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Cabezuelo MT, Torres L, Ortiz-Zapater E, López-Rodas G, Marín MP, Timoneda J, Viña JR, Zaragozá R, Barber T. Vitamin A Status Modulates Epithelial Mesenchymal Transition in the Lung: The Role of Furin. Nutrients 2024; 16:1177. [PMID: 38674868 PMCID: PMC11053499 DOI: 10.3390/nu16081177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
Vitamin A deficiency (VAD) induced TGF-β hyperactivation and reduced expression of cell adhesion proteins in the lung, suggesting that the disruption of retinoic acid (RA) signaling leads to epithelial-mesenchymal transition (EMT). To elucidate the role of lung vitamin A status in EMT, several EMT markers and the expression of the proprotein convertase furin, which activates TGF-β, were analyzed in two experimental models. Our in vivo model included control rats, VAD rats, and both control rats and VAD rats, treated with RA. For the in vitro studies, human bronchoalveolar epithelial cells treated with RA were used. Our data show that EMT and furin are induced in VAD rats. Furthermore, furin expression continues to increase much more markedly after treatment of VAD rats with RA. In control rats and cell lines, an acute RA treatment induced a significant increase in furin expression, concomitant with changes in EMT markers. A ChIP assay demonstrated that RA directly regulates furin transcription. These results emphasize the importance of maintaining vitamin A levels within the physiological range since both levels below and above this range can cause adverse effects that, paradoxically, could be similar. The role of furin in EMT is discussed.
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Affiliation(s)
- M. Teresa Cabezuelo
- Department of Physiology, University of Valencia, 46010 Valencia, Spain;
- Centro Salud Safranar, Hospital Universitario Doctor Peset, 46017 Valencia, Spain
| | - Luis Torres
- Department of Biochemistry and Molecular Biology-IIS INCLIVA, University of Valencia, 46010 Valencia, Spain; (L.T.); (E.O.-Z.); (G.L.-R.); (J.T.); (J.R.V.); (T.B.)
| | - Elena Ortiz-Zapater
- Department of Biochemistry and Molecular Biology-IIS INCLIVA, University of Valencia, 46010 Valencia, Spain; (L.T.); (E.O.-Z.); (G.L.-R.); (J.T.); (J.R.V.); (T.B.)
| | - Gerardo López-Rodas
- Department of Biochemistry and Molecular Biology-IIS INCLIVA, University of Valencia, 46010 Valencia, Spain; (L.T.); (E.O.-Z.); (G.L.-R.); (J.T.); (J.R.V.); (T.B.)
| | - M. Pilar Marín
- Microscopy Unit IIS La Fe Valencia, 46009 Valencia, Spain;
| | - Joaquín Timoneda
- Department of Biochemistry and Molecular Biology-IIS INCLIVA, University of Valencia, 46010 Valencia, Spain; (L.T.); (E.O.-Z.); (G.L.-R.); (J.T.); (J.R.V.); (T.B.)
| | - Juan R. Viña
- Department of Biochemistry and Molecular Biology-IIS INCLIVA, University of Valencia, 46010 Valencia, Spain; (L.T.); (E.O.-Z.); (G.L.-R.); (J.T.); (J.R.V.); (T.B.)
| | - Rosa Zaragozá
- Department of Human Anatomy and Embryology-IIS INCLIVA, University of Valencia, 46010 Valencia, Spain
| | - Teresa Barber
- Department of Biochemistry and Molecular Biology-IIS INCLIVA, University of Valencia, 46010 Valencia, Spain; (L.T.); (E.O.-Z.); (G.L.-R.); (J.T.); (J.R.V.); (T.B.)
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Darwar R, Rowe LA, Chadha M, Rosas AMS, Arabi M. A blueprint for fortification planning and programming: Lessons learned from an analytical review of existing fortification frameworks. MATERNAL & CHILD NUTRITION 2023:e13571. [PMID: 38155486 DOI: 10.1111/mcn.13571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 12/30/2023]
Abstract
With multiple food fortification frameworks, countries can find it challenging to determine optimal methods for planning and implementing food fortification programmes to combat vitamin and mineral deficiencies, especially without additional technical support. To address this challenge, this study aimed to review existing frameworks to determine consistencies, differences, strengths, and weaknesses across the frameworks, and based on the review findings, formulate an enhanced and streamlined fortification framework. Nineteen frameworks were ultimately examined following a comprehensive literature review and key informant interviews. Generally, the reviewed frameworks amply describe motives and methods for the determination of fortification need and feasibility, industry engagement/quality assurance and quality control, and impact evaluations/surveillance. However, there was limited inclusion or discussion throughout the reviewed frameworks around harmonization of fortification with existing micronutrient interventions; fortification policy and/or strategy; enforcement, incentives, and penalties to ensure producer compliance with industry standards; and periodic fortification programme review and reassessment. The findings were used to develop a comprehensive Fortification Blueprint that aims to provide structured guidance and a library of tools and resources to fortification programme managers and key stakeholders to ensure optimal and sustainable programme design.
