while others do not. Currently, there is insufficient evidence to recommend universal screening for iron deficiency in patients with hair loss. In addition, there is insufficient evidence to recommend giving iron supplementation therapy to patients with hair loss and iron deficiency in the absence of iron deficiency anemia. The decision to do either should be based on clinical judgment. It is our practice at the Cleveland Clinic Foundation to screen male and female patients with both cicatricial and noncicatricial hair loss for iron deficiency. Although this practice is not evidence based per se, we believe that treatment for hair loss is enhanced when iron deficiency, with or without anemia, is treated. Iron deficiency anemia should be treated. Treating iron deficiency without anemia is controversial. Treatment of nutritional iron deficiency anemia includes adequate dietary intake and oral iron supplementation. Excessive iron supplementation can cause iron overload and should be avoided, especially in high-risk patients such as those with hereditary hemochromatosis. Patients who do not respond to iron replacement therapy should undergo additional testing to identify other underlying causes of iron deficiency anemia.

Differing perspectives of inner-city parents and pediatric clinicians impact management of iron-deficiency anemia

OBJECTIVE

To ascertain the beliefs and experiences of inner-city pediatric clinicians and parents regarding anemia in young children.

DESIGN

Focus groups and in-depth interviews.

SETTING

Pediatric clinics and community agencies in Hartford, Connecticut.

PARTICIPANTS

Convenience sample of 41 pediatric clinicians (93% white, 73% female) and 85 parents (100% minority, 88% female, 47% < 12 years education).

PHENOMENON OF INTEREST

Identification, understanding, and management of anemia.

ANALYSIS

Researcher pairs coded complete transcriptions. Recurrent themes were identified, which were then contrasted and compared between clinicians and parents.

RESULTS

Both clinicians and parents were familiar with, but frustrated by the persistence of anemia. They noted time constraints and poor communication during office visits as contributing to the problem. Parents felt alarmed upon initial diagnosis; linked anemia with heredity, food patterns, and activity; reported culturally linked management strategies; but were uncertain of the seriousness. Health clinicians saw physiological processes as outside the parents' understanding and emphasized prevention through feeding recommendations.

CONCLUSIONS AND IMPLICATIONS

In order to address childhood anemia effectively, differing socio-cultural perspectives of clinicians and parents need to be incorporated into a unified health care plan. Nutritionists are well suited to collaborate on the health care team to effectively address this issue.

Serum Iron and Body Fat Distribution in a Multiethnic Cohort of Adults Living in New York City

OBJECTIVE

To examine the relationship between serum iron and body composition in a multiracial adult cohort.

METHODS

The analysis consisted of 670 participants on whom blood analysis and anthropometric data were available. The participants were recruited as part of the Rosetta Study (1990-2000), which was designed to assess body composition in a multiethnic cohort of healthy adults. Fasting iron level was measured as part of a biochemistry panel. Dual x-ray absorptiometry was used to assess fat mass. Anthropometric measures included waist circumference and body mass index (BMI; calculated as kg/m(2)) as an index of abdominal adiposity and overall body fatness, respectively.

RESULTS

In the study cohort the mean age was 54+/-17 years and 60.9% were overweight or obese (BMI > or =25). Men had higher serum iron levels (94.91+/-34.52 microg/dL [16.99+/-6.18 micromol/L] vs 82.17+/-32.62 microg/dL [14.71+/-5.84 micromol/L]) and larger waist circumference (91.98+/-11.87 cm vs 85.24+/-12.37 cm) compared with women (P<0.001). Iron was inversely correlated with BMI (r=-0.23, P<0.001), waist circumference (r=-0.19, P<0.05), and fat mass (r=-0.19, P<0.05) among Hispanic women but not among African-American, white, or Asian women or in men of any race/ethnic group.

CONCLUSIONS

The results of this study show an inverse association of measures of body fat distribution and total fat mass with serum iron level in Hispanic women. Studies designed to explore how micronutrients are used by the body at varying degrees of body fatness could provide useful information on the micronutrient-related comorbidities of obesity.

Community-based communication strategies to promote infant iron nutrition in northern Canada

OBJECTIVES

To evaluate innovative communication strategies promoting iron nutrition for infants at risk for iron deficiency anemia (IDA) in a northern Aboriginal community.

STUDY DESIGN

A prospective process evaluation.

