Cognitive Performance in Indian School-Going Adolescents Is Positively Affected by Consumption of Iron-Biofortified Pearl Millet: A 6-Month Randomized Controlled Efficacy Trial

Nutritional status of school-age children (5-19 years) in South Asia: A scoping review

Information on malnutrition for school-age children and adolescents (5-19 years) in South Asia is fragmented and inconsistent, which limits the prioritization of nutrition policies, programmes and research for this age group. This scoping review aimed to synthesize existing evidence on the burden of malnutrition for children and adolescents aged 5-19 years in South Asia, and on interventions to improve their nutritional status. Cochrane Library, EMBASE, Medline and Google Scholar were systematically searched for articles published between January 2016 and November 2022. Eligible studies reported the prevalence of undernutrition, overweight/obesity, micronutrient deficiencies and unhealthy dietary intakes, and interventions that aimed to address these in South Asia. In total, 296 articles met our inclusion criteria. Evidence revealed widespread, yet heterogeneous, prevalence of undernutrition among South Asian children and adolescents: thinness (1.9%-88.8%), wasting (3%-48%), underweight (9.5%-84.4%) and stunting (3.7%-71.7%). A triple burden of malnutrition was evident: the prevalence of overweight and obesity ranged from 0.2% to 73% and 0% to 38% (with rapidly rising trends), respectively, alongside persistent micronutrient deficiencies. Diets often failed to meet nutritional requirements and high levels of fast-food consumption were reported. Education, fortification, supplementation and school feeding programmes demonstrated beneficial effects on nutritional status. Comprehensive and regular monitoring of all forms of malnutrition among children and adolescents, across all countries in South Asia is required. Further, more large-scale intervention research is needed to ensure policy and programmes effectively target and address malnutrition among children and adolescents in South Asia.

Lower serum ferritin levels are associated with worse cognitive performance in aging

OBJECTIVES

Iron is important for neurogenesis, synaptic development, and neurotransmitter synthesis. Serum ferritin (SF) is a reliable marker for assessing iron stores. Therefore, we evaluated the cognitive function associated with SF levels. We also assessed brain iron content using R2* Magnetic Resonance Imaging (MRI) and its association with SF levels.

DESIGN

Data from three cross-sectional observational studies were used. Aging Imageomics (n = 1030) was conducted on aged subjects. Health Imageomics (n = 971) and IR0NMET (n = 175) were conducted in middle-aged subjects.

SETTING AND PARTICIPANTS

Participants were enrolled at Dr. Josep Trueta University Hospital facilities. The three cohorts included a total of 2176 subjects (mean age, 52 years; 48% men).

MEASUREMENTS

SF levels were measured by standard laboratory methods. Total Digits Span (TDS), and Phonemic Verbal Fluency (PVF) were used to assess executive function. Language function was assessed by semantic verbal fluency (SVF), attention by the Symbol Digit Modalities Test, and memory by the Memory Binding Tests - Total Free Recall and Total Delayed Free Recall. MRI was used to assess the iron content of the brain by R2*.

RESULTS

In subjects aged 65 years or older, SF levels were associated with increased TDS (β = 0.003, p = 0.02), PVF (β = 0.004, p = 0.01), and SVF (β = 0.004, p = 0.002) scores. After stratification by sex, these findings were significant only in men, where SF was associated with increased TDS (β = 0.003, p = 0.01), PVF (β = 0.004, p = 0.03), and SVF (β = 0.004, p = 0.009) scores. In middle-aged subjects, SF was also associated with increased SVF scores (β = 0.005, p = 0.011). Lastly, in men, SF levels were negatively associated with R2*, a surrogate marker of brain iron content, in both the left frontal inferior opercular area (r = -0.41, p = 0.005) and the right frontal inferior opercular area (r = -0.44, p = 0.002).

CONCLUSIONS

SF is significantly and positively associated with cognition. In older people with low SF levels, iron supplementation may be a promising therapy to improve cognition.

Does millet consumption contribute to raising blood hemoglobin levels compared to regular refined staples?: a systematic review and meta-analysis

Millets are recognized for their health and nutritional values, and the United Nations declared 2023 the International Year of Millets. Among the several health and nutritional benefits of millets, their impact on hemoglobin concentration is important since anemia is a major public health issue in many countries. To investigate the effect of millet (including sorghum) consumption on hemoglobin concentration in the blood, a systematic review and meta-analysis were conducted. Thirteen published studies featuring randomized control trials involving 590 individuals in the intervention group and 549 control individuals were eligible for the meta-analysis. The difference-in-differences analysis revealed highly significant (p < 0.01) positive effects of millet consumption on hemoglobin concentration, with an effect size of +0.68 standardized mean difference units. The change in hemoglobin concentration observed in the intervention group was +13.6%, which is statistically significant (p < 0.0005), compared to that in the control group, which was +4.8% and not statistically significant (p = 0.1362). In four studies, the consumption of millets in the intervention group demonstrated a change from mild anemia to normal status among children, whereas there was no change in the control group. The findings provide evidence that the consumption of millets can improve blood hemoglobin concentration, likely resulting from increased iron intake. Further research is needed involving the assessment of iron content and bioavailability to better understand the effect variation among millet types and the mechanisms involved.

Assessing the pattern electroretinogram as a proxy measure for dopamine in the context of iron deficiency

OBJECTIVES

Animal studies have suggested that dietary iron deficiency (ID) negatively affects dopamine (DA) synthesis and re-uptake, which in turn negatively affects memory and cognition. This study was intended to assess whether the pattern electroretinogram (pattern ERG) could be used as an indirect measure of DA in college-age women with and without ID by determining the extent to which features of the ERG were sensitive to iron status and were related to other indirect measures of DA.

METHODS

The pattern ERG was measured in 21 iron deficient non-anemic (IDNA) and 21 iron sufficient (IS) women, who also performed a contrast detection and probabilistic selection task, both with concurrent electroencephalography (EEG). Both spontaneous and task-related blink rates were also measured.

RESULTS

The implicit times of the A- and B-waves were significantly longer for the IDNA than for the IS women. Both the amplitudes and implicit times of the A- and B-waves were significantly correlated with levels of serum ferritin (sFt). Only the amplitude of the A-wave was correlated with spontaneous blink rate. It was possible to accurately identify a woman's iron status solely on the basis of the implicit time of the B-wave. Finally, the implicit times of the ERG features mediated the relationship between iron levels and accuracy in the probabilistic selection task.

CONCLUSIONS

Results suggest the utility of the pattern ERG in testing the hypothesis that iron deficiency affects DA levels in humans and that this may be one of the mechanisms by which iron deficiency negatively affects cognition.

The Effect of Iron-Fortified Lentils on Blood and Cognitive Status among Adolescent Girls in Bangladesh

BACKGROUND

Iron deficiency is highly prevalent in South Asia, especially among women and children in Bangladesh. Declines in cognitive performance are among the many functional consequences of iron deficiency.

OBJECTIVE

We tested the hypothesis that, over the course of a 4-month iron fortification trial, cognitive performance would improve, and that improvement would be related to improvements in iron status.