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Affiliation(s)
- Roopa Darwar
- Department of Public Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Laura A Rowe
- Nutrition International, Ottawa, Ontario, Canada
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Rodas-Moya S, Giudici FM, Owolabi A, Samuel F, Kodish SR, Lachat C, Abreu TC, van het Hof KH, Osendarp SJM, Brouwer ID, Feskens EJM, Melse-Boonstra A. A generic theory of change-based framework with core indicators for monitoring the effectiveness of large-scale food fortification programs in low- and middle-income countries. Front Nutr 2023; 10:1163273. [PMID: 37426192 PMCID: PMC10324612 DOI: 10.3389/fnut.2023.1163273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/17/2023] [Indexed: 07/11/2023] Open
Abstract
Large-scale food fortification (LSFF) programs are widely implemented in low- and middle-income countries (LMIC) to alleviate micronutrient deficiencies. However, these programs may not achieve the desired impact due to poor design or bottlenecks in program implementation. Monitoring and evaluation (M&E) frameworks and a set of agreed indicators can help to benchmark progress and to strengthen the evidence-base of effectiveness in a standardized way. We aimed to formulate recommendations towards core indicators for evaluating the effectiveness of LSFF programs with their associated metrics, methods, and tools (IMMT). For this, we used a multi-method iterative approach, including a mapping review of the literature, semi-structured interviews with international experts, compilation of a generic Theory of Change (ToC) framework for LSFF program delivery, and selection of IMMT for M&E of LSFF programs at key stages along the ToC delivery framework. Lastly, we conducted exploratory, qualitative interviews with key informants in Nigeria to explore experiences and perceptions related to the implementation of LSFF programs in Nigeria's context, and their opinion towards the proposed set of core IMMT. The literature search resulted in 14 published and 15 grey literature documents, from which we extracted a total of 41 indicators. Based on the available literature and interviews with international experts, we mapped a ToC delivery framework and selected nine core indicators at the output, outcome and impact level for M&E of the effectiveness of LSFF programs. Key informants in Nigeria revealed that the main bottlenecks for implementation of the proposed IMMT are related to the lack of technical capacity, equipment, laboratory infrastructure, and financial resources. In conclusion, we propose a set of nine core indicators for enabling comprehensive M&E of the effectiveness of LSFF programs in LMIC. This proposed set of core indicators can be used for further evaluation, harmonization and integration in national and international protocols for M&E of LSFF programs.
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Affiliation(s)
- Santiago Rodas-Moya
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Francesca M. Giudici
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Adedotun Owolabi
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Folake Samuel
- Department of Human Nutrition and Dietetics, College of Medicine, Faculty of Public Health, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Stephen R. Kodish
- Department of Nutritional Sciences and Biobehavioral Health, Pennsylvania State University, University Park, PA, United States
| | - Carl Lachat
- Department of Food Technology, Safety and Health, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
| | - Taymara C. Abreu
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
- Department of Epidemiology and Data Science, Amsterdam UMC, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Karin H. van het Hof
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Saskia J. M. Osendarp
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
- The Micronutrient Forum, Washington, DC, United States
| | - Inge D. Brouwer
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Edith J. M. Feskens
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Alida Melse-Boonstra
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
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Bechoff A, de Bruyn J, Alpha A, Wieringa F, Greffeuille V. Exploring the Complementarity of Fortification and Dietary Diversification to Combat Micronutrient Deficiencies: A Scoping Review. Curr Dev Nutr 2023; 7:100033. [PMID: 37180084 PMCID: PMC10111601 DOI: 10.1016/j.cdnut.2023.100033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/11/2023] [Accepted: 01/25/2023] [Indexed: 01/30/2023] Open
Abstract
Achieving a balanced and diverse diet remains a challenge for many people, contributing to an ongoing burden of micronutrient deficiencies, particularly in low-income settings. Fortification or dietary diversification are common food-based approaches. We conducted a scoping review to: 1) find evidence on whether combined food-based strategies are more effective than single strategies, and 2) understand how strategies implemented together could complement each other to achieve optimal nutritional impact on populations. Peer-reviewed articles selected (n = 21) included interventions or observational studies (n = 13) and reviews (n = 8). We found little evidence of an added nutritional impact. On the other hand, it is apparent that fortification and dietary diversification target different types of settings (urban compared with rural) and foods (that is, low priced compared with highly priced). Further research is needed to understand the complementarity of these approaches and establish evidence of the effectiveness of combined strategies to foster policy adoption.