METHODS

A social marketing approach was used in the development, implementation and evaluation of the communication strategies. A post-intervention questionnaire was administered to a sample (n = 45) to evaluate reach and exposure of the strategies, and sales of iron-rich infant foods were examined pre- and post-intervention.

RESULTS

Multiple communication channels were associated with an increased awareness of IDA and an increased self-reported use of iron-rich infant food. Radio was the most successful channel for reach and exposure of messages. Iron-rich infant food sales increased from pre- to post-intervention (p < 0.05). Breadth of exposure to cooking activity was more limited; however, participants reported increased confidence in preparing homemade baby food.

CONCLUSIONS

Communication strategies are a promising strategy for infant IDA prevention where appropriate food is available.

Iron deficiency and impaired cognition in toddlers: an underestimated and undertreated problem

Iron deficiency in toddlers is associated with impaired cognition and is an underestimated and undertreated problem. The prevalence of iron deficiency anemia (IDA) during the first year of life has been dramatically reduced in developed countries, mainly due to the increase in breastfeeding and the use of iron-fortified feeding formulae. However, in US and UK children aged 1-2 years, recent studies have shown prevalence rates of >10% and 30% for IDA and iron deficiency, respectively. The daily iron intake in children aged 1-2 years is lower than in any other age group during life. IDA during the first 2 years of life is associated with impaired mental and psychomotor development and these deficits are long lasting, and perhaps irreversible, despite the correction of the anemia. Another compelling reason to prevent iron deficiency in children, especially in children aged 1-2 years, is the proven association of iron deficiency with increased lead absorption. Lead-associated cognitive deficits occur at blood lead levels <10 microg/L, a level once thought to be harmless. The current prevalence rates of iron deficiency and IDA in toddlers, especially among those in the lower socioeconomic groups, are unacceptably high. These young children are doubly at risk for neurodevelopmental impairment, both from the iron deficiency itself as well as from CNS damage caused by the associated increased lead absorption. The current screening and treatment recommendations for IDA in the US and in other developed countries appear to have been unsuccessful in preventing iron deficiency and IDA in a large number of toddlers. Similarly, the associated problem of impaired mental and psychomotor development has not been adequately recognized or addressed in the existing medical literature. The author recommends that, after breastfeeding or an iron-fortified formula is stopped, iron deficiency and IDA be prevented by routine daily supplemental doses of 10mg of elemental iron via iron-fortified vitamins, iron drops, or iron-fortified drinks.

Identification, diagnosis, and management of anemia in adult ambulatory patients treated by primary care physicians: evidence-based and consensus recommendations

OBJECTIVE

Provide recommendations for the identification, diagnosis, and management of ambulatory patients with anemia.

MATERIALS AND METHODS

The RAND/UCLA Appropriateness Method was used to develop the recommendations. A literature review of anemia prevalence (based on a search of PubMed for the period 1990 to 2003), etiology, and treatment outcomes was reviewed by a panel comprised of nine physicians (six primary care, three specialists) who then rated 336 clinical scenarios and grouped them into three categories: 'appropriate', 'uncertain', or 'inappropriate'.

RESULTS

Performing a complete blood count on a yearly basis was rated 'appropriate' for patients with an underlying chronic condition, for men > or = 50 years old, and for all women with no chronic condition on an every-5-years basis. Specific recommendations were made for five anemia management options (observation, referral, empiric trial of iron, transfusion, and erythropoietic growth factors). Recommendations for observation alone were based on age, gender, and hemoglobin level. Immediate referral to a gastroenterologist or hematologist for a work-up was rated 'inappropriate' in all cases. An empiric trial of iron was rated 'inappropriate' for women over age 40 and for all men. Recommendations on the use of erythropoietic growth factors were based on hemoglobin level and anemia symptoms ('appropriate' if Hb < 9.5 g/dL, or if Hb = 9.5-11.0 g/dL and anemia symptoms were present). Finally, recommendations about transfusion were based on the severity of anemia and the presence of cardiovascular disease ('appropriate' in patients > or = 70 years old and in those presenting with either symptoms of anemia or underlying cardiovascular disease). The recommendations did not address anemia related to nutritional deficiencies, cancer/chemotherapy, or chronic renal failure.