METHODS

Participants included 359 adolescent girls attending Bangladesh Rural Advancement Committee (BRAC) clubs as a subsample of a larger double-blind, cluster-randomized community trial in which participants were assigned to one of three conditions: a condition in which no lentils were supplied (NL, n = 118, but which had the usual intake of lentils), a control (non-fortified) lentil condition (CL, n = 124), and an iron-fortified lentil condition (FL, n = 117). In the FL and CL conditions, approximately 200 g of cooked lentils were served five days per week for a total of 85 feeding days. In addition to biomarkers of iron status, five cognitive tasks were measured at baseline (BL) and endline (EL): simple reaction time task (SRT), go/no-go task (GNG), attentional network task (ANT), the Sternberg memory search Task (SMS), and a cued recognition task (CRT).

RESULTS

Cognitive performance at EL was significantly better for those in the FL relative to the CL and NL conditions, with this being true for at least one variable in each task, except for the GNG. In addition, there were consistent improvements in cognitive performance for those participants whose iron status improved. Although there were overall declines in iron status from BL to EL, the declines were smallest for those in the FL condition, and iron status was significantly better for those in FL condition at EL, relative to those in the CL and NL conditions.

CONCLUSIONS

the provision of iron-fortified lentils provided a protective effect on iron status in the context of declines in iron status and supported higher levels of cognitive performance for adolescent girls at-risk of developing iron deficiency.

Nourishing the Cognition with Millets: A Comprehensive Review of Their Nutritional Impact and Potential as Cognitive Enhancers

Cognition is the mental processes and abilities involved in acquiring, storing, retrieving and using it for decision making. Cognitive decline due to aging, lifestyle factor, chronic health conditions, genetic, and environmental factors are rising global concern and propose a potential threat to the cognitive health. The nutritional imbalance has led to increase in cognitive disorders around the world. Millets can be a nutritional intervention for promoting cognitive health and preventing cognitive decline. Millets has abundant phenolic compounds, flavonoids, and antioxidants to protect against oxidative stress-induced cognitive impairment. Millets exert neuroprotective effects by modulating pathways involved in neuronal-survival, synaptic-plasticity, and release of brain-derived neurotrophic factor. Millets demonstrates anti-inflammatory properties by regulating inflammatory-pathways and suppressing cytokines associated with cognitive impairment. Millets maintain healthy gut microbiota by producing metabolites such as short-chain fatty acids, which influence brain function and cognition. However, further research is needed to elucidate the underlying mechanisms and on optimizing the proportion do exploit its potential. Implementing millet-based dietary strategies through public health initiatives and educational programs can be a practical approach to support cognitive health across populations. Harnessing the potential of millets as a nutritional intervention offers a promising avenue for promoting cognitive health and improving the quality of life.

Iron status, development, and behavior in young children in the Pennsylvania foster care system

BACKGROUND

Children in foster care are classified as a highly vulnerable population and struggle with both physical and mental health problems. Medical conditions, like poor nutritional status, remain understudied in children in foster care. To our knowledge, few studies in children in U.S. foster care have quantified the prevalence of anemia, and no studies have examined the association between anemia status and relevant developmental and behavioral outcomes.

OBJECTIVE/AIMS

(1) To determine the prevalence of anemia among children in or adopted from Pennsylvania foster care, between the ages of six months to ten years and (2) To examine if a child's anemia status is associated with greater odds of relevant developmental and behavioral diagnoses.

METHODS

We conducted a secondary data analysis utilizing the Medicaid Analytic eXtract database between 2010-2015. Children six months-ten years were included in the analysis if they were in or had been adopted from Pennsylvania foster care. Logistic regression was used to calculate adjusted odds ratios (AOR) with 95% confidence intervals for the association between iron status and health outcomes.

RESULTS

A total of 50,311 children were included in our sample, of which 1,365 children (2.7%) were diagnosed with anemia. Children diagnosed with anemia had greater odds of delayed milestones (AOR: 2.38 [1.64-3.45]), specific delays in development (AOR: 1.59 [1.23-2.07]), adjustment disorder (AOR: 1.59 [1.06-2.39]), and irritability (AOR: 10.57 [3.36-33.25]), than children not diagnosed with anemia.

CONCLUSION

The prevalence of anemia among children between six months-ten years in or adopted from the Pennsylvania foster care system is within the national rate of U.S. childhood anemia. Odds of several relevant developmental and behavioral diagnoses were greater among children diagnosed with anemia than children who were not.

Development of Iron Status Measures during Youth: Associations with Sex, Neighborhood Socioeconomic Status, Cognitive Performance, and Brain Structure

BACKGROUND

Iron is essential to brain function, and iron deficiency during youth may adversely impact neurodevelopment. Understanding the developmental time course of iron status and its association with neurocognitive functioning is important for identifying windows for intervention.

OBJECTIVES

This study aimed to characterize developmental change in iron status and understand its association with cognitive performance and brain structure during adolescence using data from a large pediatric health network.

METHODS

This study included a cross-sectional sample of 4899 participants (2178 males; aged 8-22 y at the time of participation, M [SD] = 14.24 [3.7]) who were recruited from the Children's Hospital of Philadelphia network. Prospectively collected research data were enriched with electronic medical record data that included hematological measures related to iron status, including serum hemoglobin, ferritin, and transferrin (33,015 total samples). At the time of participation, cognitive performance was assessed using the Penn Computerized Neurocognitive Battery, and brain white matter integrity was assessed using diffusion-weighted MRI in a subset of individuals.

RESULTS

Developmental trajectories were characterized for all metrics and revealed that sex differences emerged after menarche such that females had reduced iron status relative to males [all R2partial > 0.008; all false discovery rates (FDRs) < 0.05]. Higher socioeconomic status was associated with higher hemoglobin concentrations throughout development (R2partial = 0.005; FDR < 0.001), and the association was greatest during adolescence. Higher hemoglobin concentrations were associated with better cognitive performance during adolescence (R2partial = 0.02; FDR < 0.001) and mediated the association between sex and cognition (mediation effect = -0.107; 95% CI: -0.191, -0.02). Higher hemoglobin concentration was also associated with greater brain white matter integrity in the neuroimaging subsample (R2partial = 0.06, FDR = 0.028).

CONCLUSIONS

Iron status evolves during youth and is lowest in females and individuals of low socioeconomic status during adolescence. Diminished iron status during adolescence has consequences for neurocognition, suggesting that this critical period of neurodevelopment may be an important window for intervention that has the potential to reduce health disparities in at-risk populations.

Shooting shadows: India's struggle to reduce the burden of anaemia

Despite several efforts by the Government of India, the national burden of anaemia remains high and its growing prevalence (between 2015-2016 and 2019-2021) is concerning to India's public health system. This article reviews existing food-based and clinical strategies to mitigate the anaemia burden and why they are premature and insufficient. In a context where multiple anaemia control programmes are in play, this article proposes a threefold strategy for consideration. First, except the Comprehensive National Nutrition Survey, 2016-2018, which measured Hb concentration among children and adolescents aged 1-19 years using venous blood samples, all national surveys use capillary blood samples to determine Hb levels, which could be erroneous. The Indian government should prioritise conducting a nationwide survey for estimating the burden of anaemia and its clinical determinants for all age groups using venous blood samples. Second, without deciding the appropriate dose of Fe needed for an individual, food fortification programmes that are often compounded with layering of other micronutrients could be harmful and further research on this issue is needed. Same is true for the pharmacological intervention of Fe tablet or syrup supplementation programmes, which is given to individuals without assessing its need. In addition, there is a dire need for robust research to understand both the long-term benefit and side effects of Fe supplementation programmes. Third and final, the WHO is in process of reviewing the Hb threshold for defining anaemia, therefore the introduction of new anaemia control programmes should be restrained.

