The influence of inflammation on plasma zinc concentration in apparently healthy, HIV+ Kenyan adults and zinc responses after a multi-micronutrient supplement

The Effect of Zinc Biofortified Wheat Produced via Foliar Application on Zinc Status: A Randomized, Controlled Trial in Indian Children

BACKGROUND

Agronomic zinc biofortification of wheat by foliar application increases wheat zinc content and total zinc absorption in humans.

OBJECTIVES

To assess the effect of agronomically biofortified whole wheat flour (BFW) on plasma zinc (PZC) compared with a postharvest fortified wheat (PHFW) and unfortified control wheat (CW) when integrated in a midday school meal scheme.

METHODS

We conducted a 20-wk double-blind intervention trial in children (4-12 y, n = 273) individually randomly assigned to 3 groups to receive a daily school lunch consisting of 3 chapattis prepared with the 3 different wheat flour types. Measurements of anthropometry, blood biochemistry, and leukocyte DNA strand breaks were conducted. We applied sparse serial sampling to monitor PZC over time, and analysis was performed using linear mixed-effects models.

RESULTS

Mean zinc content in BFW, PHFW, and CW were 48.0, 45.1, and 21.2 ppm, respectively (P < 0.001). Mean (standard deviation) daily zinc intakes in the study intervention in BFW, PHFW, and CW groups were 4.4 (1.6), 5.9 (1.9) and 2.6 (0.6) mg Zn/d, respectively, with intake in groups PHFW and BFW differing from CW (P < 0.001) but no difference between BFW and PHFW. There were no time effect, group difference, or group × time interaction in PZC. Prevalence of zinc deficiency decreased in the BFW (from 14.1%-11.2%), PHFW (from 8.9%-2.3%), and CW (9.8%-8.8%) groups, but there was no time × treatment interaction in the prevalence of zinc deficiency (P = 0.191). Compliance with consuming the study school meals was associated with PZC (P = 0.006). DNA strand breaks were not significantly associated with PZC (n = 51; r = 0.004, P = 0.945).

CONCLUSIONS

Consumption of either PHFW or BFW provided an additional ∼1.8 to 3.3 mg Zn/d, but it did not affect PZC or zinc deficiency, growth, or DNA strand breaks. This trial was registered on clinicaltrials.gov as NCT02241330 and ctri.nic.in as CTRI/2015/06/005913.

Alterations in Intestinal Brush Border Membrane Functionality and Bacterial Populations Following Intra-Amniotic Administration (Gallus gallus) of Nicotinamide Riboside and Its Derivatives

Nicotinamide riboside (NR) acts as a nicotinamide adenine dinucleotide (NAD+) precursor where NR supplementation has previously been shown to be beneficial. Thus, we synthesized and characterized nicotinamide riboside tributyrate chloride (NRTBCl, water-soluble) and nicotinamide riboside trioleate chloride (NRTOCl, oil-soluble) as two new ester derivatives of nicotinamide riboside chloride (NRCl). NRCl and its derivatives were assessed in vivo, via intra-amniotic administration (Gallus gallus), with the following treatment groups: (1) non-injected (control); and injection of (2) deionized H₂O (control); (3) NRCl (30 mg/mL dose); (4) NRTBCl (30 mg/mL dose); and (5) NRTOCl (30 mg/mL dose). Post-intervention, the effects on physiological markers associated with brush border membrane morphology, intestinal bacterial populations, and duodenal gene expression of key proteins were investigated. Although no significant changes were observed in average body weights, NRTBCl exposure increased average cecum weight. NR treatment significantly increased Clostridium and NRCl treatment resulted in increased populations of Bifidobacterium, Lactobacillus, and E. coli. Duodenal gene expression analysis revealed that NRCl, NRTBCl, and NRTOCl treatments upregulated the expression of ZnT1, MUC2, and IL6 compared to the controls, suggesting alterations in brush border membrane functionality. The administration of NRCl and its derivatives appears to trigger increased expression of brush border membrane digestive proteins, with added effects on the composition and function of cecal microbial populations. Additional research is now warranted to further elucidate the effects on inflammatory biomarkers and observe changes in the specific intestinal bacterial populations post introduction of NR and its derivatives.

The Exposome and Immune Health in Times of the COVID-19 Pandemic

Growing evidence supports the importance of lifestyle and environmental exposures-collectively referred to as the 'exposome'-for ensuring immune health. In this narrative review, we summarize and discuss the effects of the different exposome components (physical activity, body weight management, diet, sun exposure, stress, sleep and circadian rhythms, pollution, smoking, and gut microbiome) on immune function and inflammation, particularly in the context of the current coronavirus disease 2019 (COVID-19) pandemic. We highlight the potential role of 'exposome improvements' in the prevention-or amelioration, once established-of this disease as well as their effect on the response to vaccination. In light of the existing evidence, the promotion of a healthy exposome should be a cornerstone in the prevention and management of the COVID-19 pandemic and other eventual pandemics.

Prevalence of Zinc Deficiency in Healthy 1-3-Year-Old Children from Three Western European Countries

Zinc deficiency (ZnD) has adverse health consequences such as stunted growth. Since young children have an increased risk of developing ZnD, it is important to determine its prevalence and associated factors in this population. However, only a few studies have reported on ZnD prevalence in young children from Western high-income countries. This study evaluated ZnD prevalence and associated factors, including dietary Zn intake, in healthy 1–3-year-old children from Western European, high-income countries. ZnD was defined as serum Zn concentration <9.9 µmol/L. A total of 278 children were included with a median age of 1.7 years (Q1–Q3: 1.2–2.3). The median Zn concentration was 11.0 µmol/L (Q1–Q3: 9.0–12.2), and ZnD prevalence was 31.3%. No significant differences were observed in the socio-economic characteristics between children with and without ZnD. Dietary Zn intake was not associated with ZnD. ZnD is common in healthy 1–3-year-old children from Western European countries. However, the use of currently available cut-off values defining ZnD in young children has its limitations since these are largely based on reference values in older children. Moreover, these values were not evaluated in relation to health consequences, warranting further research.