CONCLUSION

Primary care physicians should obtain screening blood counts, perform diagnoses, and manage anemia in patient groups known to be at risk. These recommendations on the identification, diagnosis, and management of anemia represent an opportunity to improve outcomes in ambulatory patients with anemia.

Comparative proteomic analysis ofHelicobacter pylori strains associated with iron deficiency anemia

Helicobacter pylori is known to cause chronic gastritis, peptic ulcer, and gastric cancer, and has also been linked to iron deficiency anemia (IDA). To determine whether H. pylori clinical isolates correlate with the prevalence of H. pylori-associated IDA, we compared the proteomic profiles of H. pylori strains isolated from antral biopsy specimens of H. pylori-positive patients with or without IDA. Fifteen strains, including eight non-IDA and seven IDA strains, were cultured under iron-rich and iron-depleted conditions and then analyzed for protein expression profiles by 2-DE. The distances between two H. pylori strains were determined on the basis of similarities between their expression patterns of 189 protein spots, and a phylogenetic tree was constructed. The results revealed that the IDA strains formed a cluster separate from that of six non-IDA strains, with two non-IDA strains between the clusters. H. pylori strain 26695 was located in the non-IDA cluster. Protein spots displaying similar expression patterns were clustered, and 18 spots predominantly expressed in IDA strains were identified by MALDI-TOF analysis. These data indicate that the non-IDA and IDA strains can be distinguished by their protein expression profiles, suggesting that the polymorphism of H. pylori strains may be one of the factors determining the occurrence of H. pylori-associated IDA.

Effects of dietary zinc, iron, and copper in layer feed on distribution of these elements in eggs, liver, excreta, soil, and herbage

An experiment was conducted to evaluate the effect of dietary content and combinations of Zn, Fe, and Cu on deposition of these elements in egg components, liver, and excreta. Excreta were applied as a manure to a lawn, and 3 mo later soil and herbage samples were taken and analyzed. The experiment comprised 144 hens in 8 groups. The basal diet contained Zn, Fe, and Cu at 63.4, 92.8, and 9.0 mg/kg, respectively. It was supplemented with 1, 2, or 3 trace elements (inorganic forms) at 80 mg of Zn/kg, 120 mg of Fe/kg, and 25 mg of Cu/kg. Recovery of Zn, Fe, and Cu in eggs of hens fed the basal diet was 10.7, 9.8, and 4.4% of the alimentary intake, respectively. A Zn-Cu antagonism was observed; deposition of Zn in the yolk was significantly decreased by Cu addition and vice versa (P < 0.01). Supplementation of the basal diet with Fe increased Fe concentration in egg yolk and white by 6.3 and 2.2%, respectively. The combination of Fe with Zn and Cu, however, increased Fe concentration in the yolk and white by 36.7 and 34.9%, respectively (P < 0.01). The enrichment of eggs with the other elements was marginal (Cu) or absent (Zn). Effects of Zn, Fe, and Cu of the basal diet on liver concentrations of these elements were relatively small, and no antagonism between Zn and Cu was apparent. Supplementation of the basal diet with the combination of Zn and Fe, however, significantly decreased hepatic concentration of Cu. On the other hand, Cu supplementation significantly increased Fe concentration in livers of hens fed the Fe-supplemented diet (P < 0.01). Concentrations of Zn, Fe, and Cu in excreta were related to their dietary content. High concentrations of Zn, Fe, and Cu in excreta corresponded with limited deposition of the 3 elements in eggs and liver. Concentrations of Zn, Fe, and Cu in herbage correlated significantly with the supply of these elements by hen excreta into soil. The Zn supplied by hen excreta was more stable than Fe and Cu; thus Zn could accumulate in the soil.

Anemia, iron deficiency, and iron deficiency anemia in 12-36-mo-old children from low-income families

BACKGROUND

Iron deficiency (ID) is the most common nutritional deficiency in the world and remains relatively common in at-risk groups in the United States. The actual prevalence of anemia, ID, and iron deficiency anemia (IDA) in California remains unclear.

OBJECTIVE

The objective was to determine the prevalence of anemia, low iron stores, ID, and IDA in children participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) population, and to assess the value of using hemoglobin to predict ID.

DESIGN

This was a cross-sectional study of a convenience sample of 12-36-mo-old children from WIC clinics in 2 California counties.

