Copper, iron, and zinc status in children with moderate and severe acute malnutrition recovered following WHO protocols

Micronutrient status in children aged 6-59 months with severe wasting and/or nutritional edema: implications for nutritional rehabilitation formulations

Undernutrition remains a global struggle and is associated with almost 45% of deaths in children younger than 5 years. Despite advances in management of severe wasting (though less so for nutritional edema), full and sustained recovery remains elusive. Children with severe wasting and/or nutritional edema (also commonly referred to as severe acute malnutrition and part of the umbrella term "severe malnutrition") continue to have a high mortality rate. This suggests a likely multifactorial etiology that may include micronutrient deficiency. Micronutrients are currently provided in therapeutic foods at levels based on expert opinion, with few supportive studies of high quality having been conducted. This narrative review looks at the knowledge base on micronutrient deficiencies in children aged 6-59 months who have severe wasting and/or nutritional edema, in addition to highlighting areas where further research is warranted (See "Future Directions" section).

Increased vs. Standard Dose of Iron in Ready-to-Use Therapeutic Foods for the Treatment of Severe Acute Malnutrition in a Community Setting: A Systematic Review and Meta-Analysis

The optimal dose of iron in ready-to-use therapeutic foods (RUTF) used to treat uncomplicated severe acute malnutrition (SAM) in community settings is not well established. The objective of this systematic review was to assess if an increased iron dose in RUTF, compared with the standard iron dose in the World Health Organization (WHO)-recommended peanut-based RUTF, improved outcomes in children aged six months or older. We searched multiple electronic databases and only included randomized controlled trials. We pooled the data in a meta-analysis to obtain relative risk (RR) and reported it with a 95% confidence interval (CI). Three studies, one each from Zambia, the Democratic Republic of Congo, and Malawi, were included. In all studies, the RUTF used in the intervention group was milk-free soya–maize–sorghum-based RUTF. The pooled results showed that, compared to the control group, a high iron content in RUTF may lead to increase in hemoglobin concentration (mean difference 0.33 g/dL, 95% CI: 0.02, 0.64, two studies, certainty of evidence: low) and a decrease in any anemia (RR 0.66, 95% CI: 0.48, 0.91, two studies, certainty of evidence: low), but also decrease recovery rates (RR 0.91, 95% CI: 0.84, 0.99, three studies, certainty of evidence: low) and increase mortality (RR 1.30, 95% CI: 0.87, 1.95, three studies, certainty of evidence: moderate). However, the CIs were imprecise for the latter outcome. Future studies with large sample sizes are needed to confirm the beneficial versus harmful effects of high iron content in RUTF in treating uncomplicated SAM in children aged 6-59 months in community settings.

Optimal iron content in ready-to-use therapeutic foods for the treatment of severe acute malnutrition in the community settings: a protocol for the systematic review and meta-analysis

INTRODUCTION

The current standard of care for children with severe acute malnutrition (SAM) involves using ready-to-use therapeutic food (RUTF) to promote growth; however, the precise formulation to achieve optimal recovery remains unclear. Emerging research suggests that alternative RUTF formulations may be more effective in correcting SAM-related complications such as anaemia and iron deficiency. This systematic review commissioned by the WHO aims to synthesise the most recent research on the iron content in RUTF and related products in the community-based treatment of uncomplicated severe malnutrition in children aged 6 months and older.

METHODS AND ANALYSIS

We will search multiple electronic databases. We will include randomised controlled trials and non-randomised studies with a control arm. The intervention group will be infants who received RUTF treatments other than the current recommended guidelines set forth by the WHO. The comparison group is children receiving RUTF containing iron at the current WHO-recommended level of 1.9 mg/100 kcal (10-14 mg/100 g). The primary outcomes of interest include blood haemoglobin concentration, any anaemia, severe anaemia, iron-deficiency anaemia, recovery from SAM and any adverse outcomes. We will use meta-analysis to pool findings if sufficient homogeneity exists among included studies. The risk of bias in studies will be evaluated using the Cochrane risk of bias-2. We will use the Grading of Recommendations Assessment, Development, and Evaluation(GRADE) approach to examine the overall certainty of evidence.

