Characterisation of anaemia and associated factors among infants and pre-schoolers from rural India

Predictors of anaemia in mothers and children in Uttar Pradesh, India

OBJECTIVE

Anaemia affects more than half of Indian women and children, but the contribution of its causes remains unquantified. We examined interrelationships between Hb and nutritional, environmental, infectious and genetic determinants of anaemia in non-pregnant mothers and children in Uttar Pradesh (UP).

DESIGN

We conducted a cross-sectional survey of households in twenty-five districts of UP between October and December 2016. We collected socio-demographic data, anthropometry and venous blood in 1238 non-pregnant mothers and their children. We analysed venous blood samples for malaria, Hb, ferritin, retinol, folate, Zn, vitamin B12, C-reactive protein, α1-acid glycoprotein (AGP) and β-thalassaemia. We used path analysis to examine pathways through which predictors of anaemia were associated with Hb concentration.

SETTING

Rural and urban households in twenty-five districts of UP.

PARTICIPANTS

Mothers 18-49 years and children 6-59 months in UP.

RESULTS

A total of 36·4 % of mothers and 56·0 % of children were anaemic, and 26·7 % of women and 44·6 % of children had Fe deficiency anaemia. Ferritin was the strongest predictor of Hb (β (95 % CI) = 1·03 (0·80, 1·27) g/dL in women and 0·90 (0·68, 1·12) g/dL in children). In children only, red blood cell folate and AGP were negatively associated with Hb and retinol was positively associated with Hb.

CONCLUSIONS

Over 70 % of mothers and children with anaemia had Fe deficiency, needing urgent attention. However, several simultaneous predictors of Hb exist, including nutrient deficiencies and inflammation. The potential of Fe interventions to address anaemia may be constrained unless coexisting determinants are jointly addressed.

Iron Deficiency Anemia: Efficacy and Limitations of Nutritional and Comprehensive Mitigation Strategies

Iron deficiency anemia (IDA) has reached epidemic proportions in developing countries and has become a major global public health problem, affecting mainly 0–5-year-old children and young women of childbearing age, especially during pregnancy. Iron deficiency can lead to life-threatening loss of red blood cells, muscle function, and energy production. Therefore, the pathogenic features associated with IDA are weakness and impaired growth, motor, and cognitive performance. IDA affects the well-being of the young generation and the economic advancement of developing countries, such as India. The imbalance between iron intake/absorption/storage and iron utilization/loss culminates into IDA. However, numerous strategic programs aimed to increase iron intake have shown that improvement of iron intake alone has not been sufficient to mitigate IDA. Emerging critical risk factors for IDA include a composition of cultural diets, infections, genetics, inflammatory conditions, metabolic diseases, dysbiosis, and socioeconomic parameters. In this review, we discuss numerous IDA mitigation programs in India and their limitations. The new multifactorial mechanism of IDA pathogenesis opens perspectives for the improvement of mitigation programs and relief of IDA in India and worldwide.

Expression of iron transport protein Divalent metal transporter 1 (DMT1) increases in response to maternal iron deficiency anemia in near term to term placenta

INTRODUCTION

Iron deficiency anemia (IDA) is the most prevalent nutritional deficiency disorder in pregnant women. During pregnancy, placental transport protein Divalent metal transporter1 (DMT1) plays a crucial role in transit of iron across placenta. The developing fetus is observed to be immune to anemia despite presence of anemia in the mother. Hence, we planned the present study to explore the effect of maternal IDA on the expression of DMT1 in the placenta.

MATERIALS AND METHODS

Two hundred pregnant women recruited, were divided into anemic and nonanemic groups based on their predelivery hemoglobin levels (<11 g/dL and ≥11 g/dL respectively). After delivery, placental expression of DMT1 was studied by immunohistochemistry and mRNA analysis and neonatal anthropometry was performed.

RESULTS

Of the 200 women recruited, 58.8% were anemic with 60.35% having moderate anemia. Most of the red cell parameters were observed to be higher in cord blood than mothers. DMT1 protein immunohistochemical expression showed a statistically significant increase with increasing severity of anemia. Similarly, placental mRNA expression levels of DMT1 gene were observed to be higher in anemic mothers in comparison with nonanemic mothers.