Increased zinc and albumin but lowered copper in children with transfusion-dependent thalassemia

BACKGROUND

Measurements of copper and zinc in transfusion-dependent thalassemia (TDT) show contradictory results.

AIM OF THE STUDY

To examine serum levels of these minerals in TDT in relation to iron overload indices and erythron variables.

METHODS

This study recruited 60 children with TDT and 30 healthy controls aged 3-12 years old.

RESULTS

Zinc was significantly higher in TDT children than in controls, while copper and the copper to zinc ratio were significantly lowered in TDT. Serum zinc was significantly associated with the number of blood transfusions and iron overload variables (including serum iron and TS%) and negatively with erythron variables (including hemoglobin, mean corpuscular volume, mean corpuscular hemoglobin). Serum copper was significantly and negatively associated with the same iron overload and erythron variables. The copper to zinc ratio was significantly correlated with iron, TS%, ferritin, hemoglobin, mean corpuscular volume, and mean corpuscular hemoglobin. Albumin levels were significantly higher in TDT children than in control children.

CONCLUSION

Our results suggest that the increase in zinc in children with TDT may be explained by iron loading anemia and hemolysis and the consequent shedding of high amounts of intracellular zinc into the plasma. Increased albumin levels and treatment with Desferral may further contribute towards higher zinc levels in TDT. We suggest that the elevations in zinc in TDT are a compensatory mechanism protecting against infection, inflammation, and oxidative stress. Previous proposals for prophylactic use of zinc supplements in TDT may not be warranted.

Adjusting serum zinc concentration for inflammation based on the data of Malawian preschool children and women of reproductive age

OBJECTIVES

Serum zinc negatively reacts to inflammation yet to our knowledge only a few studies have attempted to adjust it for inflammation. The aim of this study, based on the data of Malawi Micronutrient Survey, was to correct zinc concentration for inflammation in preschool children (n = 1081) and women of reproductive age (n = 799) and to evaluate the effects of the adjustment on the prevalence of zinc deficiency (ZD).

METHODS

Based on C-reactive protein (CRP) and α-1-acid glycoprotein (AGP), inflammation status was grouped into four categories: no inflammation, incubation, early convalescence, and late convalescence. The association between zinc and inflammation was examined using linear regression analysis and correction was made by six approaches: exclusion, internal correction factor, and four regression adjustments.

RESULTS

The unadjusted prevalence of ZD was 58.9% in children and 62% in women. Inflammation was observed in 57.6% of children and 17.1% of women. Zinc demonstrated negative correlations with inflammation markers (P < 0.05). Among children, zinc showed marginally insignificant (P = 0.072) decline during incubation (β= -8.25; 95% confidence interval [CI], -17.28 to 0.78) and significant decline during early convalescence inflammation (β= -4.92; 95% CI, -7.00 to -2.31). Among women, significant change was only observed in late convalescence inflammation (β= -4.10; 95% CI, -8.06 to -0.14). However, all the corrections resulted in modest decline in the prevalence of ZD (1.4-2.1 and 0-2.6 percentage points in children and women).

CONCLUSIONS

The study observed statistically significant negative correlations between serum zinc concentration and inflammation markers (AGP and CRP). However, correction of serum zinc for inflammation using multiple options including exclusion, internal correction factor, and regression adjustment resulted in very marginal changes in the prevalence of ZD. Although inflammation adjustment may enable more precise estimation of ZD, it only resulted in modest changes in the actual prevalence of ZD in Malawi.

Inflammation Adjustment by Two Methods Decreases the Estimated Prevalence of Zinc Deficiency in Malawi

Serum zinc concentration (SZC) is used widely to assess population-level zinc status. Its concentration decreases during inflammatory responses, which can affect the interpretation of the results. This study aimed to re-estimate the prevalence of zinc deficiency in Malawi based on the 2015–2016 Malawi Micronutrient Survey (MNS) data, by adjusting SZC measures with markers of inflammation. SZC and inflammation data from 2760 participants were analysed. Adjustments were made using: (1) The Internal Correction Factor (ICF) method which used geometric means, and (2) The Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) method, which used linear regression. Mean SZC values increased significantly when adjustments were made by either ICF or BRINDA (p < 0.001). The national prevalence of zinc deficiency decreased from 62% to 59%, after ICF adjustment, and to 52% after BRINDA adjustment. ICF and BRINDA values of SZC were highly correlated (p < 0.001, r = 0.99), but a Bland–Altman plot showed a lack of agreement between the two methods (bias of 2.07 µg/dL). There was no association between the adjusted SZC and stunting, which is a proxy indicator for zinc deficiency. Inflammation adjustment of SZC, using ICF or BRINDA, produces lower estimates of zinc deficiency prevalence, but the lack of agreement between the adjustment methods warrants further research. Furthermore, the lack of association between SZC and stunting highlights the need to explore other biomarkers and proxies of population zinc assessment. This study demonstrates the importance of considering inflammatory confounders when reporting SZC, to ensure accuracy and to support policy decision making.

Adjusting plasma or serum zinc concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

BACKGROUND

The accurate estimation of zinc deficiency at the population level is important, as it guides the design, targeting, and evaluation of nutrition interventions. Plasma or serum zinc concentration (PZC) is recommended to estimate zinc nutritional status; however, concentrations may decrease in the presence of inflammation.

OBJECTIVES

We aimed to assess the relation between PZC and inflammation in preschool children (PSC; 6-59 mo) and nonpregnant women of reproductive age (WRA; 15-49 y), and to compare different inflammation adjustment approaches, if adjustment is warranted.