Biofortification to avoid malnutrition in humans in a changing climate: Enhancing micronutrient bioavailability in seed, tuber, and storage roots

Malnutrition results in enormous socio-economic costs to the individual, their community, and the nation's economy. The evidence suggests an overall negative impact of climate change on the agricultural productivity and nutritional quality of food crops. Producing more food with better nutritional quality, which is feasible, should be prioritized in crop improvement programs. Biofortification refers to developing micronutrient -dense cultivars through crossbreeding or genetic engineering. This review provides updates on nutrient acquisition, transport, and storage in plant organs; the cross-talk between macro- and micronutrients transport and signaling; nutrient profiling and spatial and temporal distribution; the putative and functionally characterized genes/single-nucleotide polymorphisms associated with Fe, Zn, and β-carotene; and global efforts to breed nutrient-dense crops and map adoption of such crops globally. This article also includes an overview on the bioavailability, bioaccessibility, and bioactivity of nutrients as well as the molecular basis of nutrient transport and absorption in human. Over 400 minerals (Fe, Zn) and provitamin A-rich cultivars have been released in the Global South. Approximately 4.6 million households currently cultivate Zn-rich rice and wheat, while ~3 million households in sub-Saharan Africa and Latin America benefit from Fe-rich beans, and 2.6 million people in sub-Saharan Africa and Brazil eat provitamin A-rich cassava. Furthermore, nutrient profiles can be improved through genetic engineering in an agronomically acceptable genetic background. The development of "Golden Rice" and provitamin A-rich dessert bananas and subsequent transfer of this trait into locally adapted cultivars are evident, with no significant change in nutritional profile, except for the trait incorporated. A greater understanding of nutrient transport and absorption may lead to the development of diet therapy for the betterment of human health.

Improving nutrition through biofortification-A systematic review

Nutritious foods are essential for human health and development. However, malnutrition and hidden hunger continue to be a challenge globally. In most developing countries, access to adequate and nutritious food continues to be a challenge. Although hidden hunger is less prevalent in developed countries compared to developing countries where iron (Fe) and zinc (Zn) deficiencies are common. The United Nations (UN) 2nd Sustainable Development Goal was set to eradicate malnutrition and hidden hunger. Hidden hunger has led to numerous cases of infant and maternal mortalities, and has greatly impacted growth, development, cognitive ability, and physical working capacity. This has influenced several countries to develop interventions that could help combat malnutrition and hidden hunger. Interventions such as dietary diversification and food supplementation are being adopted. However, fortification but mainly biofortification has been projected to be the most sustainable solution to malnutrition and hidden hunger. Plant-based foods (PBFs) form a greater proportion of diets in certain populations; hence, fortification of PBFs is relevant in combating malnutrition and hidden hunger. Agronomic biofortification, plant breeding, and transgenic approaches are some currently used strategies in food crops. Crops such as cereals, legumes, oilseeds, vegetables, and fruits have been biofortified through all these three strategies. The transgenic approach is sustainable, efficient, and rapid, making it suitable for biofortification programs. Omics technology has also been introduced to improve the efficiency of the transgenic approach.

Associations between red blood cell indices and iron status and neurocognitive function in young adults: Evidence from memory and executive function tests and event-related potentials

Cognitive impairment has been associated with anemia and iron deficiency; however, brain electrophysiological studies correlating red blood cell (RBC) indices and iron status to cognition in adulthood are scarce. We aimed to assess neurocognitive function in young adults of the general population and its correlation with RBC indices and iron status. Neurocognitive function was investigated using scalp-recorded event-related potentials (ERPs) within the context of a task-switching paradigm. ERPs and test performance were also compared across groups of "high"/"low" RBC and iron indices. Working memory was examined using the digit span test, in which mean corpuscular hemoglobin (MCH), mean corpuscular volume (MCV), and ferritin were found to be significant predictors of test performance, with higher MCH/MCV/ferritin being associated with better test scores. In the switching task, MCH, MCV, and ferritin were found to be significant predictors of task performance, with higher MCH/MCV/ferritin levels associated with a lower percentage of errors. Electrophysiological results showed that MCH and MCV were significant predictors of ERPs amplitude, with lower MCH/MCV levels associated with greater amplitude, which may reflect compensatory processes. P1, N1, P2, and P3 were greater for the low MCH/MCV groups. This is the first evidence of association between levels of MCH/MCV and brain function while engaged in an executive function task; possibly reflecting brain iron availability.

Micronutrient interventions among vulnerable population over a decade: A systematic review on Indian perspective

Background: Micronutrient deficiency has long been recognized as a public health problem, particularly among vulnerable groups such as children, adolescents, pregnant and lactating women. Micronutrient deficiency could not be ruled out in spite of the implementation of various intervention strategies. Different interventions are being used to prevent and treat micronutrient deficiencies at the national and global level. The aim of this study is to systematically review the intervention strategies among different vulnerable age groups in India.

Methods: The review was focused on identifying various interventions published based on the internet databases and the peer-reviewed papers from 2011 to 2021, on the predefined inclusive/exclusive criteria. The major intervention strategies implemented in India were recognized and evaluated based on dietary supplementation, micronutrient supplementation, knowledge interventions and food fortification among various age groups.

Results: The results show that there are still considerable gaps in identifying the effective intervention strategies, research initiatives, programs and policies addressing to tackle micronutrient deficiencies in India. Multiple interventions are effective that could lead the road to innovations in approaches with diverse dietary intake, developing multiple micronutrient supplements, fortifying foods and nutrition interventions to address calcium, zinc, iodine, vitamin D and vitamin A deficiencies among the vulnerable population.

Conclusion: Evidence-based multiple intervention studies covering a large population, in the long term cross-sectional, is the need for the hour to design policies and programs for improving the micronutrient status of vulnerable population in the community.

Modeling relationships between iron status, behavior, and brain electrophysiology: evidence from a randomized study involving a biofortified grain in Indian adolescents

Background

Iron deficiency (ID) and iron deficiency anemia (IDA) are highly-prevalent nutrient deficiencies and have been shown to have a range of negative effects on cognition and brain function. Human intervention studies including measures at three levels—blood, brain, and behavior—are rare and our objective was to model the relationships among measures at these three levels in school-going Indian adolescents.

Methods

Male and female adolescents in rural India were screened for ID/IDA. Subjects consumed 2 meals/day for 6 months; half were randomly assigned to consume meals made from a standard grain (pearl millet) and half consumed meals made from an iron biofortified pearl millet (BPM). Prior to and then at the conclusion of the feeding trial, they completed a set of cognitive tests with concurrent electroencephalography (EEG).

Results

Overall, serum ferritin (sFt) levels improved over the course of the study. Ten of 21 possible measures of cognition showed improvements from baseline (BL) to endline (EL) that were larger for those consuming BPM than for those consuming the comparison pearl millet (CPM). Critically, the best model for the relationship between change in iron status and change in cognition had change in brain measures as a mediating factor, with both change in serum ferritin as a primary predictor and change in hemoglobin as a moderator.