RESULTS

The prevalence of anemia was 11.1% (hemoglobin <110 g/L at 12-24 mo or <111 g/L at 24-36 mo). Study- and literature-determined abnormal values for iron measures were as follows: serum ferritin <or=8.7 or <10.0 microg/L, serum transferrin receptor >or=8.4 or >10.0 microg/mL, and transferrin saturation <or=13.2% or <10.0%, respectively. The prevalences of low iron stores (low ferritin) were 24.8% and 29.0%, of ID (>or=2 abnormal iron measures) were 16.2% and 8.8%, and of IDA (ID with low hemoglobin) were 3.4% and 3.2% on the basis of study- and literature-determined cutoffs, respectively. Hemoglobin concentration was used to predict study- and literature-determined ID on the basis of receiver operating characteristic curves. The sensitivity of low hemoglobin in predicting study- and literature-determined ID was low (23.2% and 40.0%, respectively).

CONCLUSIONS

Anemia and ID were prevalent in this WIC sample, but IDA was uncommon. Low hemoglobin is a poor predictor of ID.

Injection drug use is an independent risk factor for iron deficiency and iron deficiency anemia among HIV-seropositive and HIV-seronegative women

The risk factors for iron deficiency and iron deficiency anemia among female injection drug users are not well characterized. We measured hemoglobin and plasma ferritin and obtained demographic information and injection drug use history in the last 6 months in a cross-sectional study of 200 female injection drug users (134 HIV-positive and 66 HIV-negative). The women were participants in a natural history study, the AIDS Linked to Intravenous Experiences study in Baltimore, Maryland. In multivariate analyses adjusting for age, hepatitis C virus status, and HIV status, injection drug use within the last 6 months was associated with iron deficiency (odds ratio [OR] = 2.61, 95% confidence interval [CI]: 1.33 to 5.09) and iron deficiency anemia (OR = 6.65, 95% CI: 2.33 to 18.9). Among 134 HIV-positive women, injection drug use in the last 6 months was associated with iron deficiency (OR = 2.43, 95% CI: 1.08 to 5.48) and iron deficiency anemia (OR = 6.05, 95% CI: 1.82 to 20.1) in multivariate analyses adjusting for hepatitis C virus status and CD4 lymphocyte count. Injection drug use seems to be associated with iron deficiency and iron deficiency anemia. Further longitudinal studies are needed to gain insight into the nature of this association.

Risk factors for gastrointestinal malignancy in patients with iron-deficiency anaemia

OBJECTIVES

Iron-deficiency anaemia (IDA) is common and may be caused by blood loss from gastrointestinal tumours. The aim of this study was to define risk factors for gastrointestinal malignancy in patients with IDA.

METHODS

Patients with suspected IDA referred for gastrointestinal investigations were prospectively identified from two neighbouring UK hospitals (serving a population of 550,000 patients) between 1 January 1998 and 31 December 1999. Final diagnoses were determined after 2 years, and those patients with and without gastrointestinal cancer as a cause for their IDA were compared. Data collected included sex, age, haemoglobin, serum ferritin, mean cell volume and drug history.

RESULTS

A total of 695 patients (236 men, mean age 68.5 years; 459 women, mean age 66.2 years) with IDA were investigated. Malignancy was diagnosed in 91/695 (13.1%) and gastrointestinal malignancy in 78/91 (11.2%). The most frequently diagnosed cancers were colonic (n = 44, 6.3%), gastric (n = 25, 3.6%) and renal tract (n = 7, 1%). The adjusted odds ratio (+/-95% confidence interval) for gastrointestinal cancer as a cause of IDA was significantly higher for male sex [2.96 (1.80, 4.87)], age over 50 years [7.04 (1.69, 29.32)] and haemoglobin level at presentation (< or =9.0 g/dl) [2.25 (1.29, 3.90)]. There was no significant difference in gastrointestinal malignancy in those taking aspirin (12/111, 10.8%), non-aspirin non-steroidal anti-inflammatory drugs (5/84, 6.0%) or warfarin (4/31, 12.9%) compared with those not taking these drugs (57/470, 12.1%). No cause for IDA was found in 53.7%.

CONCLUSIONS

Cancer was diagnosed in 13.1% and gastrointestinal cancer in 11.2% of patients with IDA. Significant risk factors for gastrointestinal malignancy in IDA patients are male sex, age over 50 years and haemoglobin at presentation < or =9.0 g/dl. IDA should not be attributed to aspirin, non-steroidal anti-inflammatory drugs or warfarin use.