METHODS

Cross-sectional data from 13 nationally representative surveys (18,859 PSC, 22,695 WRA) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed. Correlation and decile analyses were conducted, and the following 3 adjustment methods were compared if a consistent negative association between PZC and C-reactive protein (CRP) or α-1-acid glycoprotein (AGP) was observed: 1) exclude individuals with CRP > 5 mg/L or AGP > 1 g/L; 2) apply arithmetic correction factors; and 3) use the BRINDA regression correction (RC) approach.

RESULTS

In 6 of 12 PSC surveys, the estimated prevalence of zinc deficiency increased with increasing CRP deciles, and to a lesser extent, with increasing AGP deciles. In WRA, the association of PZC with CRP and AGP was weak and inconsistent. In the 6 PSC surveys in which adjustment methods were compared, application of RC reduced the estimated prevalence of zinc deficiency by a median of 11 (range: 4-18) percentage points, compared with the unadjusted prevalence.

CONCLUSIONS

Relations between PZC and inflammatory markers were inconsistent, suggesting that correlation and decile analyses should be conducted before applying any inflammation adjustments. In populations of PSC that exhibit a significant negative association between PZC and CRP or AGP, application of the RC approach is supported. At this time, there is insufficient evidence to warrant inflammation adjustment in WRA.

Food Insecurity and Micronutrient Status among Ghanaian Women Planning to Become Pregnant

We examined the association between food insecurity (FIS) and micronutrient status among Ghanaian women planning to become pregnant. A cross-sectional analysis was completed of 95 women aged 18-35 years, living in the Upper Manya Krobo District in the Eastern Region of Ghana. Questionnaires were administered to collect sociodemographic and food security data; weight and height were measured. Blood was drawn from an antecubital vein; one drop was used to assess hemoglobin via Hemocue. Zinc and copper were analyzed using flame atomic spectrophotometry while iron biomarkers, retinol and 25-hydroxyvitamin D were analyzed using ELISA, ultra-performance liquid chromatography and liquid chromatography-tandem mass spectrometry, respectively. Logistic regression models were used to determine the relationship between food insecurity (FIS) and micronutrient deficiencies. FIS was reported among 23% of the households, while micronutrient deficiencies ranged from 7-28% irrespective of FIS status. Retinol concentrations were negatively associated with FIS (p = 0.043) after controlling for covariates, although levels were within the normal range in both groups. No statistically significant associations between FIS and micronutrient deficiencies were found. Among those with FIS, 59% were deficient in at least one nutrient with 18% deficient in two nutrients. Unmarried women were at higher risk of FIS (p = 0.017) than married women. FIS was associated with retinol concentrations but not other micronutrient biomarkers in Ghanaian women expecting to become pregnant in the next 6 months.

Zinc deficiency associated with anaemia among young children in rural Guatemala

One in four children younger than age five in Guatemala experiences anaemia (haemoglobin <11.0 g/dl). This study characterized the factors and micronutrient deficiencies associated with anaemia in a baseline cross‐sectional sample of 182 Guatemalan infants/toddlers and 207 preschoolers, using generalized linear mixed models. Associations between anaemia and maternal, child and household variables, and biomarkers (soluble transferrin receptor, ferritin, zinc, folate, vitamin B12, C‐reactive protein, and α1‐acid glycoprotein) were explored. Rates of anaemia were 56% among infants/toddlers and 12.1% among preschoolers. In children with anaemia, rates of iron deficiency (low ferritin based on inflammation status, and/or high soluble transferrin receptor, ≥1.97 mg/L) and zinc deficiency (serum zinc <65 μg/dl) were 81.1% and 53.7%, respectively. Folate deficiency (either plasma folate <3 ng/ml or erythrocyte folate <100 ng/ml) was 3.3%. Vitamin B12 deficiency (plasma vitamin B12 <148 pmol/L) was 7.5%. For infants and toddlers (<24 months), the odds ratio of anaemia was lower when higher number of adults lived in the household (OR = 0.69; 95% CI [0.53, 0.90]), and higher when children were zinc deficient (OR = 3.40; 95% CI [1.54, 7.47]). For preschoolers (36–60 months), the odds ratio of anaemia was lower for every additional month of age (OR = 0.90; 95% CI [0.81, 1.00]). Findings suggest that micronutrient deficiencies coexist in Guatemalan rural children, and zinc deficiency is associated with anaemia in children <24 months, highlighting the need of continued multidisciplinary interventions with multiple micronutrients. Further research examining how household composition, feeding practices, and accessibility to micronutrient supplements and to animal source foods is needed to incorporate strategies to improve the nutritional status of Guatemalan children.

Concurrent Micronutrient Deficiencies Are Low and Micronutrient Status Is Not Related to Common Health Indicators in Ghanaian Women Expecting to Become Pregnant

BACKGROUND

Micronutrients are important for reproductive health and pregnancy, but the status of multiple vitamins and minerals is rarely measured in women before pregnancy.

OBJECTIVES

We aimed to assess the status and concurrent deficiencies of micronutrients among women before pregnancy and their relation with common health indicators.

METHODS

This was a cross-sectional study that recruited women who expected to become pregnant within the next 6 mo in Asesewa, Ghana, a semi-urban community. Women self-reported demographics and health history. We measured blood pressure, height, and weight and conducted a blood draw and hemoglobin assessment (n = 98). We measured serum/plasma concentrations of ferritin, iron, total iron binding capacity, zinc, copper, retinol, and 25-hydroxyvitamin D, in addition to markers of inflammation. We used established cutoffs for deficiency and insufficiency/low status for each micronutrient after adjusting ferritin, zinc, and retinol for inflammation. We compared biomarker distributions by common health indicators.