Conclusions

A dietary intervention involving a biofortified staple grain was shown to be efficacious in improving blood iron biomarkers, behavioral measures of cognition, and EEG measures of brain function. Modeling the relationships among these variables strongly suggests multiple mechanisms by which blood iron level affects brain function and cognition.

Trial registration

Registered at ClinicalTrials.gov, NCT02152150, 02 June 2014.

Supplementary Information

The online version contains supplementary material available at (10.1186/s12889-022-13612-z).

Changes in anemia and anthropometry during adolescence predict learning outcomes: findings from a 3-year longitudinal study in India

BACKGROUND

Anemia and poor physical growth during adolescence have far-ranging consequences, but limited longitudinal evidence exists on how changes in these factors relate to changes in learning skills as adolescents mature.

OBJECTIVES

We examined the association between changes in anemia and physical growth during adolescence and learning outcomes.

METHODS

We used longitudinal data from the Understanding the Lives of Adolescents and Young Adults (UDAYA) project, which surveyed adolescents aged 10-19 y in northern India in 2015-2016 and 2018-2019 (n = 5963). We used multilevel mixed-effects logistic regression models to examine associations between changes in anemia/thinness/stunting status (4 groups: never, improved, new, and persistent) and reading (ability to read a story) and math proficiency (ability to solve division problems) at follow-up.

RESULTS

Persistent anemia and stunting were higher among girls than among boys (46% compared with 8% and 37% compared with 14%, respectively), but persistent thinness was lower (7% compared with 16%). Improvement in anemia, thinness, and stunting was 1.4-1.7 times higher among boys than among girls. Boys who were anemic in both waves were 74% [adjusted odds ratio (AOR): 0.26; 95% CI: 0.12, 0.59] and 65% (AOR: 0.35; 95% CI: 0.16, 0.76) less likely to be able to read a story and solve division problems, respectively, than boys who were nonanemic in both waves. Persistent thinness in boys was negatively associated with both reading (AOR: 0.37; 95% CI: 0.21, 0.66) and math proficiency (AOR: 0.27; 95% CI: 0.16, 0.46). Persistent stunting contributed to lower reading and math proficiency in boys and girls (AORs: 0.29-0.46). Boys whose anemia or thinness status improved and girls whose stunting status improved had similar learning skills at follow-up as those who were never anemic/thin/stunted.

CONCLUSIONS

Persistent anemia, thinness, and short stature during adolescence were associated with poor learning. Programs targeted at adolescents should contribute to nurturing environments that foster healthy growth and learning.

Can Nutrients and Dietary Supplements Potentially Improve Cognitive Performance Also in Esports?

Factors influencing brain function and cognitive performance can be critical to athletic performance of esports athletes. This review aims to discuss the potential beneficial effects of micronutrients, i.e., vitamins, minerals and biologically active substances on cognitive functions of e-athletes. Minerals (iodine, zinc, iron, magnesium) and vitamins (B vitamins, vitamins E, D, and C) are significant factors that positively influence cognitive functions. Prevention of deficiencies of the listed ingredients and regular examinations can support cognitive processes. The beneficial effects of caffeine, creatine, and probiotics have been documented so far. There are many plant products, herbal extracts, or phytonutrients that have been shown to affect precognitive activity, but more research is needed. Beetroot juice and nootropics can also be essential nutrients for cognitive performance. For the sake of players’ eyesight, it would be useful to use lutein, which, in addition to improving vision and protecting against eye diseases, can also affect cognitive functions. In supporting the physical and mental abilities of e-athletes the base is a well-balanced diet with adequate hydration. There is a lack of sufficient evidence that has investigated the relationship between dietary effects and improved performance in esports. Therefore, there is a need for randomized controlled trials involving esports players.

Biofortified Wheat Increases Dietary Zinc Intake: A Randomised Controlled Efficacy Study of Zincol-2016 in Rural Pakistan

A new variety of zinc biofortified wheat (Zincol-2016) was released in Pakistan in 2016. The primary aim of this study was to examine the effects of consuming Zincol-2016 wheat flour on biochemical and functional markers of zinc status in a population with widespread zinc deficiency. An individually-randomised, double-blind, placebo-controlled cross over design was used. Fifty households were recruited to participate in the study, with each household included at least one woman of reproductive age (16–49 years) who was neither pregnant nor breast feeding or currently taking nutritional supplements. All households were provided with control flour for an initial 2-week baseline period, followed by the intervention period where households were randomly allocated in a 1:1 ratio to receive biofortified flour (group A; n = 25) and control flour (group B; n = 25) for 8-weeks, then switched to the alternate flour for 8-weeks. The trial has been registered with the ISRCTN (https://www.isrctn.com), ID ISRCTN83678069. The primary outcome measure was plasma zinc concentration, and the secondary outcome measures were plasma selenium and copper concentrations, plasma copper:zinc ratio and fatty acid desaturase and elongase activity indices. Nutrient intake was assessed using 24-h dietary recall interviews. Mineral concentrations in plasma were measured using inductively coupled plasma mass spectrometry and free fatty acids and sphingolipids by mass spectrometry. Linear Mixed Model regression and General Linear Model with repeated measures were used to analyse the outcomes. Based on an average flour consumption of 224 g/day, Zincol-2016 flour provided an additional daily zinc intake of between 3.0 and 6.0 mg for white and whole grain flour, respectively. No serious adverse events were reported. This resulted in significant, increase in plasma zinc concentration after 4 weeks [mean difference 41.5 μg/L, 95% CI (6.9–76.1), p = 0.02]. This was not present after 8 weeks (p = 0.6). There were no consistent significant effects of the intervention on fatty acid desaturase and elongase activity indices. Regular consumption of Zincol-2016 flour increased the daily zinc intake of women of reproductive age by 30–60%, however this was not associated with a sustained improvement in indices of zinc status.

Iron Status, Anemia, and Iron Interventions and Their Associations with Cognitive and Academic Performance in Adolescents: A Systematic Review

In adolescents, iron-deficiency anemia is the leading cause of disability-adjusted life years lost. The World Health Organization recommends delivering iron supplementation through school-based platforms, requiring partnerships with the education sector. This anemia-reduction intervention is valued for the perceived benefits of improved learning and school performance. This article aims to systematically review the available evidence on the relationship between iron status and anemia and impacts of iron interventions on cognitive and academic performance in adolescents. Fifty studies were included: n = 26 cross-sectional and n = 24 iron-containing interventions. Our review suggests that iron status and anemia may be associated with academic performance in some contexts and that iron supplementation during adolescence may improve school performance, attention, and concentration. However, nearly all supplementation trials were judged to have moderate or high risk of bias. We did not find evidence suggesting that iron status and anemia influenced or were associated with attention, intelligence, nor memory in adolescents. Further, iron supplementation did not improve memory and recall or intelligence. Overall, more high-quality research is needed to guide programmers and policy makers to understand the relationships between anemia and educational performance and the potential impacts of iron interventions, which effectively reduce anemia, on adolescents’ learning and school performance.