ETHICS AND DISSEMINATION

This is a systematic review and will not involve direct contact with human subjects. The findings of this review will be published in a peer-reviewed journal and will guide the WHO's recommendation on the optimal iron content in RUTFs for the treatment of SAM in children aged 6-59 months.

Soya, maize and sorghum ready-to-use therapeutic foods are more effective in correcting anaemia and iron deficiency than the standard ready-to-use therapeutic food: randomized controlled trial

BACKGROUND

The prevalence of anaemia and iron deficiency (ID) among children with severe acute malnutrition (SAM) and their correction during nutritional rehabilitation are not well documented. This study assessed anaemia and ID prevalence and their predictors at start of SAM treatment, and the efficacy of their treatment and effect on gut health of two novel Ready-To-Use Therapeutic foods (RUTF) prepared from soybean, maize and sorghum (SMS) with (MSMS-RUTF) or without added milk (FSMS-RUTF) compared to those of the standard formulation prepared from peanut and milk (PM-RUTF).

METHODS

This was a 3-arms parallel groups, simple randomised, controlled non-inferiority trial in 6-59 months old Central Malawian children with SAM. Anaemia was defined using altitude- and ethnicity-adjusted haemoglobin. Iron status was defined using soluble transferrin receptor (sTfR) and body iron stores (BIS). We used Pearson's chi-square test, t-test for paired or unpaired data, Kruskal-Wallis test for between-arm differences as appropriate and logistic regression to identify independent predictors of anaemia or iron deficiency anaemia (IDA).

RESULTS

The sample size was 389. At admission, the prevalence [%(95%CI)] of anaemia was 48.9(41.4-56.5)% while that of ID and IDA were 55.7(48.6-62.5)% and 34.3(28.2-41.0)% when using sTfR criterion and 29.1(24.4-34.4)% and 28.9(23.7-34.9)% when using BIS criterion, respectively. At discharge, nutrition rehabilitation with SMS-RUTF was associated with the lowest prevalence of anaemia [12.0(6.9-20.3)% for FSMS-RUTF, 18.2(11.9-26.8)% for MSMS-RUTF and 24.5(15.8-35.9)% for PM-RUTF; p = 0.023] and IDA [7.9(3.4-17.3)% for FSMS-RUTF, 10.9(4.8-22.6)% for MSMS-RUTF and 20.5(10.7-35.5)% for PM-RUTF; p = 0.028]. SMS-RUTF was also associated with the highest increase in BIS [Change in BIS (95%CI)] among the iron deplete at admission [6.2 (3.7; 8.6), 3.2 (0.8; 5.6), 2.2 (0.2; 4.3) for the same study arms; Anova p = 0.045]. Compared to P-RUTF, FSMS-RUTF had the highest adjusted recovery rate [OR (95%CI = 0.3 (0.2-0.5) with p < 0.001 for FSMS-RUTF and 0.6 (0.3-1.0) with p = 0.068 for MSMS-RUTF]. No effect of iron content on risk of iron overload or gut inflammation was observed.

CONCLUSIONS

Anaemia and ID are common among children with SAM. FSMS-RUTF is more efficacious in treating anaemia and correcting BIS among this group than PM-RUTF.

TRIAL REGISTRATION

This study was registered on 15 April 2015 ( PACTR201505001101224 ).