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Affiliation(s)
- Aurélie Bechoff
- Natural Resources Institute, University of Greenwich, Chatham, United Kingdom
| | - Julia de Bruyn
- Australian Research Council Centre of Excellence for Children and Families over the Life Course, The University of Melbourne, Melbourne, Australia
| | - Arlène Alpha
- Centre de Recherche Agronomique pour le Développement, Montpellier, France
| | - Frank Wieringa
- Institut de Recherche pour le Développement, Montpellier, France
- Unité Mixte de Recherche Qualisud, (alliance between Université Montpellier, Université Avignon, Centre de Recherche Agronomique pour le Développement, Institut Agro, Institut de Recherche pour le Développement and Université de la Réunion), Montpellier, France
| | - Valérie Greffeuille
- Institut de Recherche pour le Développement, Montpellier, France
- Unité Mixte de Recherche Qualisud, (alliance between Université Montpellier, Université Avignon, Centre de Recherche Agronomique pour le Développement, Institut Agro, Institut de Recherche pour le Développement and Université de la Réunion), Montpellier, France
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Sinha S, Loechl CU. Atoms for Nutrition: IAEA's Contribution to Tackling Malnutrition. J Nutr 2023; 153:10-16. [PMID: 36913443 DOI: 10.1016/j.tjnut.2022.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/03/2022] [Accepted: 11/11/2022] [Indexed: 12/24/2022] Open
Abstract
Nuclear techniques, including stable isotope techniques, provide great potential for understanding nutrition and human health with better accuracy and precision compared with other routine techniques. The International Atomic Energy Agency (IAEA) has been at the forefront for more than 25 y to offer guidance and support on the use of nuclear techniques. This article demonstrates how the IAEA has enabled its Member States to contribute to good health and well-being in their countries and to assess progress toward achieving global nutrition and health targets to combat malnutrition in all its forms. Support is provided in several ways including research, capacity building, education, and training as well as the provision of guidance materials. The nuclear techniques help to objectively measure nutritional and health-related outcomes such as body composition, energy expenditure, nutrient uptake, and body stores and assess breastfeeding practices as well as environmental interactions. These techniques are continuously improved to make nutritional assessments more affordable and less invasive with wide use in field settings. New research areas are emerging to assess diet quality with changing food systems and to explore stable isotope-assisted metabolomics to address key questions on nutrient metabolism. Through a deeper understanding of mechanisms, nuclear techniques can contribute to eradicating malnutrition worldwide.
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Affiliation(s)
- Srishti Sinha
- Nutritional and Health-Related Environmental Studies Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Cornelia U Loechl
- Nutritional and Health-Related Environmental Studies Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria.