Effects of iron intake on neurobehavioural outcomes in African children: a systematic review and meta-analysis of randomised controlled trials

Background: Iron deficiency and developmental delay are common in African children. While experimental studies indicate an important role of iron in brain development, effects of iron on child development remain unclear. We aimed to evaluate the effects of iron supplementation or fortification on neurobehavioural outcomes in African children and further summarise these effects in children living in non-African countries for comparison. Methods: We searched PubMed, EMBASE, PsycINFO, Scopus and Cochrane Library for studies published up to 22 nd October 2021. We included randomised controlled trials (RCTs) evaluating effects of iron supplementation or fortification on neurobehavioural outcomes in children. Due to heterogeneity in study methods, we analysed all studies qualitatively and in secondary analyses only seven RCTs with 11 arms were meta-analysed. Results: We identified 2231 studies and included 35 studies (n=9988) in the systematic review. Only five studies (n=1294) included African children while 30 (n=8694) included children living in non-African countries. Of the five African studies, two (n=647) reported beneficial effects of iron supplementation on neurobehavioural outcomes in anaemic children, while three (n=647) found no beneficial effects. Of 30 studies in children living in non-African countries, 10 (n=3105) reported beneficial effects of iron supplementation or fortification on neurobehavioural outcomes, seven (n=786) reported beneficial effects only in children who had iron deficiency, iron deficiency anaemia or anaemia while 13 (n=4803) reported no beneficial effects. Conclusions: There are few studies in African children despite the high burden of iron deficiency and developmental delay in this population. Evidence on the effects of iron supplementation on neurobehavioural outcomes remains unclear and there is need for further well-powered studies evaluating these effects in African populations. PROSPERO registration: CRD42018091278 (20/03/2018).

Nutrients for executive function development and related brain connectivity in school-aged children

Executive functions refer to a set of higher-order cognitive processes involved in the control and organization of information to serve goal-directed behaviors. Skills in executive functioning are developed throughout childhood and adolescence and have been shown to be predictive of academic achievement. The coordination of these complex processes is critically dependent on brain maturation and connectivity, including key neurodevelopmental processes like myelination and synaptogenesis. Among other factors, research highlights the influential effect of nutrition and diet on these neurodevelopmental processes, which may impact executive function performance in healthy and deficient populations. This review considers the research to date on the role of key nutrients that have been identified for executive function development and their underlying neurophysiological processes in school-aged children.

Millets Can Have a Major Impact on Improving Iron Status, Hemoglobin Level, and in Reducing Iron Deficiency Anemia-A Systematic Review and Meta-Analysis

The prevalence of iron deficiency anemia is highest among low and middle-income countries. Millets, including sorghum, are a traditional staple in many of these countries and are known to be rich in iron. However, a wide variation in the iron composition of millets has been reported, which needs to be understood in consonance with its bioavailability and roles in reducing anemia. This systematic review and meta-analysis were carried out to analyze the scientific evidence on the bioavailability of iron in different types of millets, processing, and the impact of millet-based food on iron status and anemia. The results indicated that iron levels in the millets used to study iron bioavailability (both in vivo and in vitro) and efficacy varied with the type and variety from 2 mg/100 g to 8 mg/100 g. However, not all the efficacy studies indicated the iron levels in the millets. There were 30 research studies, including 22 human interventions and 8 in vitro studies, included in the meta-analysis which all discussed various outcomes such as hemoglobin level, serum ferritin level, and absorbed iron. The studies included finger millet, pearl millet, teff and sorghum, or a mixture of millets. The results of 19 studies conducted on anaemic individuals showed that there was a significant (p < 0.01) increase in hemoglobin levels by 13.2% following regular consumption (21 days to 4.5 years) of millets either as a meal or drink compared with regular diets where there was only 2.7% increase. Seven studies on adolescents showed increases in hemoglobin levels from 10.8 ± 1.4 (moderate anemia) to 12.2 ± 1.5 g/dl (normal). Two studies conducted on humans demonstrated that consumption of a pearl millet-based meal significantly increased the bioavailable iron (p < 0.01), with the percentage of bioavailability being 7.5 ± 1.6, and provided bioavailable iron of 1 ± 0.4 mg. Four studies conducted on humans showed significant increases in ferritin level (p < 0.05) up to 54.7%. Eight in-vitro studies showed that traditional processing methods such as fermentation and germination can improve bioavailable iron significantly (p < 0.01) by 3.4 and 2.2 times and contributed to 143 and 95% of the physiological requirement of women, respectively. Overall, this study showed that millets can reduce iron deficiency anemia.

Plant-Based Dietary Practices and Socioeconomic Factors That Influence Anemia in India

While rates of malnutrition have declined over the last decade in India due to successful government interventions, the prevalence of anemia remains high. Staple foods provide almost 70% of the daily iron intake. As staple foods are a rich source of phytate, this ingested iron is poorly absorbed. Currently, 59% of children below 3 years of age, 50% of expectant mothers and 53% of women aged 15-19 years are anemic. The most common intervention strategy has been through the use of iron supplements. While the compliance has been low and supplies irregular, such high rates of anemia cannot be explained by iron deficiency alone. This review attempts to fit dietary and cooking practices, field-level diagnostics, cultural beliefs and constraints in implementation of management strategies into a larger picture scenario to offer insights as to why anemia continues to plague India. Since the rural Indian diet is predominantly vegetarian, we also review dietary factors that influence non-heme iron absorption. As a reference point, we also contrast anemia-related trends in India to the U.S.A. Thus, this review is an effort to convey a holistic evaluation while providing approaches to address this public health crisis.

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.

Effects of iron intake on neurobehavioural outcomes in African children: a systematic review and meta-analysis of randomised controlled trials

Background: Iron deficiency and developmental delay are common in African children. While experimental studies indicate an important role of iron in brain development, effects of iron on child development remain unclear. We aimed to evaluate the effects of iron supplementation or fortification on neurobehavioural outcomes in African children and further summarise these effects in children living in non-African countries for comparison. Methods: We searched PubMed, EMBASE, PsycINFO, Scopus and Cochrane Library for studies published up to 9 th March 2021. We included randomised controlled trials (RCTs) evaluating effects of iron supplementation or fortification on neurobehavioural outcomes in children. Due to heterogeneity in study methods, we analysed the studies qualitatively and only seven RCTs with 11 arms were meta-analysed. Results: We identified 2155 studies and included 34 studies (n=9808) in the systematic review. Only five studies (n=1294) included African children while 29 (n=8514) included children living in non-African countries. Of the five African studies, two (n=647) reported beneficial effects of iron supplementation on neurobehavioural outcomes in anaemic children while three (n=647) found no beneficial effects. Of 29 studies in children living in non-African countries, nine (n=2925) reported beneficial effects of iron supplementation or fortification on neurobehavioural outcomes, seven (n=786) reported beneficial effects only in children who had iron deficiency, iron deficiency anaemia or anaemia while 13 (n=4803) reported no beneficial effects. Meta-analysis of seven studies (n=775) in non-African countries showed no beneficial effects of iron supplementation on cognitive or motor development in children. Conclusions: There are few studies in African children despite the high burden of iron deficiency and developmental delay in this population. Evidence on the effects of iron supplementation on neurobehavioural outcomes remains unclear and there is need for further well-powered studies evaluating these effects in African populations. PROSPERO registration: CRD42018091278 (20/03/2018).