Copper and zinc levels in soil, water, wheat, and hair of inhabitants of three areas of the Orenburg region, Russia

The objective of the present study was to assess the level of zinc and copper in soil, water, wheat and hair of inhabitants of the western, central, and eastern areas of the Orenburg region. A total of 525 water, soil, and wheat samples, as well as 420 hair samples were assessed using atomic absorption spectrometry (water, soil, wheat) and inductively-coupled plasma mass spectrometry (hair). The highest levels of Zn and Cu in water (4.9(4.2-5.1) and 1.0(0.9-1.1) mg/l), soil (23.8(20.7-27.0) and 2.6(1.9-3.1) mg/kg), and wheat (24.7(20.5-31.0) and 4.8(4.2-5.5) mg/kg) were observed in the eastern area (p < 0.001). Hair zinc levels in inhabitants of the western (184(165-198) µg/g) and eastern (224(211-253) µg/g) areas of the region exceeded the respective values from the central area by 32% and 61% (p < 0.001). In turn, hair Cu levels in the central (16.4(14.3-17.8) µg/g) and eastern (17.9(16.4-19.0) µg/g) areas exceeded the values from the western area by 10% and 20%, respectively. Correlation analysis demonstrated that hair Zn levels were positively correlated with water and soil content, whereas wheat Zn levels were associated with soil and water content. For copper significant direct correlation was observed only between soil and water Cu content. In multiple regression models, only water zinc level was significantly associated with hair Zn content, although the general model accounted for 55% of variability of hair Zn content. Higher zinc and copper exposure in the eastern area is presumably associated with higher activity of metal-processing industry.

Assessing chaperone for Zn, Cu-superoxide dismutase as an indicator of copper deficiency in malnourished children

It is not clear how frequent is copper deficiency in humans. Current copper markers are not sensitive enough to detect early copper deficiency and new markers are needed. CCS is a candidate to become a copper biomarker.

OBJECTIVE

Measuring CCS mRNA relative expression in malnourished children and compare results (a) with those of the same children after nutritional recovery and (b) with well-nourished children.

METHOD

On admission to the protocol and after 15 day nutritional treatment, severely (G1=18) and moderately (G2=10) malnourished children were compared with well-nourished healthy controls (G3=15), measuring anthropometric indicators, blood biochemistry, Cu, Fe and Zn serum concentrations, ceruloplasmin, C Reactive protein and mRNA abundance of CCS, SOD and MT2 in peripheral mononuclear cells.

RESULT

In malnourished groups, mean serum copper concentration was below the cut-off on admission to hospital and increased after 15 days (t-test, p<0.01). On admission to protocol, CCS mRNA abundance in G1 and G2 was higher than in G3 (one way ANOVA, p<0.001). After 15 days, CCS expression decreased as expected (t-test, p<0.001). Initial SOD mRNA relative abundance was higher in study groups than controls and also between G1 and G2 (One way ANOVA, both p<0.01); after 15 days, G1 and G2 were not different (t-test, NS). MT2A abundance of transcripts did not follow a clear change pattern.

CONCLUSION

CCS mRNA abundance responded as expected, being higher in malnourished children than in controls; nutritional recovery in these latter resulted in decreasing expression of the chaperone, supporting the hypothesis that CCS may be a copper biomarker.

Copper supplementation at 8 mg neither affects circulating lipids nor liver function in apparently healthy Chilean men

Copper (Cu) deficiency has been reported to influence lipid metabolism, but the effects in humans are controversial. To evaluate the effects of 8 mg Cu/day supplementation (as copper sulfate) for 6 months on the lipid profile and hepatic function of apparently healthy men. The design was randomized double-blind placebo-controlled clinical trial.

SUBJECTS AND METHODS

60 apparently healthy males aged 18-51 years were randomly assigned to Cu supplementation (n = 30) or placebo (n = 30). There was a nonsignificant reduction of 17 % in total cholesterol in both groups after supplementation. A 23 % nonsignificant reduction was observed in LDL cholesterol levels in the supplemented group. There was a nonsignificant increase of HDL cholesterol of 47 and 66 % in the control and supplemented groups, respectively. Triglyceride levels over 150 mg/dl were found in 17 subjects supplemented and 13 controls at baseline and decreased after supplementation to seven and eight subjects, respectively. There were no effects on serum Cu concentration or ceruloplasmin (protein) and hepatic transaminases. Supplementation of 8 mg Cu for 6 months had no effect on lipid profile of apparently healthy Chilean men with adequate Cu status.