CONCLUSION

Our study thus demonstrated a definite increase in expression of DMT1 at both protein and mRNA levels in term placenta, in maternal IDA.

Effect of Maternal Iron Deficiency Anaemia on the Expression of Iron Transport Proteins in the Third Trimester Placenta

BackgroundDuring pregnancy, iron is transferred from mother to fetus with placental iron transport proteins (Transferrin receptor, Divalent metal transporter/DMT1, ferroportin/FPN1 and Zyklopen). The aim of the study was to evaluate the effect of maternal iron deficiency anemia on placental iron transporters. Study Design: Two hundred pregnant women, in third trimester of pregnancy were divided into anemic (Hemoglobin/Hb < 11g/dl) and non-anemic groups (Hb ≥ 11 g/dl). After delivery, placental expression of iron transport proteins were studied by immunohistochemistry and by mRNA analysis. Results: Of the 200 subjects, 59% were anemic. All 3 placental proteins showed statistically significant increase in immunohistochemical expression, proportionate to the severity of maternal anemia. The mRNA expression of DMT-1 gene was only significantly elevated in placentas of anemic mothers. Conclusion: Although in our study mRNA expression of only the DMT-1 gene was significantly high, immunohistochemically however all the 3 proteins showed significantly higher expression in placentas of anemic mothers.

Prevalence of Iron Deficiency and its Sociodemographic Patterning in Indian Children and Adolescents: Findings from the Comprehensive National Nutrition Survey 2016-18

BACKGROUND

Anemia control programs in India focus mainly on the measurement of hemoglobin in response to iron-folic acid supplementation. However, representative national estimates of iron deficiency (ID) are not available.

OBJECTIVES

The objective of the present study was to evaluate ID prevalence among children and adolescents (1-19 y) using nationally representative data and to examine the sociodemographic patterning of ID.

METHODS

Cross-sectional data from the Comprehensive National Nutrition Survey in children (1-4 y: n = 9635; 5-9 y: n = 11,938) and adolescents (10-19 y; n = 11,507) on serum ferritin (SF) and other biomarkers were analyzed to determine inflammation-adjusted ID prevalence [SF (μg/L): <12 in 1-4 y and <15 in 5-19 y] and its relation to sociodemographic indicators. Multiple-regression analyses were conducted to identify the exposure associations of iron status. In addition, the relation between SF and hemoglobin was assessed as an indicator of iron utilization in different wealth quintiles.

RESULTS

ID prevalence was higher in 1- to 4-y-old children (31.9%; 95% CI: 31.0%, 32.8%) and adolescent girls (30.4%; 95% CI: 29.3%, 31.5%) but lower in adolescent boys and 5- to 9-y-old children (11%-15%). In all age groups, ID prevalence was higher in urban than in rural participants (1-4 y: 41% compared with 29%) and in those from richer quintiles (1-4 y: 44% in richest compared with 22% in poorest), despite adjustment for relevant confounders. SF significantly interacted with the wealth index, with declining trends in the strength of association between hemoglobin and SF from the richest to the poorest groups suggesting impaired iron utilization for hemoglobin synthesis in poorer wealth quintiles.

CONCLUSIONS

ID prevalence was indicative of moderate (in preschool children and adolescent girls) or mild (in 5- to 9-y-old children and adolescent boys) public health problem with significant variation by state and age. Focusing on increasing iron intake alone, without addressing the multiple environmental constraints related to poverty, may not result in intended benefits.

A Randomized Multiple Micronutrient Powder Point-of-Use Fortification Trial Implemented in Indian Preschools Increases Expressive Language and Reduces Anemia and Iron Deficiency

BACKGROUND

Anemia is a global public health problem that undermines childhood development. India provides government-sponsored integrated nutrition/child development preschools.

OBJECTIVES

This double-masked, cluster-randomized controlled trial examines whether point-of-use multiple micronutrient powder (MNP) compared with placebo fortification of preschool meals impacts child development and whether effects vary by preschool quality (primary outcome) and biomarkers of anemia and micronutrients (secondary outcomes). We also measured growth and morbidity.