In pursuit of a better world: crop improvement and the CGIAR

The CGIAR crop improvement (CI) programs, unlike commercial CI programs, which are mainly geared to profit though meeting farmers' needs, are charged with meeting multiple objectives with target populations that include both farmers and the community at large. We compiled the opinions from >30 experts in the private and public sector on key strategies, methodologies, and activities that could the help CGIAR meet the challenges of providing farmers with improved varieties while simultaneously meeting the goals of: (i) nutrition, health, and food security; (ii) poverty reduction, livelihoods, and jobs; (iii) gender equality, youth, and inclusion; (iv) climate adaptation and mitigation; and (v) environmental health and biodiversity. We review the crop improvement processes starting with crop choice, moving through to breeding objectives, production of potential new varieties, selection, and finally adoption by farmers. The importance of multidisciplinary teams working towards common objectives is stressed as a key factor to success. The role of the distinct disciplines, actors, and their interactions throughout the process from crop choice through to adoption by farmers is discussed and illustrated.

Iron-biofortified pearl millet consumption increases physical activity in Indian adolescent schoolchildren after a 6-month randomised feeding trial

Fe deficiency has negative effects on voluntary physical activity (PA); however, the impact of consuming Fe-biofortified staple foods on voluntary PA remains unclear. This study compared the effects of consuming Fe-biofortified pearl millet or a conventional pearl millet on measures of voluntary PA in Indian schoolchildren (ages 12-16 years) during a 6-month randomised controlled feeding trial. PA data were collected from 130 children using Actigraph GT3X accelerometers for 6 d at baseline and endline. Minutes spent in light and in moderate-to-vigorous PA were calculated from accelerometer counts using Crouter's refined two-regression model for children. Mixed regression models adjusting for covariates were used to assess relationships between intervention treatment or change in Fe status and PA. Children who consumed Fe-biofortified pearl millet performed 22·3 (95 % CI 1·8, 42·8, P = 0·034) more minutes of light PA each day compared with conventional pearl millet. There was no effect of treatment on moderate-to-vigorous PA. The amount of Fe consumed from pearl millet was related to minutes spent in light PA (estimate 3·4 min/mg Fe (95 % CI 0·3, 6·5, P = 0·031)) and inversely related to daily sedentary minutes (estimate -5·4 min/mg Fe (95 % CI -9·9, -0·9, P = 0·020)). Consuming Fe-biofortified pearl millet increased light PA and decreased sedentary time in Indian schoolchildren in a dose-dependent manner.

Knowledge and practices of dietary iron and anemia among early adolescents in a rural district in Ghana

The study assessed knowledge and practices of dietary iron intake and anemia among early adolescents in the Asante-Akim Municipality of Ghana. A cross-sectional study was conducted among 137 adolescents, aged 10-14 years. Structured questionnaire was used to collect data on sociodemographic, knowledge of iron, and anemia, and iron intake practices. Hemoglobin levels were determined using Hemocue 301. Data were analyzed using descriptive, chi-square test, and binary logistics regression. The mean age of participants was 11.5 years. About 40% had knowledge of iron deficiency anemia, 29.4% knew anemia causes, 86% knew symptoms of anemia, and 35% knew anemia consequences. Although 41.2% of participants knew its prevention as eating iron-rich foods, 31.4% knew the food sources of iron, and 4.4% mentioned animal-based foods as rich sources, with the bulk (27%) mentioning plant-based foods instead. Moreover, 18.2% knew iron enhancers, while 0.7% knew iron inhibitors. More chicken consumers (72.2%) than nonconsumers (56.6%) met the Estimated Average Requirement for dietary iron intake (Chi-square 3.4, p = .073), while more dried fish consumers (88%) than nonconsumers (66.7%) had normal hemoglobin levels (Chi-square 4.5, p = .050). Knowledge of food sources of iron and iron-rich foods was positively associated with intake of chicken, fresh fish, and dried fish. Moreover, lower knowledge of iron-based food sources (β = -1.015, p = .020) and iron-rich foods (β = -2.188, p = .015) was inversely associated with beef intake. Anemia was negatively associated with chicken (β = -0.310, p = .416) and dried fish (β = -1.299, p = .045) consumption. Majority of the adolescents had low knowledge of iron. Chicken and dried fish intake reduced the risk of anemia development. Our study may be the first to assess knowledge on iron, anemia, and its impact among young Ghanaian adolescents. Our findings provide insights into this topic, calling for to improve knowledge, and practices on anemia in Ghanaian adolescents.

Index of Nutritional Quality (INQ) and the Risk of Obesity in Male Adolescents: a Case-Control Study

Dietary factors may play a key role in the etiology of obesity. The Index of Nutritional Quality (INQ) provides a comprehensive overview of the nutrients content of the diet. This study aimed to investigate the association between INQ and obesity in male adolescents. We hypothesize that receiving a high-quality diet reduces the risk of overweight or obese. This study was carried out on 214 obese/overweight as the case group and 321 normal-weight male adolescents as the control group. Dietary intakes of the participants were collected using a food frequency questionnaire (FFQ). The FFQ-derived dietary data were used to calculate the INQ scores. After adjustments for age and height, an inverse association was found between obesity and INQ of iron, vitamin B6, and magnesium, and a positive association was found between obesity and INQ of zinc (all P < 0.05). After further adjustments for nutritional knowledge and calorie intake, an inverse association was observed between obesity and INQ of vitamin C, iron, vitamin B6, pantothenic acid, selenium, and magnesium (all P < 0.05). The positive association of obesity and INQ of zinc remained significant after adjustments. A higher intake of vitamin C, iron, vitamin B6, pantothenic acid, selenium, and magnesium and a lower intake of zinc may be protective against adolescent obesity. More longitudinal studies are required to investigate the relationship between these nutrients and obesity.

Limited Shared Variance among Measures of Cognitive Performance Used in Nutrition Research: The Need to Prioritize Construct Validity and Biological Mechanisms in Choice of Measures

BACKGROUND

The literature on correlates of nutrition has seen an increase in studies focused on functional consequences at the levels of neural, perceptual, and cognitive functioning. A range of measurement methodologies have been used in these studies, and investigators and funding agencies have raised the questions of how and if these various methodologies are at all comparable.

OBJECTIVE

The aim was to determine the extent to which 3 different sets of cognitive measures provide comparable information across 2 subsamples that shared culture and language but differed in terms of socioeconomic status (SES) and academic preparation.

METHODS

A total of 216 participants were recruited at 2 US universities. Each participant completed 3 sets of cognitive measures: 1 custom-designed set based on well-understood laboratory measures of cognition [cognitive task battery (COGTASKS)] and 2 normed batteries [Cambridge Neuropsychological Test Automated Battery (CANTAB), Weschler Adult Intelligence Scale, fourth edition (WAIS-IV)] designed for assessing general cognitive function.

RESULTS

The 3 sets differed with respect to the extent to which SES and educational preparation affected the results, with COGTASKS showing no differences due to testing location and WAIS-IV showing substantial differences. There were, at best, weak correlations among tasks sharing the same name or claiming to measure the same construct.

CONCLUSIONS

Comparability of measures of cognition cannot be assumed, even if measures have the same name or claim to assess the same construct. In selecting and evaluating different measures, construct validity and underlying biological mechanisms need to be at least as important as population norms and the ability to connect with existing literatures.