RESULTS

Forty percent of women had overweight/obesity, 33% were anemic, and 23% had elevated blood pressure. Overall, 27% had ≥1 deficiencies, whereas only 4% had 2 deficiencies. Fifty-eight percent of women had ≥1 insufficiencies and 18% had ≥2 insufficiencies. Prevalence of individual deficiencies was 12%, 7%, 7%, 4%, and 0% and prevalence of individual insufficiencies was 18%, 12%, 29%, 13%, and 13% for iron, copper, vitamin A, zinc, and vitamin D, respectively. Iron biomarkers and retinol concentrations differed by anemia status, and copper was higher in those with elevated blood pressure. Micronutrient concentrations were not associated with self-reported medical history (parity or history of anemia, malaria, or night blindness).

CONCLUSIONS

In Asesewa, Ghana, there was a relatively low prevalence of individual micronutrient deficiencies, but the majority of women were insufficient in ≥1 micronutrients. Iron and vitamin A status was lower in those with anemia, but otherwise, micronutrient status did not relate to common health markers.

Effects on body composition and handgrip strength of a nutritional intervention for malnourished HIV-infected adults referred for antiretroviral therapy: a randomised controlled trial

Lipid-based nutrient supplements (LNS) may be beneficial for malnourished HIV-infected patients starting antiretroviral therapy (ART). We assessed the effect of adding vitamins and minerals to LNS on body composition and handgrip strength during ART initiation. ART-eligible HIV-infected patients with BMI <18·5 kg/m² were randomised to LNS or LNS with added high-dose vitamins and minerals (LNS-VM) from referral for ART to 6 weeks post-ART and followed up until 12 weeks. Body composition by bioelectrical impedance analysis (BIA), deuterium (²H) diluted water (D₂O) and air displacement plethysmography (ADP), and handgrip strength were determined at baseline and at 6 and 12 weeks post-ART, and effects of LNS-VM v. LNS at 6 and 12 weeks investigated. BIA data were available for 1461, D₂O data for 479, ADP data for 498 and handgrip strength data for 1752 patients. Fat mass tended to be lower, and fat-free mass correspondingly higher, by BIA than by ADP or D₂O. At 6 weeks post-ART, LNS-VM led to a higher regain of BIA-assessed fat mass (0·4 (95 % CI 0·05, 0·8) kg), but not fat-free mass, and a borderline significant increase in handgrip strength (0·72 (95 % CI −0·03, 1·5) kg). These effects were not sustained at 12 weeks. Similar effects as for BIA were seen using ADP or D₂O but no differences reached statistical significance. In conclusion, LNS-VM led to a higher regain of fat mass at 6 weeks and to a borderline significant beneficial effect on handgrip strength. Further research is needed to determine appropriate timing and supplement composition to optimise nutritional interventions in malnourished HIV patients.

Multiple micronutrient status and predictors of anemia in young children aged 12-23 months living in New Delhi, India

Anemia has been identified as a severe public health concern among young children in India, however, information on the prevalence of anemia attributed to micronutrient deficiencies is lacking. We aimed to assess multiple micronutrient status (iron, zinc, selenium, vitamin A, vitamin D, folate and vitamin B12) in young Indian children and to investigate the role of these seven micronutrients and other non-nutritional factors on hemoglobin concentrations and anemia. One-hundred and twenty children aged 12 to 23 months were included in a cross-sectional nutritional assessment survey, of which 77 children provided a blood sample. Hemoglobin (Hb), serum ferritin, soluble transferrin receptor (sTfR), total body iron, zinc, selenium, retinol binding protein (RBP), folate, vitamin B12 and 25-hydroxyvitamin D (25(OH)D) were measured, and adjusted for inflammation using C-reactive protein (CRP) and α-1-acid glycoprotein (AGP), where appropriate. Predictors for hemoglobin and anemia were identified in multiple regression models. Most of the children were classified as anemic, of which 86 to 93% was associated with iron deficiency depending on the indicator applied. Deficiencies of folate (37%), and notably vitamin D (74%) were also common; fewer children were classified with deficiencies of vitamin B12 (29%), zinc (25%), and vitamin A (17%) and selenium deficiency was nearly absent. Multiple micronutrient deficiencies were common with over half (57%) deficient in three or more micronutrients, and less than 10% of children were classified with adequate status for all the micronutrients measured. Iron status was found to be the only nutritional factor statistically significantly inversely associated with anemia (P = 0.003) in multivariate analysis after controlling for sex. A coordinated multi-micronutrient program is urgently needed to combat the co-existing micronutrient deficiencies in these young children to improve micronutrient status and reduce the high burden of childhood anemia.

The effect of inflammation on serum zinc concentrations and the prevalence estimates of population-level zinc status among Congolese children aged 6-59 months

BACKGROUND/OBJECTIVES

Zinc is a negative acute-phase reactant; hence, its concentration decreases in the presence of inflammation. There is no current consensus on how to control for the effect of inflammation on serum zinc, which has implications for accurate estimates of population-level zinc status. We aimed to measure the association between inflammation and serum zinc concentrations and to compare the means and the prevalence of zinc deficiency using unadjusted and inflammation-adjusted serum zinc concentrations among Congolese children.

SUBJECTS/METHODS

Non-fasting blood was collected in the afternoon in trace element-free vacutainers from 744 apparently healthy children aged 6-59 months in the Democratic Republic of the Congo. Serum was analyzed for zinc, C-reactive protein (CRP) and α-1 acid glycoprotein (AGP) for 665 children with complete data for all three biomarkers. Linear regression was used to generate correction factors (CFs) based on three stages of inflammation: incubation (CRP >5 mg/l and normal AGP), early convalescence (CRP >5 mg/l and AGP >1 g/l) and late convalescence (AGP >1 g/l and normal CRP), relative to no inflammation.

RESULTS

Overall unadjusted mean±s.d. serum zinc concentration was 9.4±2.1 μmol/l. Study-generated CFs (95% confidence interval) for incubation, early and late convalescence were 1.01 (0.88, 1.14), 1.15 (1.11, 1.21) and 1.07 (1.03, 1.11), respectively. After applying the CFs, overall adjusted mean±s.d. serum zinc concentration was 10.1±2.2 μmol/l, and prevalence of zinc deficiency (<8.7 μmol/l) decreased from 35% (n=234/665) to 24% (n=160/665).