METHODS

We randomly assigned 22 preschools in rural India to receive MNP/placebo fortification. We administered baseline and endline blood sampling and measures of childhood development (Mullen Scales of Early Learning, inhibitory control, social-emotional), anthropometry, and morbidity to preschoolers (aged 29-49 mo). Preschools added MNP/placebo to meals 6 d/wk for 8 mo. We conducted linear mixed-effects regression models accounting for preschool clustering and repeated measures. We evaluated child development, examining effects in high- compared with low-quality preschools using the Early Childhood Environment Rating Scale-Revised and the Home Observation for the Measurement of the Environment Inventory, modified for preschools.

RESULTS

At baseline, mean age ± SD was 36.6 ± 5.7 mo, with 47.8% anemic, 41.9% stunted, and 20.0% wasted. Baseline expressive/receptive language scores were higher in high-quality compared with low-quality preschools (P = 0.02 and P = 0.03, respectively). At endline (91% retention, n = 293/321), we found MNP compared with placebo effects in expressive language (Cohen's standardized effect d = 0.4), inhibitory control (d = 0.2), and social-emotional (d = 0.3) in low-quality, not high-quality, preschools. MNP had significantly greater reduction of anemia and iron deficiency compared with placebo (37% compared with 13.5% and 41% compared with 1.2%, respectively). There were no effects on growth or morbidity.

CONCLUSIONS

Providing multiple micronutrient-fortified meals in government-sponsored preschools is feasible; reduced anemia and iron deficiency; and, in low-quality preschools, increased preschoolers' expressive language and inhibitory control and reduced developmental disparities. Improving overall preschool quality by incorporating multiple components of nurturing care (responsive care, learning, and nutrition) may be necessary to enhance preschoolers' development. This trial was registered at clinicaltrials.gov as NCT01660958.

Prevention of iron deficiency anemia in infants and toddlers

Anemia, defined as a low blood hemoglobin concentration, is a major global public health problem. Identification of anemia is crucial to public health interventions. It is estimated globally that 273 million children under 5 years of age were anemic in 2011, and about ~50% of those cases were attributable to iron deficiency (Lancet Global Health 1:e16-e25, 2013). Iron-deficiency anemia (IDA) in infants adversely impacts short-term hematological indices and long-term neuro-cognitive functions of learning and memory that result in both fatigue and low economic productivity. IDA contributes to death and disability and is an important risk factor for maternal and perinatal mortality, including the risks for stillbirths, prematurity, and low birth weight (Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributable to Selected Major Risk Factors. Ch. 3 (World Health Organization, Geneva, 2004)). Reduction in early infantile anemia and newborn mortality rates is possible with easily implemented, low- to no-cost intervention such as delayed cord clamping (DCC). DCC until 1-3 min after birth facilitates placental transfusion and iron-rich blood flow to the newborn. DCC, an effective anemia prevention strategy, requires cooperation among health providers involved in childbirth, and a participatory culture change in public health. Public intervention strategies must consider multiple factors associated with anemia listed in this review before designing intervention studies that aim to reduce anemia prevalence in infants and toddlers. IMPACT: Anemia, defined as a low blood hemoglobin concentration, is a major global public health problem and identification of anemia is crucial to public health interventions. Delayed cord clamping (DCC) until 1-3 min after birth facilitates placental transfusion and iron-rich blood flow to the newborn. Reduction in early infantile anemia and newborn mortality rates is possible with easily implemented, low- to no-cost intervention such as DCC.

High dietary micronutrient inadequacy in peri-urban school children from a district in South India: Potential for staple food fortification and nutrient supplementation

Multiple micronutrient deficiencies (MNDs) co-exist, often because of poor intakes and adversely impact health. Habitual diets were assessed in 300 school children (6-17 years old) recruited from two government schools by simple random sampling. Probability of adequacy (PA) for 11 micronutrients and mean probability of adequacy (MPA) was calculated. Haemoglobin, plasma ferritin, folic acid, vitamin B12 and C-reactive protein were estimated. Descriptive statistics and regression analysis were used to estimate magnitude and factors associated with MNDs. The contribution of fortified foods and/or supplements in addressing inadequacies and excessive intakes was modelled. The PA ranged from 0.04 for folate to 0.70 for zinc, and the MPA was 0.27. Prevalence of anaemia (53%), iron deficiency (57%; ID), iron deficiency anaemia (38%; IDA), folate deficiency (24%) and B12 deficiency (43%) was high. Dietary inadequacy of iron, zinc and a low MPA was associated with anaemia and IDA. Inclusion of double fortified salt (DFS), fortified rice (FR) or iron folic acid (IFA) supplements individually in habitual diet reduced probability of iron inadequacy significantly from 82% to ≤13%. Inclusion of DFS and FR simultaneously led to disappearance of iron inadequacy, but risk of excessive intake increased to 16%. Inclusion of DFS, FR and IFA together increased risk of excess iron intake to 40%. Nevertheless, intakes of folate and B12 remained inadequate even with FR and/or IFA. These results indicate a high risk of dietary MNDs in children and suggest need for more systematic intake measurements in representative sample and adjustment of iron dosages to avoid excessive intakes.