The global challenge of hidden hunger: perspectives from the field

The aim of this review paper is to explore the strategies employed to tackle micronutrient deficiencies with illustrations from field-based experience. Hidden hunger is the presence of multiple micronutrient deficiencies (particularly iron, zinc, iodine and vitamin A), which can occur without a deficit in energy intake as a result of consuming an energy-dense, but nutrient-poor diet. It is estimated that it affects more than two billion people worldwide, particularly in low- and middle-income countries where there is a reliance on low-cost food staples and where the diversity of the diet is limited. Finding a way to improve the nutritional quality of diets for the poorest people is central to meeting the UN sustainable development goals particularly sustainable development goal 2: end hunger, achieve food security and improved nutrition and promote sustainable agriculture. As we pass the midpoint of the UN's Decade for Action on Nutrition, it is timely to reflect on progress towards achieving sustainable development goal 2 and the strategies to reduce hidden hunger. Many low- and middle-income countries are falling behind national nutrition targets, and this has been exacerbated by the COVID-19 pandemic as well as other recent shocks to the global food system which have disproportionately impacted the world's most vulnerable communities. Addressing inequalities within the food system must be central to developing a sustainable, cost-effective strategy for improving food quality that delivers benefit to the seldom heard and marginalised communities.

Scaling Up Delivery of Biofortified Staple Food Crops Globally: Paths to Nourishing Millions

BACKGROUND

Micronutrient deficiencies affect over one quarter of the world's population. Biofortification is an evidence-based nutrition strategy that addresses some of the most common and preventable global micronutrient gaps and can help improve the health of millions of people. Since 2013, HarvestPlus and a consortium of collaborators have made impressive progress in the enrichment of staple crops with essential micronutrients through conventional plant breeding.

OBJECTIVE

To review and highlight lessons learned from multiple large-scale delivery strategies used by HarvestPlus to scale up biofortification across different country and crop contexts.

RESULTS

India has strong public and private sector pearl millet breeding programs and a robust commercial seed sector. To scale-up pearl millet, HarvestPlus established partnerships with public and private seed companies, which facilitated the rapid commercialization of products and engagement of farmers in delivery activities. In Nigeria, HarvestPlus stimulated the initial acceptance and popularization of vitamin A cassava using a host of creative approaches, including "crowding in" delivery partners, innovative promotional programs, and development of intermediate raw material for industry and novel food products. In Uganda, orange sweet potato (OSP) is a traditional subsistence crop. Due to this, and the lack of formal seed systems and markets, HarvestPlus established a network of partnerships with community-based nongovernmental organizations and vine multipliers to popularize and scale-up delivery of OSP.

CONCLUSIONS

Impact of biofortification ultimately depends on the development of sustainable markets for biofortified seeds and products. Results illustrate the need for context-specific, innovative solutions to promote widespread adoption.

The acceptance of zinc biofortified rice in Latin America: A consumer sensory study and grain quality characterization

Zinc deficiency is a major public health problem in vulnerable populations of Latin America and the Caribbean. Biofortification of rice (Oryza sativa L.) with zinc has the potential to alleviate zinc deficiencies. However, as plant breeding processes can alter grain culinary quality and favorable sensory attributes, grain quality and consumer acceptability need to be assessed prior to releasing a variety to the public. A grain quality characterization and a sensory acceptability analysis were carried out with two varieties of zinc biofortified rice and a local control both in Bolivia and Colombia. The aim of this study was to evaluate the physicochemical parameters that are significant in consumer acceptance and to determine the acceptability of zinc biofortified rice by consumers. Results of physicochemical parameters were analyzed using ANOVA. The sensory acceptability was evaluated in 243 adults utilizing a 7-point hedonic scale and a Wilcoxon's signed rank test was used to determine the overall acceptability of the varieties. Biofortified rice variety T2-11 and MAC-18 -control 1- were equally accepted by consumers in Bolivia with no significant differences (p<0.05). The grain quality analysis reported that both presented long and slender rice grains (L>7.5 mm and L/B>3), an intermediate to high amylose content (>25%) and a similar level of chalkiness. In Colombia, the biofortified variety 035 presented a higher score in overall acceptance in comparison to biofortified variety 021 and the local variety CICA4 -control 2-. However, no significant differences were observed (p<0.05). Conversely to the other two varieties, the biofortified variety 035 presented the largest size grain (L/B = 2.97), a lower chalkiness and an amylose content above 25%. This study shows that the grain quality properties of rice have an influence on acceptability and that zinc biofortified rice varieties are accepted by consumers.

Nicotianamine-chelated iron positively affects iron status, intestinal morphology and microbial populations in vivo (Gallus gallus)

Wheat flour iron (Fe) fortification is mandatory in 75 countries worldwide yet many Fe fortificants, such as Fe-ethylenediaminetetraacetate (EDTA), result in unwanted sensory properties and/or gastrointestinal dysfunction and dysbiosis. Nicotianamine (NA) is a natural chelator of Fe, zinc (Zn) and other metals in higher plants and NA-chelated Fe is highly bioavailable in vitro. In graminaceous plants NA serves as the biosynthetic precursor to 2' -deoxymugineic acid (DMA), a related Fe chelator and enhancer of Fe bioavailability, and increased NA/DMA biosynthesis has proved an effective Fe biofortification strategy in several cereal crops. Here we utilized the chicken (Gallus gallus) model to investigate impacts of NA-chelated Fe on Fe status and gastrointestinal health when delivered to chickens through intraamniotic administration (short-term exposure) or over a period of six weeks as part of a biofortified wheat diet containing increased NA, Fe, Zn and DMA (long-term exposure). Striking similarities in host Fe status, intestinal functionality and gut microbiome were observed between the short-term and long-term treatments, suggesting that the effects were largely if not entirely due to consumption of NA-chelated Fe. These results provide strong support for wheat with increased NA-chelated Fe as an effective biofortification strategy and uncover novel impacts of NA-chelated Fe on gastrointestinal health and functionality.

The reduction in anemia through normative innovations (RANI) project: study protocol for a cluster randomized controlled trial in Odisha, India

BACKGROUND

More than half of women in India are anemic. Anemia can result in fatigue, poor work productivity, higher risk of pre-term delivery, and maternal mortality. The Indian government has promoted the use of iron-folic acid supplements (IFA) for the prevention and treatment of anemia for the past five decades, but uptake remains low and anemia prevalence high. Current programs target individual-level barriers among pregnant women and adolescents, but a more comprehensive approach that targets multiple levels among all women of reproductive age is needed to increase uptake of IFA and iron-rich foods.

METHODS

The Reduction in Anemia through Normative Innovations (RANI) project is a norms-based intervention to reduce anemia among women of reproductive age. We will evaluate the intervention through a clustered randomized controlled trial in Odisha, India. We will collect data at three time points (baseline, midline, and end line). For the study, we selected 89 clusters of villages, which we randomized into treatment and control on a 1:1 basis. The treatment arm will receive the RANI project components while the control arm will receive usual care. Fifteen clusters (40-41 villages) were selected and 4000 women (2000 in each arm) living in the selected clusters will be randomly selected to take part in data collection. Women in both study arms will have their hemoglobin concentrations measured. They will also complete in-person surveys about their knowledge, attitudes, perceptions of iron folic acid supplements, and nutritional intake. We will also select a smaller cohort of 300 non-pregnant women (150 in each arm) from this cohort for additional physical activity and cognitive testing. We will conduct both within- and between-group comparisons (treatment and control) at baseline, midline and end line using t-tests. We will also conduct structural equation modeling to examine how much each factor accounts for IFA use and hemoglobin levels.