CONCLUSIONS

Adjustment of zinc concentrations for inflammation is warranted when assessing population-level zinc status.European Journal of Clinical Nutrition advance online publication, 23 August 2017; doi:10.1038/ejcn.2017.127.

Evaluation of Serum Trace Element Levels and Superoxide Dismutase Activity in Patients with Inflammatory Bowel Disease: Translating Basic Research into Clinical Application

The relationship of minerals and trace elements with inflammatory bowel disease (IBD) is complex. Alterations in their metabolism can be induced by the diseases and their complications. To study the role of trace elements in IBD patients' serum zinc and copper and their related enzymes, including superoxide dismutase (SOD), activity were measured in patients with IBD patients as well as in healthy subjects. In addition, the correlation between serum trace element levels, albumin, total protein, urea level, copper/zinc ratio, and disease activity (DA) was determined in these subjects. Serum samples were obtained from 35 patients (19 ulcerative colitis (UC) and 16 Crohn's disease (CD)) in the active phase of the disease and 30 healthy control subjects. Serum levels of zinc, copper, SOD activity, albumin, total protein, and urea were measured. The results were compared between the two groups using independent Student's t test in statistical analysis. Serum levels of zinc, SOD activity, albumin, and total protein were significantly lower (P < 0.05) in patients than controls, while serum urea level was significantly higher in patients compared to controls. Copper concentrations did not differ between patients with IBD (mean ± SD, 58.8 ± 20.7 μg/d) and controls (55.57 ± 12.6 μg/d). Decreased levels of zinc and SOD activity are associated with increased inflammatory processes indicating inappropriate antioxidant system in patients with IBD. Additionally, lower levels of albumin and total protein with higher level of urea reflect metabolic problems in liver system.

Micronutrient supplementation in adults with HIV infection

BACKGROUND

Micronutrient deficiencies are common among adults living with HIV disease, particularly in low-income settings where the diet may be low in essential vitamins and minerals. Some micronutrients play critical roles in maintenance of the immune system, and routine supplementation could therefore be beneficial. This is an update of a Cochrane Review previously published in 2010.

OBJECTIVES

To assess whether micronutrient supplements are effective and safe in reducing mortality and HIV-related morbidity of HIV-positive adults (excluding pregnant women).

SEARCH METHODS

We performed literature searches from January 2010 to 18 November 2016 for new randomized controlled trials (RCTs) of micronutrient supplements since the previous review included all trials identified from searches prior to 2010. We searched the CENTRAL (the Cochrane Library), Embase, and PubMed databases. Also we checked the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and the ClinicalTrials.gov trials registers. We also checked the reference lists of all new included trials.

SELECTION CRITERIA

We included RCTs that compared supplements that contained either single, dual, or multiple micronutrients with placebo, no treatment, or other supplements. We excluded studies that were primarily designed to investigate the role of micronutrients for the treatment of HIV-positive participants with metabolic morbidity related to highly active antiretroviral therapy (HAART). Primary outcomes included all-cause mortality, morbidity, and disease progression.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, and appraised trial quality for risk of bias. Where possible, we presented results as risk ratios (RR) for dichotomous variables, as hazard ratios (HRs) for time-to-event data, and as mean differences (MD) for continuous variables, each with 95% confidence intervals (CIs). Since we were often unable to pool the outcome data, we tabulated it for each comparison. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 33 trials with 10,325 participants, of which 17 trials were new trials. Ten trials compared a daily multiple micronutrient supplement to placebo in doses up to 20 times the dietary reference intake, and one trial compared a daily standard dose with a high daily dose of multivitamins. Nineteen trials compared supplementation with single or dual micronutrients (such as vitamins A and D, zinc, and selenium) to placebo, and three trials compared different dosages or combinations of micronutrients. Multiple micronutrientsWe conducted analyses across antiretroviral therapy (ART)-naive adults (3 trials, 1448 participants), adults on antiretroviral therapy (ART) (1 trial, 400 participants), and ART-naive adults with concurrent active tuberculosis (3 trials, 1429 participants). Routine multiple micronutrient supplementation may have little or no effect on mortality in adults living with HIV (RR 0.91, 95% CI 0.72 to 1.15; 7 trials, 2897 participants, low certainty evidence).Routine supplementation for up to two years may have little or no effect on the average of mean CD4+ cell count (MD 26.40 cells/mm³, 95% CI -22.91 to 75.70; 6 trials, 1581 participants, low certainty evidence), or the average of mean viral load (MD -0.1 log₁₀viral copies, 95% CI -0.26 to 0.06; 4 trials, 840 participants, moderate certainty evidence). One additional trial in ART-naïve adults did report an increase in the time to reach a CD4+ cell count < 250 cells/mm³ after two years of high dose supplementation in Botswana (HR 0.48, 95% CI 0.26 to 0.88; 1 trial, 439 participants). However, the trial authors reported this effect only in the trial arm that received multiple micronutrients plus selenium (not either supplementation alone), which is inconsistent with the findings of other trials that used similar combinations of micronutrients and selenium.In one additional trial that compared high-dose multiple micronutrient supplementation with standard doses in people on ART, peripheral neuropathy was lower with high dose supplements compared to standard dose (incidence rate ratio (IRR) 0.81, 95% CI 0.7 to 0.94; 1 trial, 3418 participants), but the trial was stopped early due to increased adverse events (elevated alanine transaminase (ALT) levels) in the high dose group. Single or dual micronutrientsNone of the trials of single or dual micronutrient supplements were adequately powered to assess for effects on mortality or morbidity outcomes. No clinically significant changes in CD4 cell count (data not pooled, 14 trials, 2370 participants, very low or low certainty evidence) or viral load (data not pooled, seven studies, 1334 participants, very low or low certainty evidence), were reported. Supplementation probably does increase blood concentrations of vitamin D and zinc (data not pooled, vitamin D: 4 trials, 299 participants, zinc: 4 trials, 484 participants, moderate certainty evidence) and may also increase blood concentrations of vitamin A (data not pooled, 3 trials, 495 participants, low certainty evidence), especially in those who are deficient.