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Suri DJ, Wirth JP, Adu-Afarwuah S, Petry N, Rohner F, Sheftel J, Tanumihardjo SA. Inflammation Adjustments to Serum Retinol and Retinol-Binding Protein Improve Specificity but Reduce Sensitivity when Estimating Vitamin A Deficiency Compared with the Modified Relative Dose-Response Test in Ghanaian Children. Curr Dev Nutr 2021; 5:nzab098. [PMID: 34386690 PMCID: PMC8352745 DOI: 10.1093/cdn/nzab098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Serum retinol and retinol-binding protein (RBP) concentrations are commonly used biomarkers of vitamin A deficiency (VAD); however, evidence indicates that they are not always accurate, especially in populations with high exposure to inflammation. OBJECTIVE The aim was to assess sensitivity and specificity of serum retinol and RBP concentrations to predict VAD, with and without adjustment for inflammation (using categorical and regression-adjusted approaches), using the modified relative dose-response (MRDR) as the reference standard for liver reserves. METHODS This secondary analysis of diagnostic accuracy used inflammation and RBP data and analyzed serum retinol and MRDR from a subsample of women of reproductive age (n = 178) and preschool children (n = 166) in the cross-sectional 2017 Ghana Micronutrient Survey. RESULTS Inflammation (elevated C-reactive protein and/or α1-acid glycoprotein) was present in 41% of children and 16% of women. Among children, estimates of VAD prevalence were as follows: 7% (MRDR), 40% (serum retinol), 29% (categorical-adjusted serum retinol), 24% (RBP), 13% (categorical-adjusted RBP), and 7% (regression-adjusted RBP). Sensitivity (95% CI) ranged from 22.2% (2.81%, 60.0%; both adjusted RBPs) to 80.0% (44.4%, 97.5%; serum retinol), whereas specificity ranged from 63.3% (54.7%, 71.3%; serum retinol) to 93.5% (88.0%, 97.0%; regression-adjusted RBP). Among women, VAD prevalence ranged from 1% (RBP) to 4% (all others); sensitivity was 0% and specificity was >96% for all indicators. CONCLUSIONS Serum retinol and RBP had varying accuracy in estimating VAD, especially in children; adjustment for inflammation increased accuracy by increasing specificity at the expense of sensitivity. Effects of inflammation adjustment in the context of high inflammation and VAD prevalence need to be further explored. Especially in populations with high inflammation, the MRDR test should accompany serum retinol or RBP measurements in a subsample of subjects in population-based surveys. This trial was registered with the Open Science Framework registry (doi: 10.17605/OSF.IO/J7BP9).
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Affiliation(s)
- Devika J Suri
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana-Legon, Legon, Accra, Ghana
| | | | | | - Jesse Sheftel
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Sherry A Tanumihardjo
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
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Palmer AC, Jobarteh ML, Chipili M, Greene MD, Oxley A, Lietz G, Mwanza R, Haskell MJ. Biofortified and fortified maize consumption reduces prevalence of low milk retinol, but does not increase vitamin A stores of breastfeeding Zambian infants with adequate reserves: a randomized controlled trial. Am J Clin Nutr 2021; 113:1209-1220. [PMID: 33693468 DOI: 10.1093/ajcn/nqaa429] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 12/16/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Replacement of conventional staples with biofortified or industrially fortified staples in household diets may increase maternal breast milk retinol content and vitamin A intakes from complementary foods, improving infant total body stores (TBS) of vitamin A. OBJECTIVES To determine whether biofortified or industrially fortified maize consumption by Zambian women and their breastfeeding infants could improve milk retinol concentration and infant TBS. METHODS We randomly assigned 255 lactating women and their 9-mo-old infants to a 90-d intervention providing 0 µg retinol equivalents (RE)/d as conventional maize or ∼315 µg RE/d to mothers and ∼55 µg RE/d to infants as provitamin A carotenoid-biofortified maize or retinyl palmitate-fortified maize. Outcomes were TBS, measured by retinol isotope dilution in infants (primary), and breast milk retinol, measured by HPLC in women (secondary). RESULTS The intervention groups were comparable at baseline. Loss to follow-up was 10% (n = 230 mother-infant pairs). Women consumed 92% of the intended 287 g/d and infants consumed 82% of the intended 50 g/d maize. The baseline geometric mean (GM) milk retinol concentration was 1.57 μmol/L (95% CI: 1.45, 1.69 μmol/L), and 24% of women had milk retinol <1.05 μmol/L. While mean milk retinol did not change in the biofortified arm (β: 0.11; 95% CI: -0.02, 0.24), the intervention reduced low milk retinol (RR: 0.42; 95% CI: 0.21, 0.85). Fortified maize increased mean milk retinol (β: 0.17; 95% CI: 0.04, 0.30) and reduced the prevalence of low milk retinol (RR: 0.46; 95% CI: 0.25, 0.82). The baseline GM TBS was 178 μmol (95% CI: 166, 191 μmol). This increased by 24 µmol (± 136) over the 90-d intervention period, irrespective of treatment group. CONCLUSIONS Both biofortified and fortified maize consumption improved milk retinol concentration. This did not translate into greater infant TBS, most likely due to adequate TBS at baseline. This trial was registered at clinicaltrials.gov as NCT02804490.