Guidelines on anaemia: effect on primary-care midwives in The Netherlands

OBJECTIVE

To assess the adherence and perceived barriers for implementation of a clinical-practice guideline on anaemia, which was the first national guideline for primary-care midwifery in The Netherlands.

DESIGN

Cross-sectional survey study.

SETTING

Primary-care midwifery in The Netherlands.

PARTICIPANTS

160 midwives (60% response rate).

MEASUREMENTS

Questionnaire on the knowledge of, and attitudes and self-reported adherence to, 14 key recommendations in the guideline; attitudes to guidelines in general; and perceived barriers to implementation.

FINDINGS

The number of midwives agreeing with and adhering to specific recommendations varied between 29 and 90%. Most midwives had a positive attitude to the guidelines. The most relevant general barriers were related to the behaviour of general practitioners and obstetricians (32% of the midwives reported this). Larger numbers of midwives mentioned barriers to specific aspects of the guideline, particularly alternative iron supplementation or dietary supplements (59%), and not prescribing iron supplementation if haemoglobin was low but mean corpuscular volume was normal (49%).

KEY CONCLUSIONS

The guideline on anaemia was well received by primary-care midwives in The Netherlands, but implementation of specific recommendations needs further attention.

IMPLICATIONS FOR PRACTICE

The study provides evidence for the national organisation of midwives to continue with the development and implementation of clinical guidelines.

Milk versus medicine for the treatment of iron deficiency anaemia in hospitalised infants

AIMS

To compare iron fortified follow-on milk (iron follow-on), iron fortified partially modified cows' milk (iron milk), and iron medicine for the treatment of iron deficiency anaemia (IDA) in hospitalised infants.

METHODS

In a randomised controlled trial, infants aged 9-23 months with IDA and who were hospitalised with an acute illness received iron follow-on (12 mg/l ferrous iron), iron milk (12.9 mg/l ferrous iron), or iron medicine (ferrous gluconate at 3 mg/kg of elemental iron once daily). All interventions were given for three months. Changes in measures of iron status three months after hospital discharge were determined.

RESULTS

A total of 234 infants were randomised. Iron status was measured at follow up in 59 (70%) iron medicine, 49 (66%) iron follow-on, and 54 (70%) iron milk treated infants. There was a significant (mean, 95% CI) increase in haemoglobin (15 g/l, 13 to 16) and iron saturation (9%, 8 to 10) and decrease in ferritin (-53 microg/l, -74 to -31) in all three groups. Mean cell volume increased in iron follow-on (2 fl, 1 to 3) and iron milk (1 fl, 0.1 to 3) treated infants, but not in the iron medicine group (1 fl, -1 to 2). The proportion with IDA decreased in all three groups: iron medicine 93% to 7%, iron follow-on 83% to 8%, and iron milk 96% to 30%. Adverse effects, primarily gastrointestinal, occurred in 23% of the iron medicine, 14% of the iron follow-on, and 13% of the iron milk group.

CONCLUSIONS

Iron fortified follow-on milk, iron fortified partially modified cows' milk, and iron medicine all effectively treat IDA in infancy.

Iron status in 6-y-old children: associations with growth and earlier iron status

OBJECTIVE

To investigate the iron status of 6-y-old children and its association with growth and earlier iron status.

DESIGN

In a cross-sectional study, children's body size measurements were recorded and blood samples taken near their sixth birthday.

SUBJECTS

A sample of 188 children, randomly selected in two previous studies, was contacted, and 139(74%) agreed to participate.