A study of oxidative stress biomarkers and effect of oral antioxidant supplementation in severe acute malnutrition

BACKGROUND

Malnutrition represents one of the most severe health problems in India. Free radicals play an important role in immunological response, which induces the oxidative surplus in severe acute malnutrition. Severe dietary deficiency of nutrients leads to increased oxidative stress in cellular compartments.

AIM

The goal of this study was to inspect impact of oxidative stress in the form of serum malondialdehyde as product of lipid peroxidation, vitamin E, zinc and erythrocyte superoxide dismutase in patients with severe acute malnutrition.

MATERIAL AND METHODS

Sixty severe acute malnutrition patients were studied before and after supplementation of antioxidants for one month, and their status were compared with those of 60 age and sex matched healthy controls. The level of serum MDA was analyzed by the Kei Satoh method, serum vitamin E concentration was measured by Baker and Frank Method, serum zinc was measured by using Atomic Absorption Spectrophotometer (AAS) and erythrocyte superoxide dismutase was measured by Kajari Das Method.

RESULTS

Significantly increased levels of serum malondialdehyde (p<0.001) were found in the patients as compared to those in controls, and significant depletions were found in the levels of serum vitamin E, zinc and erythrocyte superoxide dismutase in patients with severe acute malnutrition as compared to those in controls. After supplementation of antioxidants for one month, the levels of malondialdehyde were found to be decreased significantly (p<0.001) and zinc and erythrocyte superoxide dismutase capacity levels were increased significantly (p<0.05). Also, there was a non-significant (p>0.05) increase in vitamin E levels as compared to those before supplementation results.

CONCLUSION

Harsh deficiency of various nutrients in severe acute malnutrition leads to generation of heavy oxidative stress. These effects may be minimized with supplementation of antioxidants.

Severe acute malnutrition in very low birth weight preterm infants

Malnutrition in preterm low birth weight infants has adverse long-term metabolic, growth, and neurodevelopmental effects. In the past 3 decades, parenteral nutrition, enriched preterm formula, and fortification of human milk have been used to alleviate these adverse effects. Unfortified human breast milk does not provide sufficient nutrients for the growth and development of preterm infants at the volumes recommended; however, it is usually the only source of nutrition available for such infants in low-resource countries. Many newborns, including very low birth weight infants, are surviving in these countries because of concerted efforts to achieve the fourth millennium development goal. These efforts have not addressed the nutrition needs of sick preterm very low birth weight infants. The authors report 3 cases of severe acute malnutrition in very low birth weight newborns and suggest possible interventions.

Searching for specific responses to copper exposure: an in vitro copper challenge in peripheral mononuclear cells

Acute and chronic cellular responses to changes in copper availability are not clear when these changes are mild to moderate, as what often occur in human daily life. The aims of the study were to develop an in vitro copper challenge in peripheral mononuclear cells (PMNCs) obtained from healthy individuals with different preconditioning copper treatments, and measure copper and iron content, and MT2A and TfR mRNA abundance after the copper challenge. (1) Screening using clinical and biochemical indicators defined healthy participants, who received 8 mg Cu/day (copper sulfate) or placebo for 2 months. (2) Mononuclear cells were obtained on days 0, 2 (acute changes), and 60 (chronic changes). (3) Cells were challenged with a 1, 5, and 20 μM Cu-histidine for 20 h, at T0, T2, and T60. Cells from both supplemented and placebo individuals showed a clear trend to increase copper content when there was more copper in the media. Increases were greater in the supplemented group, larger with 20 μM Cu (p < 0.02, one-way ANOVA), and mostly not significant when incubated with 5 μM Cu. By two-way ANOVA, differences were significant by treatment and by time (both p < 0.001). Differences between T0/T2 and T0/T60 were also significant (both p < 0.001). Changes of iron content were significant by treatment and time (two-way ANOVA); mRNA relative abundance of MT2A changed significantly and paralleled those of copper concentration, but TfR transcripts did not change. An in vitro challenge of PMNC showed specific changes of cellular copper and MT2A, while changes of iron content and TfR mRNA abundance were not consistent. PMNCs appear as good candidates to assess changes of cellular copper availability. That results differed after acute (T2) and chronic (T60) supplementation suggests that acute and chronic changes are handled differently by these cells.