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Affiliation(s)
- Amanda C Palmer
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Modou L Jobarteh
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA, USA
| | | | - Matthew D Greene
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anthony Oxley
- Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Georg Lietz
- Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Rose Mwanza
- Provincial Medical Office for Central Province, Kabwe, Zambia
| | - Marjorie J Haskell
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, CA, USA
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Iqbal WA, Mendes I, Finney K, Oxley A, Lietz G. Reduced plasma carotenoids in individuals suffering from metabolic diseases with disturbances in lipid metabolism: a systematic review and meta-analysis of observational studies. Int J Food Sci Nutr 2021; 72:879-891. [PMID: 33586569 DOI: 10.1080/09637486.2021.1882962] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This review summarises the association between serum carotenoids, serum retinoids and dietary intake outcomes with obesity/overweight and individuals with metabolic diseases with disturbances in lipid metabolism. Observational studies reporting dietary intakes and serum concentrations of carotenoids and retinol were collected from Medline and Web of Science. Mean differences were calculated between "cases" (classified as obese, overweight or having a metabolic disease with disturbances in lipid metabolism; i.e. non-alcoholic fatty liver disease, type 2 diabetes, dyslipidaemia or metabolic syndrome) and "comparator group" (classified as normal weight healthy individuals) and summarised in meta-analyses. Significant summary measures were observed for most serum provitamin A and non-provitamin A carotenoids. Studies reporting total serum carotenoids had shown the greatest decrease (-0.28 µmol/l [-0.33, -0.23], p<.001, I2=62.5%, n = 7). There were no significant summary measures for dietary outcomes, suggesting a physiological role of low serum carotenoids in the development of obesity and associated diseases.
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Affiliation(s)
- Wasim A Iqbal
- Plant and Microbe Group, School of Natural and Environmental Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Ines Mendes
- Endocrinology and Nutrition Service, Divino Espírito Santo Hospital, Ponta Delgada, Portugal
| | - Kieran Finney
- Human Nutrition Research Centre, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Anthony Oxley
- Human Nutrition Research Centre, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Georg Lietz
- Human Nutrition Research Centre, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
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Green MH, Ford JL, Green JB. Development of a Compartmental Model to Investigate the Influence of Inflammation on Predictions of Vitamin A Total Body Stores by Retinol Isotope Dilution in Theoretical Humans. J Nutr 2021; 151:731-741. [PMID: 33484140 PMCID: PMC7948205 DOI: 10.1093/jn/nxaa407] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/13/2020] [Accepted: 11/23/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Inflammation, both acute and chronic, is associated with reductions in the synthesis of retinol-binding protein (RBP) and the concentration of retinol in plasma. Consequently, it is currently recommended that the retinol isotope dilution (RID) method not be used to estimate vitamin A total body stores (TBS) in subjects with inflammation. OBJECTIVES To apply compartmental analysis to study the effects of inflammation on hepatic apo-RBP input, plasma retinol pool size, and RID-predicted TBS in theoretical subjects with known steady state values for these parameters. METHODS We selected 6 previously generated hypothetical subjects who ingested a dose of stable isotope-labeled vitamin A (day 0). Starting with each subject's published steady state model for retinol tracer kinetics, we developed a parallel model for unlabeled retinol and RBP that incorporated links between these entities and tied liver retinol secretion to RBP availability. Then we perturbed the steady state model by initiating chronic or acute inflammation on day 0 or acute inflammation on day 3 or 9 and simulating results for RBP, plasma retinol, and TBS. RESULTS Chronic inflammation led to substantial reductions in RID-predicted TBS for at least 2 weeks after tracer administration. In contrast, acute inflammation induced on day 0 or 3 resulted in less dramatic impacts on TBS (37% or 20% reduction, respectively, from steady state levels, with levels rebounding by 14 days). When inflammation was induced 9 days after administration of the tracer, the effects on predicted TBS were minimal. Overall, for acute inflammation initiated at 0, 3, or 9 days, accurate predictions of TBS were obtained by 2 weeks. CONCLUSIONS Compartmental analysis can be applied in the novel way described here to study the influence of perturbations such as inflammation on predictions of vitamin A status using RID. Such an approach has potential value for studying other perturbations and different nutrients.