RESULTS

No children had iron deficiency anaemia, one was iron-deficient (serum ferritin (SF) <15 microg/l and mean corpuscular volume (MCV) <76 fl but 16% had depleted iron stores (SF<15 microg/l). Iron status indices were generally higher than at 1 and 2 y, but correlation was seen between iron status indices at 6 y and earlier values. Haemoglobin concentration at 6 y was negatively associated with length gain from birth to 1 y (B+/-s.e.=-1.269+/-0.452; P=0.007; adj. R2=0.119) (n=52), and proportional weight gain from birth to 1 y was higher among children with SF<15 microg/l at 6 y (295+/-33%; n=10) than those with SF> or =15 microg/l (258+/-31%; n=49) (P=0.001). MCV at 2 y predicted weight gain from 2 to 6 y (B+/-s.e.=1.721+/-0.581; P=0.005; adj. R2=0.153) (n=44); also, children with SF<15 microg/l at 6 y (n=9) gained 7.8+/-1.2 kg from 2 to 6 y, while children with SF> or =15 microg/l (n=35) gained 9.6+/-2.8 kg (P=0.007), furthermore a difference was seen in proportional weight gain from 2 to 6 y between children with depleted iron stores at 2 y and not, or 156+/-13 vs 169+/-18% (P=0.038).

CONCLUSION

The results suggest that low iron status at 1 and 2 y might lead to slower growth up to 6 y of age. Low iron status at 1 and 2 y and/or slower growth from 1 and 2 y up to 6 y might contribute to worse iron status at 6 y, while faster growth in early childhood is related to lower iron status.

Nutritional risk factors for iron-deficiency anaemia in children 12-24 months old in the area of Thessalia in Greece

Iron-deficiency anaemia (IDA) is a common problem all over the world, which mainly attacks pregnant women, infants and children. The main objectives were to assess the prevalence of IDA in children 12-24 months old in the area of Thessalia located in the central part of Greece and to identify, by means of a simple questionnaire, its nutritional risk factors. The research was applied as a cross-sectional and case-control study. In the first part of the study, the haemoglobin (Hb) levels were estimated by a mobile photometer analyser in 938 children (approximately one-third of the total children population). In the second part, children with Hb?<?11 g/dl were compared with their random selected healthy controls in haematological, anthropometric and nutritional parameters. The estimated laboratory values were Hb, haematocrit, mean corpuscular volume, mean corpuscular Hb, mean corpuscular Hb concentration, zinc protoporphyrin, serum iron, serum ferritin, transferring saturation, total iron binding capacity and Hb electrophoresis. Finally, 75 children (34 boys, 41 girls; mean age 17.51+/-3.5 months), who were found to have IDA, constituted the case group while 75 healthy children constituted the control group. The studied nutritional variables through the application of a standardized food frequency questionnaire were: duration of breast feeding, milk that the child drinks during the research, age of solid food introduction, child's health status according to the mother's point of view, child's appetite and frequency of bread, cereals, meat, fish, egg, legumes, chocolate, marmalade, vegetables, fruit and tea intake. The prevalence of IDA in the region was 7.99%. The carriers of b-thalassaemia (2.13%) were excluded from the study. Significant statistical difference has been observed between the two groups (P?<?0.001) in all haematological and anthropometric parameters except head circumference (P?=?0.85). Concerning the nutritional indices the two groups were statistically different (P?<?0.001) in the following: the cases were breastfed less, were drinking fresh cow's milk and tea, were eating meat, vegetables and fruit less often, had a bad appetite and were more likely to get sick. In conclusion, the prevalence of IDA in this area of Greece is approximately similar to other areas in the developed world. The application of simple food frequency questionnaires for the detection of the nutritional IDA risk factors could prognose and prevent anaemia.

The 2005 Dietary Guidelines Advisory Committee: Developing a Key Message

The 2005 Dietary Guidelines Advisory Committee used an evidence-based approach to evaluate the science base for the relationships of diet and physical activity and health. Nine key messages and corresponding conclusions were included in the 2005 Dietary Guidelines Advisory Committee report. This article describes the development process, scientific basis, and specific recommendations for one of the key messages.

Prevalence of iron deficiency with and without anemia in recreationally active men and women

The objective of this study was to determine the prevalence of iron deficiency with and without anemia in a convenience sample of trained male and female adults. One hundred twenty-one adults (72 female, 49 male) involved in aerobic training (11.2+/-6.3 hr/wk for >/=6 consecutive months), ages 18 to 41 years old, participated in an iron status screening. The concentrations of hemoglobin (Hb), ferritin, and transferrin receptor were measured in serum to determine the prevalence of iron deficiency with and without anemia. Eight individuals (seven female, one male) had iron deficiency with anemia (serum ferritin <16 microg/L; Hb<120 g/L female, <136 g/L male). Iron deficiency without anemia (serum ferritin </=16 microg/L) was found in 29% of female and 4% of male subjects. Determination of iron deficiency without anemia using the transferrin receptor-ferritin index (serum transferrin receptor:log serum ferritin>/=4.5) found 36% of female and 6% of male subjects to be iron deficient without anemia. Recreational athletes should be screened for iron deficiency without anemia using serum ferritin, serum transferrin receptor, and Hb.