Retention, stability, iron bioavailability and sensory evaluation of extruded rice fortified with iron, folic acid and vitamin B12

Fortification of rice with micronutrients using extrusion technology is considered a sustainable strategy to prevent nutritional deficiencies in general population. The objective of the present study is to assess the retention, stability and iron bioavailability from indigenously developed triple fortified rice (iron, folic acid and vitamin B12 ) during rinsing and different cooking methods. Further, we also assessed the acceptability of fortified rice in adult human volunteers. The retention of iron during rinsing with excess water was ≥90%, whereas folic acid and vitamin B12 levels were reduced by ~25% during rinsing. Watertight cooking of rice (in electric cooker or on flame) had no additional effect on the nutrient levels as compared with rinsed rice, implying their stability during cooking. However, cooking with excess water followed by decanting led to loss of 45% iron and ≥70% folic acid and vitamin B12 . The dialyzable iron and ferritin synthesis in Caco-2 cells was significantly (P < .01) higher from fortified rice compared with unfortified rice. In addition, inclusion of ascorbic acid significantly (P < .01) increased the iron bioavailability from the fortified rice. Triangle tests in adult human subjects revealed that there are no significant sensory differences among fortified and unfortified rice. Further, fortified rice consumption appears to bridge the gaps in dietary iron intake deficits in children and women of reproductive age. These results suggest that the iron-, folic acid- and vitamin B12 -fortified rice has higher retention and stability of fortified nutrients and is acceptable for consumption in adult human volunteers.

Quantitative absorption imaging of red blood cells to determine physical and mechanical properties

Red blood cells or erythrocytes, constituting 40 to 45 percent of the total volume of human blood are vesicles filled with hemoglobin with a fluid-like lipid bilayer membrane connected to a 2D spectrin network. The shape, volume, hemoglobin mass, and membrane stiffness of RBCs are important characteristics that influence their ability to circulate through the body and transport oxygen to tissues. In this study, we show that a simple two-LED set up in conjunction with standard microscope imaging can accurately determine the physical and mechanical properties of single RBCs. The Beer–Lambert law and undulatory motion dynamics of the membrane have been used to measure the total volume, hemoglobin mass, membrane tension coefficient, and bending modulus of RBCs. We also show that this method is sensitive enough to distinguish between the mechanical properties of RBCs during morphological changes from a typical discocyte to echinocytes and spherocytes. Measured values of the tension coefficient and bending modulus are 1.27 × 10⁻⁶ J m⁻² and 7.09 × 10⁻²⁰ J for discocytes, 4.80 × 10⁻⁶ J m⁻² and 7.70 × 10⁻²⁰ J for echinocytes, and 9.85 × 10⁻⁶ J m⁻² and 9.69 × 10⁻²⁰ J for spherocytes, respectively. This quantitative light absorption imaging reduces the complexity related to the quantitative imaging of the biophysical and mechanical properties of a single RBC that may lead to enhanced yet simplified point of care devices for analyzing blood cells.

The constant thickness in the microfluidic channel is used for controlled absorption of red and blue light to measure red blood cell hemoglobin and height mapping. High speed recording of the height mapping provides us the membrane fluctuation.

Maternal Anaemia in Pregnancy: A Significantly Greater Risk Factor for Anaemia in Australian Aboriginal Children than Low Birth Weight or Prematurity

OBJECTIVES

To identify maternal and perinatal risk factors associated with childhood anaemia.