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Affiliation(s)
| | - Jennifer Lynn Ford
- Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, PA, USA
| | - Joanne Balmer Green
- Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, PA, USA
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10
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Ford JL, Lopez-Teros V. Prediction of Vitamin A Stores in Young Children Provides Insights into the Adequacy of Current Dietary Reference Intakes. Curr Dev Nutr 2020; 4:nzaa119. [PMID: 32818165 PMCID: PMC7419538 DOI: 10.1093/cdn/nzaa119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/25/2020] [Accepted: 07/09/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Limited data were available in infants and children when vitamin A (VA) DRIs were established; recommendations were developed based on average breast milk VA intake and extrapolation of data from adults. OBJECTIVES Our objective was to evaluate whether DRIs and reported intakes, with and without VA from intervention programs, would be sufficient to develop adequate VA stores from birth to age 5 y in Bangladeshi, Filipino, Guatemalan, and Mexican children. METHODS A mathematical relationship was established, defined by a series of equations, to predict VA total body stores (TBS) as a function of age based on VA intake and utilization. TBS calculated using reported VA intakes, with and without additional VA from intervention programs, were compared to those predicted using DRIs (specifically, Adequate Intake and RDA). Liver VA concentrations were also estimated. RESULTS Our predictions showed that for these 4 groups, DRIs were sufficient to attain liver VA concentrations >0.07 μmol/g by 1 wk of age and sustain positive VA balance for 5 y. Using reported intakes, which were lowest in Bangladeshis from 1 y on and highest in Guatemalans, predicted VA stores in Bangladeshi and Filipino children increased until ∼2-3 y, then TBS stabilized and liver VA concentrations decreased with age. When VA interventions were included, stores exceeded those predicted using DRIs by 12-18 mo. In contrast, reported intakes alone in Guatemalan and Mexican children resulted in VA stores that surpassed those calculated using DRIs. For all populations, reported intakes were sufficient to build liver concentrations >0.07 μmol/g by 3 mo. CONCLUSIONS Although more information is needed to better define dietary VA requirements in children, our results suggest that for an average, generally healthy child in a low- or middle-income country, current DRIs are sufficient to maintain positive VA balance during the first 5 y of life.
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Affiliation(s)
- Jennifer Lynn Ford
- Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, PA, USA
| | - Veronica Lopez-Teros
- Posgrado en Ciencias de la Salud, Universidad de Sonora, Hermosillo, Sonora, Mexico
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11
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Raiten DJ, Darnton-Hill I, Tanumihardjo SA, Suchdev PS, Udomkesmalee E, Martinez C, Mazariegos DI, Mofu M, Kraemer K, Martinez H. Perspective: Integration to Implementation (I-to-I) and the Micronutrient Forum-Addressing the Safety and Effectiveness of Vitamin A Supplementation. Adv Nutr 2020; 11:185-199. [PMID: 31566677 PMCID: PMC7442412 DOI: 10.1093/advances/nmz100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/07/2019] [Accepted: 08/27/2019] [Indexed: 01/03/2023] Open
Abstract
An ongoing challenge to our ability to address the role of food and nutrition in health promotion and disease prevention is how to design and implement context-specific interventions and guidance that are safe, efficacious, and avoid unintended consequences. The integration to effective implementation (I-to-I) concept is intended to address the complexities of the global health context through engagement of the continuum of stakeholders involved in the generation, translation, and implementation of evidence to public health guidance/programs. The I-to-I approach was developed under the auspices of the Micronutrient Forum and has been previously applied to the question of safety and effectiveness of interventions to prevent and treat nutritional iron deficiency. The present article applies the I-to-I approach to questions regarding the safety and utility of large-dose vitamin A supplementation programs, and presents the authors' perspective on key aspects of the topic, including coverage of the basic and applied biology of vitamin A nutrition and assessment, clinical implications, and an overview of the extant data with regard to both the justification for and utility of available intervention strategies. The article includes some practical considerations based on specific country experiences regarding the challenges of implementing vitamin A-related programs. This is followed by an overview of some challenges associated with engagement of the enabling communities that play a critical role in the implementation of these types of public health interventions. The article concludes with suggestions for potential approaches to move this important agenda forward.