AUTHORS' CONCLUSIONS

The analyses of the available trials have not revealed consistent clinically important benefits with routine multiple micronutrient supplementation in people living with HIV. Larger trials might reveal small but important effects.These findings should not be interpreted as a reason to deny micronutrient supplements for people living with HIV where specific deficiencies are found or where the person's diet is insufficient to meet the recommended daily allowance of vitamins and minerals.

Association between serum vitamin D, retinol and zinc status, and acute respiratory infections in underweight and normal-weight children aged 6–24 months living in an urban slum in Bangladesh

We conducted a longitudinal assessment in 466 underweight and 446 normal-weight children aged 6–24 months living in the urban slum of Dhaka, Bangladesh to determine the association between vitamin D and other micronutrient status with upper respiratory tract infection (URI) and acute lower respiratory infection (ALRI). Incidence rate ratios of URI and ALRI were estimated using multivariable generalized estimating equations. Our results indicate that underweight children with insufficient and deficient vitamin D status were associated with 20% and 23–25% reduced risk of URI, respectively, compared to children with sufficient status. Underweight children, those with serum retinol deficiency were at 1·8 [95% confidence interval (CI) 1·4–2·4] times higher risk of ALRI than those with retinol sufficiency. In normal-weight children there were no significant differences between different vitamin D status and the incidence of URI and ALRI. However, normal-weight children with zinc insufficiency and those that were serum retinol deficient had 1·2 (95% CI 1·0–1·5) times higher risk of URI and 1·9 (95% CI 1·4–2·6) times higher risk of ALRI, respectively. Thus, our results should encourage efforts to increase the intake of retinol-enriched food or supplementation in this population. However, the mechanisms through which vitamin D exerts beneficial effects on the incidence of childhood respiratory tract infection still needs further research.

Serum Zinc Concentration and C-Reactive Protein in Individuals with Human Immunodeficiency Virus Infection: the Positive Living with HIV (POLH) Study

Low zinc levels and chronic inflammation are common in individuals infected with human immunodeficiency virus (HIV). Zinc deficiency may promote systemic inflammation, but research on the role of zinc in inflammation among HIV-positive individuals taking account of anti-retroviral therapy is lacking. We assessed the association between serum zinc and C-reactive protein (CRP) concentration in a cohort of HIV-positive individuals. A cross-sectional survey was conducted among 311 HIV-positive individuals (177 men and 134 women) aged 18-60 years residing in Kathmandu, Nepal. High-sensitive or regular serum CRP concentrations were measured by the latex agglutination nephelometry or turbidimetric method, and zinc concentrations were measured by the atomic absorption method. Relationships were assessed using multiple linear regression analysis. The geometric means of zinc in men and women were 73.83 and 71.93 ug/dL, respectively, and of CRP were 1.64 and 0.96 mg/L, respectively. Mean serum CRP concentration was significantly decreased with increasing serum zinc concentration across zinc tertiles (P for trend = 0.010), with mean serum CRP concentration in the highest tertile of serum zinc concentration was 44.2 % lower than that in the lowest tertile. The mean serum CRP concentrations in men and women in the highest tertile of serum zinc concentrations were 30 and 35.9 % lower, respectively, than that in the lowest tertile (P for trend = 0.263 and 0.162, respectively). We found a significant inverse relation between log zinc and log CRP concentrations (beta for 1 unit change in log zinc; β = -1.79, p = 0.0003). Serum zinc concentration may be inversely associated with serum CRP concentration in HIV-positive individuals.

Inflammation and Nutritional Science for Programs/Policies and Interpretation of Research Evidence (INSPIRE)

An increasing recognition has emerged of the complexities of the global health agenda—specifically, the collision of infections and noncommunicable diseases and the dual burden of over- and undernutrition. Of particular practical concern are both 1) the need for a better understanding of the bidirectional relations between nutritional status and the development and function of the immune and inflammatory response and 2) the specific impact of the inflammatory response on the selection, use, and interpretation of nutrient biomarkers. The goal of the Inflammation and Nutritional Science for Programs/Policies and Interpretation of Research Evidence (INSPIRE) is to provide guidance for those users represented by the global food and nutrition enterprise. These include researchers (bench and clinical), clinicians providing care/treatment, those developing and evaluating programs/interventions at scale, and those responsible for generating evidence-based policy. The INSPIRE process included convening 5 thematic working groups (WGs) charged with developing summary reports around the following issues: 1) basic overview of the interactions between nutrition, immune function, and the inflammatory response; 2) examination of the evidence regarding the impact of nutrition on immune function and inflammation; 3) evaluation of the impact of inflammation and clinical conditions (acute and chronic) on nutrition; 4) examination of existing and potential new approaches to account for the impact of inflammation on biomarker interpretation and use; and 5) the presentation of new approaches to the study of these relations. Each WG was tasked with synthesizing a summary of the evidence for each of these topics and delineating the remaining gaps in our knowledge. This review consists of a summary of the INSPIRE workshop and the WG deliberations.