METHODS

A retrospective cohort study was conducted in three remote Katherine East Aboriginal communities in Northern Territory, Australia. Children born 2004-2014 in Community A and 2010-2014 in Community B and C, and their respective mothers were recruited into the study. Maternal and child data were linked to provide a longitudinal view of each child for the first 1000 days from conception to 2-years of age. Descriptive analyses were used to calculate mean maternal age, and proportions were used to describe other antenatal and perinatal characteristics of the mother/child dyads. The main outcome was the prevalence of maternal anaemia in pregnancy and risk factors associated with childhood anaemia at age 6 months.

RESULTS

Prevalence of maternal anaemia in pregnancy was higher in the third trimester (62%) compared to the first (46%) and second trimesters (48%). There was a strong positive linear association (R² = 0.46, p < 0.001) between maternal haemoglobin (Hb) in third trimester pregnancy and child Hb at age 6 months. Maternal anaemia in pregnancy (OR 4.42 95% CI 2.08-9.36) and low birth weight (LBW, OR 2.62, 95% CI 1.21-5.70) were associated with an increased risk of childhood anaemia at 6 months of age.

CONCLUSIONS FOR PRACTICE

This is the first study to identify the association of maternal anaemia with childhood anaemia in the Australian Aboriginal population. A review of current policies and practices for anaemia screening, prevention and treatment during pregnancy and early childhood would be beneficial to both mother and child. Our findings indicate that administering prophylactic iron supplementation only to children who are born LBW or premature would be of greater benefit if expanded to include children born to anaemic mothers.

Is Anemia in Low Income Pregnant Women Related to Their Infants' Having Anemia? A Cohort Study of Pregnant Women-Infant Pairs in the United States

OBJECTIVE

Given evidence that anemia in the first year of life is associated with long-term cognitive, motor, and behavioral deficits, reducing infant anemia is important. The primary objective of this research is to examine whether anemia in low income pregnant women in the United States is associated with anemia in the women's infants.

METHODS

This cohort study linked Centers for Disease Control and Prevention surveillance data on pregnant women with incomes below 185% of the federal poverty level from 2010 and 2011 with data on 6-11 month olds from 2011, resulting in a sample of 21,246 uniquely matched mother-infant pairs. We examined bivariate and multivariate relationship between anemia severity in pregnant women and in their infants.

RESULTS

Seventeen percent of women had anemia (13.1% mild and 3.9% moderate to severe) and 20.1% infants had anemia (16.4% mild and 3.7% moderate to severe). For both women and infants, blacks had substantially higher anemia rates than whites. In bivariate analysis and multivariate analyses maternal anemia showed a dose-response relationship to infant anemia. In predicted probabilities from the multivariate models, 27.2% of infants born to pregnant women with moderate to severe anemia had anemia, compared to 23.3% for infants whose mothers had mild anemia, and 18.3% for infants whose mothers did not have anemia.

CONCLUSION

This study provides strong evidence of a relationship between maternal and infant anemia in the United States among people with low incomes. Efforts to reduce anemia during pregnancy may be an important strategy for minimizing childhood anemia.

Trace Element Status in Children with Infantile Tremor Syndrome: An Inductively Coupled Plasma-Mass Spectrometry Based Study

The primary objective of the study was to compare the trace element status in children with infantile tremor syndrome (ITS) with healthy controls. Blood counts, serum vitamin B12, plasma homocysteine, plasma ferritin and trace elements - magnesium, zinc and selenium were compared. Twenty-six children (11 with tremors, 14 boys, mean age 11.5 ± 3.5 mo) and 19 controls were enrolled for this study. Low vitamin B12 levels (67% vs. 5%) and elevated plasma homocysteine 96% vs. 26%) was significantly more (P < 0.001) in cases. Eight controls had hypoferritinemia, while none with ITS had it (p < 0.001). None of the children in either group had low serum levels of zinc or magnesium. Low levels of selenium were seen in six cases and five controls. This study did not show any association between the studied nutrients/ trace elements and ITS while, it showed a strong association of ITS with vitamin B12 deficiency supporting that it is a Neurocutaneous Infantile B-12 deficiency (NIB) syndrome.