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Affiliation(s)
- Daniel J Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Ian Darnton-Hill
- The Boden Collaboration for Obesity, Nutrition, Exercise, and Eating Disorders, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- The Gerald J and Dorothy R Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA, USA
| | - Sherry A Tanumihardjo
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Parminder S Suchdev
- Department of Pediatrics and Emory Global Health Institute, Emory University, Atlanta, GA, USA
| | - Emorn Udomkesmalee
- Department of Human Nutrition, Institute of Nutrition, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Carolina Martinez
- Instituto de Nutrición de Centro América y Panamá (INCAP), Guatemala City, Guatemala
| | - Dora Inés Mazariegos
- Instituto de Nutrición de Centro América y Panamá (INCAP), Guatemala City, Guatemala
| | - Musonda Mofu
- National Food and Nutrition Commission, Lusaka, Zambia
| | - Klaus Kraemer
- Sight and Life, Basel, Switzerland
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Homero Martinez
- Nutrition International, Ottawa, Ontario, Canada
- Hospital Infantil de México Federico Gomez, Mexico City, Mexico
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12
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Abstract
The placenta, a hallmark of mammalian embryogenesis, allows nutrients to be exchanged between the mother and the fetus. Vitamin A (VA), an essential nutrient, cannot be synthesized by the embryo, and must be acquired from the maternal circulation through the placenta. Our understanding of how this transfer is accomplished is still in its infancy. In this chapter, we recapitulate the early studies about the relationship between maternal dietary/supplemental VA intake and fetal VA levels. We then describe how the discovery of retinol-binding protein (RBP or RBP4), the development of labeling and detection techniques, and the advent of knockout mice shifted this field from a macroscopic to a molecular level. The most recent data indicate that VA and its derivatives (retinoids) and the pro-VA carotenoid, β-carotene, are transferred across the placenta by distinct proteins, some of which overlap with proteins involved in lipoprotein uptake. The VA status and dietary intake of the mother influence the expression of these proteins, creating feedback signals that control the uptake of retinoids and that may also regulate the uptake of lipids, raising the intriguing possibility of crosstalk between micronutrient and macronutrient metabolism. Many questions remain about the temporal and spatial patterns by which these proteins are expressed and transferred throughout gestation. The answers to these questions are highly relevant to human health, considering that those with either limited or excessive intake of retinoids/carotenoids during pregnancy may be at risk of obtaining improper amounts of VA that ultimately impact the development and health of their offspring.
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13
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van Stuijvenberg ME, Dhansay MA, Nel J, Suri D, Grahn M, Davis CR, Tanumihardjo SA. South African preschool children habitually consuming sheep liver and exposed to vitamin A supplementation and fortification have hypervitaminotic A liver stores: a cohort study. Am J Clin Nutr 2019; 110:91-101. [PMID: 31089689 DOI: 10.1093/ajcn/nqy382] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 12/12/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND In some regions, multiple vitamin A (VA) interventions occur in the same target groups, which may lead to excessive stores. Retinol isotope dilution (RID) is a more sensitive technique than serum retinol to measure VA status. OBJECTIVE We evaluated VA status before and after a high-dose supplement in preschool children living in a region in South Africa with habitual liver consumption and exposed to VA supplementation and fortification. METHODS After baseline blood samples, subjects (46.7 ± 8.4 mo; n = 94) were administered 1.0 μmol [14,15]-13C2-retinyl acetate to estimate total liver retinol reserves by RID with a follow-up 14-d blood sample. Liver intake was assessed with a frequency questionnaire. In line with current practice, a routine 200,000 IU VA capsule was administered after the RID test. RID was repeated 1 mo later. Serum retinyl esters were evaluated using ultra-performance liquid chromatography. RESULTS At baseline, 63.6% of these children had hypervitaminosis A defined as total liver retinol reserves ≥1.0 μmol/g liver, which increased to 71.6% after supplementation (1.13 ± 0.43 to 1.29 ± 0.46 μmol/g; P < 0.001). Total serum VA as retinyl esters was elevated in 4.8% and 6.1% of children before and after supplementation. The odds of having hypervitaminosis A at baseline were higher in children consuming liver ≥1/mo (ratio 3.70 [95% CI: 1.08, 12.6]) and in children receiving 2 (4.28 [1.03, 17.9]) or 3 (6.45 [0.64, 65.41]) supplements in the past 12 mo. Total body stores decreased after the supplement in children in the highest quartile at baseline compared with children with lower stores, who showed an increase (P = 0.007). CONCLUSIONS In children, such as this cohort in South Africa, with adequate VA intake through diet, and overlapping VA fortification and supplementation, preschool VA capsule distribution should be re-evaluated. This trial was registered at https://clinicaltrials.gov/ct2/show/NCT02915731 as NCT02915731.