DISCUSSION

This RCT will enable us to examine whether a social norms-based intervention can increase uptake of iron folic acid supplements and iron rich foods to reduce anemia.

TRIAL REGISTRATION

This trial was registered with Clinical Trial Registry- India (CTRI) (CTRI/2018/10/016186) on 29 October 2018.

Iron Deficiency in Menstruating Adult Women: Much More than Anemia

Background: Iron deficiency anemia (IDA) is highly prevalent in women of child-bearing age. However, their nonhematological symptoms have been overlooked. This study aims to analyze the nonhematological features and symptoms of IDA in a group of women of reproductive age and the changes occurred during iron therapy. Materials and Methods: IDA women underwent dietary, physical activity, menstrual blood loss, and cognitive function assessment at baseline. Hematological and biochemical parameters were analyzed. Executive attention was tested by the flanker task and working memory by the 2-back task. Oral iron therapy (ferrous sulfate) was given to 35 women for 8 weeks and the changes in iron status, biochemical markers, cognitive function, and nonhematological symptoms were evaluated. Results: Patients presented nonhematological symptoms: pica, 32.4%; cheilitis, 20.6%; restless legs syndrome (RLS), 20.6%; diffuse hair loss, 55.9%; and ungual alterations, 38.2%. Two or more symptoms were present in 58.8% of women. Serum iron and working memory were correlated at baseline. Multivariate analyses show associations (odds ratio [OR], 95% confidence interval [CI]) between pica and reaction time in the working memory test (OR 2.14, 95% CI 1.19-3.87, p = 0.012); RLS with total serum protein (OR 0.08, 95% CI 0.06-0.92, p = 0.043); and cheilitis with mean corpuscular hemoglobin (OR 0.388, 95% CI 0.189-0.799, p = 0.01). Pica, cheilitis, and RLS completely resolved with iron therapy, and ungual alterations and hair loss improved in 92.3% and 84.2% of women, respectively. Better performance in executive attention and working memory was observed after iron therapy. Conclusions: More attention should be given to the nonhematological manifestations of IDA to improve the quality of life of menstruating women.

Vitamins and Minerals for Energy, Fatigue and Cognition: A Narrative Review of the Biochemical and Clinical Evidence

Vitamins and minerals are essential to humans as they play essential roles in a variety of basic metabolic pathways that support fundamental cellular functions. In particular, their involvement in energy-yielding metabolism, DNA synthesis, oxygen transport, and neuronal functions makes them critical for brain and muscular function. These, in turn, translate into effects on cognitive and psychological processes, including mental and physical fatigue. This review is focused on B vitamins (B1, B2, B3, B5, B6, B8, B9 and B12), vitamin C, iron, magnesium and zinc, which have recognized roles in these outcomes. It summarizes the biochemical bases and actions of these micronutrients at both the molecular and cellular levels and connects them with cognitive and psychological symptoms, as well as manifestations of fatigue that may occur when status or supplies of these micronutrients are not adequate.

Iron-fortified lentils to improve iron (Fe) status among adolescent girls in Bangladesh - study protocol for a double-blind community-based randomized controlled trial

Background

Lentils are generally considered to be a nutrient-dense food, and a good source of iron (Fe). This study aims to establish novel evidence of the effectiveness of the consumption of Fe-fortified lentils in improving the body Fe status and thus cognitive performance in non-pregnant adolescent girls in rural Bangladesh, compared to consumption of ordinary lentils.

Methods

We have designed a double-blind (both trial participants and outcome assessors), community-based, cluster-randomized controlled trial among 1260 Bangladeshi adolescent girls between the ages of 10–17 years who are non-smoking, not married, not pregnant, not breastfeeding, and generally healthy at the time of enrollment. The intervention will include three arms who will receive: (1) Fe-fortified lentils; (2) unfortified lentils; or (3) usual intake. Participants will be served a thick preparation of cooked Fe-fortified lentils (37.5 g raw lentils, approximately 200 g cooked lentils) 5 days per week for 85 feeding days (around 4 months) using a locally acceptable recipe. Lentils were fortified with Fe in the laboratory at the Department of Plant Sciences at the University of Saskatchewan in Canada. A subsample of participants (n = 360) will be randomly invited to be included in cognitive testing.

Discussion

Data on socio-demographic characteristics, household food security status, adolescent food habits and cognitive testing will be collected at baseline and endline (4 months). Venous blood samples will be collected at baseline, midline (2 months) and endline to measure adolescents’ Fe status. Computerized cognitive testing will include five common measures of attentional (three of attention) and mnemonic functioning (two of memory) carried out using DMDX software. The results of this study will be used to garner support for and to substantiate large-scale production and market expansion of Fe-fortified lentils, and will contribute to knowledge about how to enhance Fe status in adolescents worldwide in resource-poor settings, using staple food crops.

Trial registration

ClinicalTrials.gov NCT03516734. Registered on 24 May 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3309-4) contains supplementary material, which is available to authorized users.

Iron Metabolism and Brain Development in Premature Infants

Iron is important for a remarkable array of essential functions during brain development, and it needs to be provided in adequate amounts, especially to preterm infants. In this review article, we provide an overview of iron metabolism and homeostasis at the cellular level, as well as its regulation at the mRNA translation level, and we emphasize the importance of iron for brain development in fetal and early life in preterm infants. We also review the risk factors for disrupted iron metabolism that lead to high risk of developing iron deficiency and subsequent adverse effects on neurodevelopment in preterm infants. At the other extreme, iron overload, which is usually caused by excess iron supplementation in iron-replete preterm infants, might negatively impact brain development or even induce brain injury. Maintaining the balance of iron during the fetal and neonatal periods is important, and thus iron status should be monitored routinely and evaluated thoroughly during the neonatal period or before discharge of preterm infants so that iron supplementation can be individualized.

Iron biofortification interventions to improve iron status and functional outcomes

This analysis was conducted to evaluate the evidence of the efficacy of iron biofortification interventions on iron status and functional outcomes. Iron deficiency is a major public health problem worldwide, with a disproportionate impact on women and young children, particularly those living in resource-limited settings. Biofortification, or the enhancing of micronutrient content in staple crops, is a promising and sustainable agriculture-based approach to improve nutritional status. Previous randomised efficacy trials and meta-analyses have demonstrated that iron-biofortification interventions improved iron biomarkers; however, no systematic reviews to date have examined the efficacy of biofortification interventions on health outcomes. We conducted a systematic review of the efficacy of iron-biofortified staple crops on iron status and functional outcomes: cognitive function (e.g. attention, memory) and physical performance. Five studies from three randomised efficacy trials (i.e. rice, pearl millet, beans) conducted in the Philippines, India and Rwanda were identified for inclusion in this review. Iron status (Hb, serum ferritin, soluble transferrin receptor, total body iron, α-1-acid glycoprotein) was measured at baseline and endline in each trial; two studies reported cognitive outcomes, and no studies reported other functional outcomes. Meta-analyses were conducted using DerSimonian and Laird random-effects methods. Iron-biofortified crop interventions significantly improved cognitive performance in attention and memory domains, compared with conventional crops. There were no significant effects on categorical outcomes such as iron deficiency or anaemia. Further studies are needed to determine the efficacy of iron-biofortified staple crops on human health, including additional functional outcomes and other high-risk populations.