Effect of a Community Health Worker-Delivered Parental Education and Counseling Intervention on Anemia Cure Rates in Rural Indian Children: A Pragmatic Cluster Randomized Clinical Trial

IMPORTANCE

Iron deficiency anemia, the largest cause of anemia worldwide, adversely affects cognitive development in children. Moreover, the imperceptible childhood anemia prevalence reduction in response to anemia control measures is associated with tremendous social and economic cost.

OBJECTIVE

To evaluate the effects of community-based parental education/counseling when combined with usual treatment on children's anemia cure rate.

DESIGN, SETTING, AND PARTICIPANTS

A pragmatic cluster randomized clinical trial in children aged 12 to 59 months from 55 villages from the rural Chamrajnagar district in southern India was conducted between November 2014 and July 2015; 6-month follow-up ended in January 2016. Villages were randomly assigned to either usual treatment (n = 27) or to the intervention (n = 28). Among 1144 participating children, 534 were diagnosed as having anemia (hemoglobin levels <11 g/dL and >7.9 g/dL; to convert to grams per liter, multiply by 10) and constituted the study sample in this analysis. Data were analyzed between July 2016 and September 2017.

INTERVENTIONS

Iron and folic acid (IFA), 20 mg/d, 5 times daily per week, for 5 months (usual treatment) or health worker-delivered education/counseling combined with usual treatment (intervention).

MAIN OUTCOMES AND MEASURES

The primary outcome was anemia cure rate defined as hemoglobin level at or greater than 11 g/dL during follow-up.

RESULTS

Of the children included in the study, the mean age was 30 months, with a slightly higher ratio of boys to girls. Of 534 children with anemia (intervention n = 303; usual treatment n = 231), 517 were reassessed after 6 months (intervention n = 298; usual treatment n = 219) while 17 were lost to follow-up (intervention n = 5 and usual treatment n = 12). Anemia cure rate was higher in children in the intervention group compared with children receiving usual treatment (55.7% [n = 166 of 298] vs 41.4% [n = 90 of 219]). The risk ratio derived through multilevel logistic regression was 1.37 (95% CI, 1.04-1.70); the model-estimated risk difference was 15.1% (95% CI, 3.9-26.3). Intervention-group children demonstrated larger mean hemoglobin increments (difference, intervention vs control: 0.25 g/dL; 95% CI, 0.07-0.44 g/dL) and improved IFA adherence (61.7%; 95% CI, 56.2-67.3 vs 48.4%; 95% CI, 41.7-55.1 consumed >75% of tablets provided). Adverse events were mild (intervention: 26.8%; 95% CI, 21.8-31.9 vs usual treatment: 21%; 95% CI, 15.6-26.4). To cure 1 child with anemia, 7 mothers needed to be counseled (number needed to treat: 7; 95% CI, 4-26).

CONCLUSIONS AND RELEVANCE

Parental education and counseling by a community health worker achieved perceivable gains in curing childhood anemia. Policy makers should consider this approach to enhance population level anemia control.

TRIAL REGISTRATION

ISRCTN identifier: ISRCTN68413407.

Micronutrient intakes and status assessed by probability approach among the urban adult population of Hyderabad city in South India

PURPOSE

To assess the dietary inadequacies of micronutrients and the associated factors among the apparently healthy urban adults.

METHODS

This community-based cross-sectional study involved 300 urban adults (distributed into age groups: 21-40, 41-60, and > 60 years) residing in Hyderabad city, South India. Hemoglobin in whole blood, ferritin, folate, and vitamin B12 (B12) in plasma was estimated. Dietary intakes were assessed by three 24-h dietary recalls and calculated the probability of adequacy (PA) using estimated average requirement.

RESULTS

The prevalence of anemia (30%), iron deficiency (ID, 23%), and iron deficiency anemia (IDA, 14.3%) was independent of age but higher in women. While folate deficiency (32.2%) was independent of age and gender, B12 deficiency (35.5%) varied by both age and gender. The PA of iron (89%) was higher, while that of folate, B12, and zinc (1-11%) were noticeably low. The mean PA (MPA) across the ten micronutrients was 38%, independent of age and gender, but associated with the educational status. Energy intake was a strong predictor of the MPA. Cereals and millets predominantly contributed to the intake of thiamine, niacin, zinc, and iron; green leafy vegetables and fruits to vitamins A, C, folate, and iron; animal foods to B12; and milk and milk products to calcium, vitamin A, riboflavin, and B12. The unadjusted and adjusted logistic regression models revealed that micronutrient inadequacy was associated with greater risk of IDA and folate deficiency.