Interactions between nutrition and immune function: using inflammation biomarkers to interpret micronutrient status

The immune response promotes a complex series of reactions by the host in an effort to prevent ongoing tissue damage, isolate and destroy the infective organism and activate the repair processes that are necessary for restoring normal function. The homoeostatic process is known as inflammation and the early set of reactions that are induced are known as the acute phase response (APR). The APR has marked effects on the circulation, metabolism in the liver and the plasma concentration of many nutrients. The changes in nutrient concentrations follow a cyclic pattern; occurring before any clinical evidence of disease, being at their most pronounced during the disease and remaining in convalescence when all evidence of disease or trauma has disappeared. Therefore, where susceptibility to disease is high as in people who are HIV+ but still apparently healthy, obtaining an accurate measurement of nutritional status may not be possible. Accurate measurements of status are important for national statistics to plan for the proper utilisation of government resources and they are especially important to evaluate the effectiveness of nutritional interventions. Many acute phase proteins (APP) are synthesised during inflammation and they are used to monitor the progress of disease and recovery but, individually, none of their lifecycles compare well with those of the nutritional biomarkers. Nevertheless, recognising the presence of inflammation can help interpret data and, using two APP, this review paper will illustrate the methods we have developed to assist interpretation of plasma retinol, ferritin and zinc concentrations in apparently healthy, HIV+, Kenyan adults.

Zinc and glycemic control: a meta-analysis of randomised placebo controlled supplementation trials in humans

BACKGROUND

Impaired zinc metabolism is prominent in chronic disorders including cardiovascular disease and diabetes. Zinc has the potential to affect glucose homeostasis in animals and humans and hence impact the risk of type 2 diabetes mellitus.

METHODS

A systematic review and meta-analysis of randomised placebo controlled trials was conducted to determine the effect of zinc supplementation on fasting blood glucose, HbA1c, serum insulin and serum zinc concentrations. Relevant studies for inclusion were identified from a literature search of electronic databases up to July 2011.

RESULTS

Fourteen reports (n=3978 subjects) were included in the meta-analysis. In the overall analysis, a small but statistically significant reduction in fasting glucose concentrations was observed (-0.19±0.08mmol/L, P=0.013) after zinc supplementation. HbA1c tended to decrease in zinc-supplemented individuals (-0.64±0.36%, P=0.072). No significant effect was observed for serum insulin concentrations. Plasma zinc concentrations increased significantly following supplementation (+4.03±0.81μmol/L, P=0.001). In secondary analyses of participants with chronic metabolic disease (types 1 and 2 diabetes mellitus, metabolic syndrome and obesity), zinc supplementation produced a greater reduction in glucose concentrations (-0.49±0.11mmol/L, P=0.001) compared to the effect that was observed in healthy participants.

CONCLUSION

The significant albeit modest reduction in glucose concentrations and tendency for a decrease in HbA1c following zinc supplementation suggest that zinc may contribute to the management of hyperglycemia in individuals with chronic metabolic disease.

The importance of controlling for the acute-phase response in the population-based assessment of vitamin A status: a study in children of pre-school age in Uganda

OBJECTIVE

To improve estimates of vitamin A deficiency in children of pre-school age in the 2006 Uganda Demographic and Health Survey (UDHS 2006).

DESIGN

A cross-sectional study in which dried blood spot samples were analysed for C-reactive protein (CRP). Retinol-binding protein (RBP) had previously been analysed using a commercial enzyme immunoassay.

SETTING

A population-based study in Uganda.

SUBJECTS

A systematically selected subset of the dried blood spot samples collected from children aged 6–59 months for UDHS 2006. Children were categorized into ‘normal CRP’ (Group A) and ‘raised CRP’ (Group B) using a CRP cut-off of 5mg/l. A correction factor was calculated to adjust the Group B RBP values for the influence of the acute-phase response.

RESULTS

Geometric mean CRP was 6.2 (95% CI 5.5, 7.0) mg/l, 1.6 (95% CI 1.5, 1.8) mg/l and 17.9 (95% CI 16.4, 19.6) mg/l in all children, in Group A and in Group B, respectively. Geometric mean RBP in all children, in Group A and in Group B was 1.18 (95% CI 1.14, 1.22)mmol/l, 1.26 (95% CI 1.20, 1.33)mmol/l and 1.12 (95% CI 1.07, 1.17)mmol/l, respectively, before correction. Correction increased mean RBP in Group B to 1.26 (95% CI 1.21, 1.31)mmol/l. The prevalence of vitamin A deficiency (RBP,0.825mmol/l) reduced from 18.4% (95% CI 17.2, 23.0%) to 13.9% (95% CI 11.3, 16.5%).

CONCLUSIONS

Correcting for the acute-phase response significantly reduced the prevalence of vitamin A deficiency; thus, the acute-phase response should be considered when vitamin A status is assessed using RBP in order to improve population-level estimates of vitamin A deficiency.

Correlation of selenium and zinc levels to antiretroviral treatment outcomes in Thai HIV-infected children without severe HIV symptoms

Background

Deficiencies in antioxidants contribute to immune dysregulation and viral replication.

Objective

To evaluate the correlation of selenium (Se) and zinc (Zn) levels on the treatment outcomes in HIV-infected children.

Design

HIV-infected Thai children 1–12 years old, CD4 15–24%, without severe HIV symptoms were included. Se and Zn levels were measured by graphite furnace atomic absorption spectrometry at baseline and 48 weeks. Deficiency cut-offs were Se<0.1 μmol/L and Zn<9.9 μmol/L. Serum ferritin and C-reactive protein (CRP) were performed every 24 weeks. No micronutrient supplement was prescribed.

Results

141 children (38.3% male) with a median (IQR) age of 7.3 (4.2–9.0) years, were enrolled. Median baseline CD4% was 20%, HIV-RNA was 4.6 log₁₀copies/mL. At baseline, median (IQR) Se and Zn levels were 0.9 (0.7–1.0) μmol/L and 5.9 (4.8–6.9) μmol/L, respectively. None had Se deficiency while all had Zn deficiency.