Dietary fat intake is associated with psychosocial and cognitive functioning of school-aged children in the United States

Using cross-sectional data from the Third National Health and Nutrition Survey, 1988-1994, we examined whether dietary fat intake is associated with cognitive and psychosocial functioning in school-aged children. Based upon 24-h diet recall interviews, dietary intakes of total fat, SFA, monounsaturated fatty, PUFAs, and cholesterol were estimated in 3666 participants aged 6 to 16 y. Psychosocial functioning was evaluated in interviews of each child's mother. Cognitive functioning was measured using achievement and intelligence tests. Overall, total fat and saturated fat were unrelated to measures of cognitive and psychosocial functioning. Compared with equivalent energy intake from saturated fat or carbohydrate, each 5% increase in energy intake from PUFAs was associated with lower risks of poor performance on the digit span test (replacing SFA, OR = 0.58, 95% CI = 0.37-0.91; replacing carbohydrate, OR = 0.61, 95% CI = 0.43-0.88). Cholesterol intake was associated with an increased risk of poor performance on the digit span test (OR = 1.25, 95% CI = 1.11-1.42 for each 100-mg increment intake of cholesterol). The associations were independent of socioeconomic status, maternal education and marital status, and children's nutrition status and were consistent across different methods of energy adjustment in regression models. We conclude that high intake of PUFAs may contribute to an improved performance on the digit span test. In contrast, increased intake of cholesterol may be associated with a poorer performance.

Nutrition and student performance at school

This article reviews research from published studies on the association between nutrition among school-aged children and their performance in school and on tests of cognitive functioning. Each reviewed article is accompanied by a brief description of its research methodology and outcomes. Articles are separated into 4 categories: food insufficiency, iron deficiency and supplementation, deficiency and supplementation of micronutrients, and the importance of breakfast. Research shows that children with iron deficiencies sufficient to cause anemia are at a disadvantage academically. Their cognitive performance seems to improve with iron therapy. A similar association and improvement with therapy is not found with either zinc or iodine deficiency, according to the reviewed articles. There is no evidence that population-wide vitamin and mineral supplementation will lead to improved academic performance. Food insufficiency is a serious problem affecting children's ability to learn, but its relevance to US populations needs to be better understood. Research indicates that school breakfast programs seem to improve attendance rates and decrease tardiness. Among severely undernourished populations, school breakfast programs seem to improve academic performance and cognitive functioning.

Hemoglobin and ferritin are currently the most efficient indicators of population response to iron interventions: an analysis of nine randomized controlled trials

Governments and donor agencies have implemented pilot and large-scale iron fortification programs, but there has been no consensus on the best choice of indicators to monitor population response to these interventions. We analyzed data from 9 randomized iron intervention trials to determine which of the following indicator(s) of iron status show the largest response in a population: hemoglobin (Hb), ferritin, transferrin receptor (TfR), zinc protoporphyrin (ZPP), mean cell volume (MCV), transferrin saturation (TS), and total body-iron store. We expressed the change in each indicator in response to the iron intervention in SD units (SDU) for the intervention group compared with the control group. Ferritin increased by > or =0.2 SDU in all trials and was significant in 7. Hb changed by > or =0.2 SDU in 6 and was significant in 5. TfR increased by > or =0.2 SDU in 5 of 8 interventions in which it was measured and was significant in 4. ZPP increased by > or =0.2 SDU and was significant in 3 of 6 interventions. Excluding Hb, the indicator with the largest change in SDU was ferritin in 4 trials, TS in 2 trials, body-iron store in 2 trials, and TfR in 1. In the 2 cases in which body-iron stores showed the largest change, the change in ferritin was nearly as large. Our results suggest that with currently available technologies, ferritin shows larger and more consistent response to iron interventions than ZPP or TfR. We cannot make confident inference about MCV or TS, which were included in only 4 and 2 trials, respectively. It is possible that the optimal indicator(s) may differ with age, sex, and pregnancy. There were too few trials in each age and sex group to allow us to explore this question.