CONCLUSIONS

These results indicate a higher prevalence of micronutrient deficiencies among the healthy urban adults possibly due to the inadequacy of multiple micronutrients.

A food synergy approach in a national program to improve the micronutrient status of preschoolers: a randomized control trial protocol

Iron deficiency anemia (IDA) is a significant public health issue in India affecting nearly all vulnerable segments of the population. Causes of IDA include low consumption of iron-rich foods combined with poor iron bioavailability of nonheme iron sources. To date, interventions aimed at correcting IDA focus on increasing iron intake through iron supplementation or fortification strategies. In contrast, dietary diversification is a long-term sustainable approach to improve bioavailable iron intake. In this context, the inclusion of vitamin C-rich fruits in the regular diet has proven to improve iron absorption, but the effect on iron status is inconclusive. Considering the ongoing national program for preschoolers in India, we designed a cluster randomized controlled trial (RCT) to test the hypothesis that inclusion of vitamin C-rich fruit in a regular meal would improve iron absorption and lead to better child iron and micronutrient status, cognitive development, gut health, and growth while reducing morbidity. This paper illustrates a context-specific framework and activities to design and functionalize an open-label, three-arm cluster RCT to test a specific hypothesis. The results of this designed trial should generate evidence to inform policy on the effect of a food-based intervention on iron status.

Food insecurity and anaemia risk: a systematic review and meta-analysis

OBJECTIVE

Increasing evidence has suggested an association between food insecurity and the risk of anaemia. Therefore, a systematic review and meta-analysis were performed to examine the associations between food insecurity and anaemia risk.

SETTING

Pertinent studies were identified by searching PubMed and EMBASE databases up to August 2017. Data were available from nineteen studies; seventeen studies were cross-sectional and two studies were longitudinal. Risk ratios of 95993 individual participants from twelve different countries in these studies were pooled for the meta-analysis.

RESULTS

The results showed that there was an overall positive relationship between food insecurity and anaemia risk (OR=1·27; 95 % CI 1·13, 1·40). Similar results were observed for Fe-deficiency anaemia (OR=1·45; 95 % CI 1·04, 1·86). These results revealed that food insecurity at two levels, including mild food insecurity (OR=1·15; 95 % CI 1·00, 1·31) and moderate food insecurity (OR=1·36; 95 % CI 1·23, 1·48), increased the risk of anaemia. In addition, it was found that age had an impact on the associations between food insecurity and anaemia risk (OR=1·22; 95 % CI 1·09, 1·36). Age subgroup analysis indicated that food insecurity significantly increased the risk of anaemia among infants/toddlers (OR=1·17; 95 % CI 1·05, 1·29) and adult women (OR=1·35; 95 % CI 1·16, 1·54).

CONCLUSIONS

It seems that infants, toddlers and adult women in food-insecure households are at a higher risk of anaemia. To prevent anaemia in food-insecure households, these age groups may require more nutritional support.

Growth and development among infants and preschoolers in rural India

Economic inequities are common in low and middle-income countries (LMIC), and are associated with poor growth and development among young children. The objectives are to examine whether maternal education and home environment quality: 1) protect children by attenuating the association between economic inequities and children’s growth and development, or 2) promote children’s growth and development, regardless of economic inequities. The sample includes 512 infants and 321 preschoolers in 26 villages in rural India (Project Grow Smart). Data for children: physical growth (weight and length/height measured) and development (Mullen Scales of Early Learning); for mothers/households: economic inequities measured by household assets, education, depressive symptoms, and home environment (HOME Inventory). Data are analyzed with linear mixed models (LMM) for infants and preschoolers separately, adjusted for village/preschool clustering, including asset-by-education/home interactions. Among infants, but not preschoolers, the education/home factor attenuates relations between assets and growth, eliminating differential relations in infant growth between high/low-asset families, suggesting protection. Among infants and preschoolers, the education/home factor is significantly or marginally associated with most child development scales, regardless of economic inequities, suggesting promotion. Strategies to enhance maternal education and home environment quality may protect infants in low-asset families from poor growth, promote development among infants and preschoolers, and prevent early disparities.