Over 48 weeks, 97 initiated antiretroviral therapy (ART) and 81% achieved HIV-RNA <50 copies/mL with 11% median CD4 gain. The mean change of Se was 0.06 μmol/L (p = 0.003) and Zn was 0.42 μmol/L (p=0.003), respectively. By multivariate analysis in children who received ART, predictors for greater increase of CD4% from baseline were lower baseline CD4% (p<0.01) and higher baseline Zn level (p=0.02). The predictors for greater decrease of HIV-RNA from baseline were higher baseline HIV-RNA and higher ferritin (both p<0.01). No association of CRP to the changes from baseline of CD4% or HIV-RNA was found.

Conclusion

In HIV-infected Thai children without severe immune deficiency who commenced ART, no correlation between selenium and ART treatment outcomes were found. Higher pre-ART Zn levels were associated with significant increases in CD4 percent at 48 weeks.

Short-term zinc supplementation with dispersible tablets or zinc sulfate solution yields similar positive effects on plasma zinc concentration of young children in Burkina Faso: a randomized controlled trial

OBJECTIVE

To assess zinc absorption from dispersible tablets by investigating the effects of short-term zinc supplementation, provided either as zinc (Zn) sulfate dispersible tablets or solution, on changes in plasma Zn concentration in young children.

STUDY DESIGN

We conducted a randomized, partially-masked, placebo-controlled trial in 451 children 6 to 23 months of age in Burkina Faso, randomly assigned to receive a dispersible tablet containing 5 mg Zn, a Zn solution containing 5 mg Zn/5 mL, or a placebo solution, daily for 3 weeks. The main outcome measure was change in plasma zinc concentration after supplementation compared with baseline.

RESULTS

The mean plus or minus SD change in plasma Zn concentration (μg/dL) was significantly greater in both Zn supplemented groups (tablets: 16.9±13.1μg/dL, liquid: 16.6±14.2 μg/dL), compared with the placebo group (0.2±10.9 μg/dL; P<.001, ANOVA). In both Zn supplemented groups, but not in the placebo group, change in plasma Zn concentration was progressively less with increasing age in months (-0.79 μg/dL/mo and -1.15 μg/dL/mo, respectively; P<.001); this effect did not differ in the Zn supplemented groups (P=.18).

CONCLUSIONS

Short-term supplementation results in a large increase in plasma Zn concentration, regardless of whether the additional Zn is provided as a dispersible tablet or solution.

Effect of probiotic bacteria on microbial host defense, growth, and immune function in human immunodeficiency virus type-1 infection

The hypothesis that probiotic administration protects the gut surface and could delay progression of Human Immunodeficiency Virus type1 (HIV-1) infection to the Acquired Immunodeficiency Syndrome (AIDS) was proposed in 1995. Over the last five years, new studies have clarified the significance of HIV-1 infection of the gut associated lymphoid tissue (GALT) for subsequent alterations in the microflora and breakdown of the gut mucosal barrier leading to pathogenesis and development of AIDS. Current studies show that loss of gut CD4+ Th17 cells, which differentiate in response to normal microflora, occurs early in HIV-1 disease. Microbial translocation and suppression of the T regulatory (Treg) cell response is associated with chronic immune activation and inflammation. Combinations of probiotic bacteria which upregulate Treg activation have shown promise in suppressing pro inflammatory immune response in models of autoimmunity including inflammatory bowel disease and provide a rationale for use of probiotics in HIV-1/AIDS. Disturbance of the microbiota early in HIV-1 infection leads to greater dominance of potential pathogens, reducing levels of bifidobacteria and lactobacillus species and increasing mucosal inflammation. The interaction of chronic or recurrent infections, and immune activation contributes to nutritional deficiencies that have lasting consequences especially in the HIV-1 infected child. While effective anti-retroviral therapy (ART) has enhanced survival, wasting is still an independent predictor of survival and a major presenting symptom. Congenital exposure to HIV-1 is a risk factor for growth delay in both infected and non-infected infants. Nutritional intervention after 6 months of age appears to be largely ineffective. A meta analysis of randomized, controlled clinical trials of infant formulae supplemented with Bifidobacterium lactis showed that weight gain was significantly greater in infants who received B. lactis compared to formula alone. Pilot studies have shown that probiotic bacteria given as a supplement have improved growth and protected against loss of CD4+ T cells. The recognition that normal bacterial flora prime neonatal immune response and that abnormal flora have a profound impact on metabolism has generated insight into potential mechanisms of gut dysfunction in many settings including HIV-1 infection. As discussed here, current and emerging studies support the concept that probiotic bacteria can provide specific benefit in HIV-1 infection. Probiotic bacteria have proven active against bacterial vaginosis in HIV-1 positive women and have enhanced growth in infants with congenital HIV-1 infection. Probiotic bacteria may stabilize CD4+ T cell numbers in HIV-1 infected children and are likely to have protective effects against inflammation and chronic immune activation of the gastrointestinal immune system.

Gastrointestinal factors influencing zinc absorption and homeostasis

Diet-derived luminal factors have a major influence on zinc available for uptake across the apical membrane of enterocytes. Malabsorption and possibly intestinal microbiota limit this zinc availability. The transporter ZIP4 is expressed along the entire gastrointestinal tract and acts as a major processor of dietary zinc for loading into enterocytes from the apical membrane. Zip4 and other Zip family genes expressed in the gastrointestinal tract are up-regulated in periods of dietary zinc restriction. This provides for powerful homeostatic control. The transporter ZIP14 is up-regulated along the entire gastrointestinal tract by proinflammatory conditions. Intracellular transporters such as ZnT7, influence the transcellular movement of zinc across the enterocyte. Metallothionein, an intracellular metal buffer, and the transporter ZnT1 at the basolateral membrane, regulate the amount of zinc released to the portal circulation for systemic distribution. Pancreatic release of zinc by acinar cells is through the secretory process and apical membrane and involves transporters ZnT2 and ZnT1, respectively. Expression of both transporters is zinc-responsive. Enterocytes and acinar cells constitutively express Zip5 at the basolateral membrane, where it may serve as a monitor of zinc status.