Risks and benefits of copper in light of new insights of copper homeostasis

Copper is an essential micronutrient involved in a variety of biological processes indispensable to sustain life. At the same time, it can be toxic when present in excess, the most noticeable chronic effect being liver damage. Potent, efficient regulatory mechanisms control copper absorption in the digestive tract and copper biliary excretion; absorption ranges between 12 and 60% in humans, depending on Cu intake, presence of other factors in the diet that may promote or inhibit its absorption and on the copper status of the individual. Current evidence suggests that copper deficiency may be more prevalent than previously thought, while copper toxicity is uncommon under customary daily life conditions. Menkes syndrome and Wilson disease are genetic conditions associated with severe copper deficiency and severe copper toxicity, respectively. Effects of milder degrees of copper deficiency and excess copper exposure are not well described, mainly due to lack of sensitive and specific indicators; serum copper concentration and ceruloplasmin are the most frequently used indicators, but they only detect rather intense changes of copper status. Of the many proteins assessed as potential markers of copper status the chaperone of Zn-Cu superoxide dismutase (CCS1) has yielded promising results; data on its performance under different conditions are needed to confirm its use as an indicator of early copper deficiency. Defining copper requirements and upper safe limits of consumption (UL) is a complex process since there are adverse health consequences from both copper deficiency and copper excess (U shape curve). The regulatory framework for risk assessment of essential trace elements introduced by the International Programme on Chemical Safety (IPCS) has proposed a homeostatic model to determine the Adequate Range of Oral Intake (AROI) of essential trace elements; the nadir of the resulting U shape curve serves to define the AROI. At this range of intake physiological mechanisms allow for normal homeostasis and basically, there are no detectable adverse effects. At present, Recommended Dietary Intakes (DRIs) and Adequate Intakes (AIs) are used to recommend copper intakes at different ages and life situations. Evidence obtained in humans and non-human primates presented here suggest that current copper UL should be re evaluated. Developing the scientific basis for a copper UL and evaluating the relevance of copper deficiency globally are future key challenges for copper researchers.

Efeitos da deficiência de cobre, zinco e magnésio sobre o sistema imune de crianças com desnutrição grave

OBJETIVO: Esclarecer as repercussões da deficiência de cobre, zinco e magnésio sobre o sistema imune de crianças desnutridas graves. FONTES DE DADOS: Foi realizada revisão bibliográfica mediante consulta às bases de dados Pubmed Medline, Lilacs e SciELO, selecionando-se publicações científicas recentes, da última década, e representativas do tema por meio dos descritores: desnutrição infantil, cobre, zinco, magnésio e sistema imune. SÍNTESE DE DADOS: Os micronutrientes são compostos orgânicos essenciais. Além de sua função regulatória, atuam de maneira decisiva na modulação da resposta imune. Sua deficiência pode ocorrer devido à ingestão inadequada ou associada a doenças específicas. Quando associada à desnutrição, a multideficiência de minerais pode acarretar disfunções imunológicas e aumento na suscetibilidade a infecções, afetando gravemente a eficácia de intervenções terapêuticas. Cobre, zinco e magnésio atuam como cofatores de enzimas responsáveis tanto por diversas atividades metabólicas como na resposta imune inata e adquirida, além do papel importante na maturação dos tecidos e células linfoides. Sua deficiência acarreta neutropenia e linfopenia, comprometendo a imunocompetência. CONCLUSÕES: As alterações ocasionadas pelos déficits séricos dos minerais cobre, zinco e magnésio comprometem o funcionamento do sistema imune, levando à imunossupressão. A reposição desses elementos no manejo da desnutrição grave, como preconizada pela Organização Mundial da Saúde, é essencial, uma vez que tais alterações podem ser reversíveis.