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Affiliation(s)
- Martha E van Stuijvenberg
- Non-Communicable Diseases Research Unit, South African Medical Research Council.,Division of Human Nutrition, Cape Town, South Africa
| | - Muhammad A Dhansay
- Burden of Disease Research Unit, South African Medical Research Council.,Division of Human Nutrition, Cape Town, South Africa.,Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Jana Nel
- Integrated Nutrition Programme, Northern Cape Department of Health, Kimberley, South Africa
| | - Devika Suri
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI
| | - Michael Grahn
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI
| | - Christopher R Davis
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI
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14
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Tanumihardjo SA, Kaliwile C, Boy E, Dhansay MA, van Stuijvenberg ME. Overlapping vitamin A interventions in the United States, Guatemala, Zambia, and South Africa: case studies. Ann N Y Acad Sci 2019; 1446:102-116. [PMID: 30265402 PMCID: PMC7999526 DOI: 10.1111/nyas.13965] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/01/2018] [Accepted: 08/15/2018] [Indexed: 01/12/2023]
Abstract
Vitamin A (VA) deficiency is a serious public health problem, especially in preschool children who are at risk of increased mortality. In order to address this problem, the World Health Organization recommends periodic high-dose supplementation to children 6-59 months of age in areas of highest risk. Originally, supplementation was meant as a short-term solution until more sustainable interventions could be adopted. Currently, many countries are fortifying commercialized common staple and snack foods with retinyl palmitate. However, in some countries, overlapping programs may lead to excessive intakes. Our review uses case studies in the United States, Guatemala, Zambia, and South Africa to illustrate the potential for excessive intakes in some groups. For example, direct liver analysis from 27 U.S. adult cadavers revealed 33% prevalence of hypervitaminosis A (defined as ≥1 μmol/g liver). In 133 Zambian children, 59% were diagnosed with hypervitaminosis A using a retinol isotope dilution, and 16% had ≥5% total serum VA as retinyl esters, a measure of intoxication. In 40 South African children who frequently consumed liver, 72.5% had ≥5% total serum VA as retinyl esters. All four countries have mandatory fortified foods and a high percentage of supplement users or targeted supplementation to preschool children.
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Affiliation(s)
| | | | | | - Muhammad A. Dhansay
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
- Division of Human Nutrition, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Martha E. van Stuijvenberg
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
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15
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Mendu VVR, Nair KPM, Athe R. Systematic review and meta-analysis approach on vitamin A fortified foods and its effect on retinol concentration in under 10 year children. Clin Nutr ESPEN 2019; 30:126-130. [DOI: 10.1016/j.clnesp.2019.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/10/2019] [Indexed: 02/06/2023]
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16
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Maximising benefits and minimising adverse effects of micronutrient interventions in low- and middle-income countries. Proc Nutr Soc 2019; 78:540-546. [PMID: 30853033 DOI: 10.1017/s0029665119000557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Micronutrient deficiencies are widespread and disproportionately affect women and children in low- and middle-income countries (LMIC). Among various interventions, food fortification and supplementation with micronutrients have been proven to be cost-effective. The aim of the present paper is to review existing literature to assess risks of excessive intake in LMIC to then highlight programmatic changes required to maximise benefits of micronutrient interventions while minimising risks of adverse effects. While very few LMIC have national food consumption surveys that can inform fortification programmes, many more are implementing mandatory fortification programmes. The risks of inadequate micronutrient intakes were common, but risks of excessive intakes were also present for iodine, vitamin A, folic acid and iron. Excessive salt consumption, high concentrations of iodine in ground-water and excessive levels of iodisation were linked with excessive iodine intake. For vitamin A, overlapping interventions were the main risk for excessive intake; whereas for iron, contamination with iron from soil and screw-wares of millers and high iron concentration in drinking-water increased the risk of excessive intake, which could be further exacerbated with fortification. Before implementing micronutrient interventions, adherence to the basic principles of documenting evidence confirming that the deficiency in question exists and that fortification will correct this deficiency is needed. This can be supported with dietary intake assessments and biochemical screening that help diagnose nutrient deficiencies. Targeting micronutrient interventions, although programmatically challenging, should be considered whenever possible. Moreover, closer monitoring of appropriate fortification of foods and overlapping interventions is needed.
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17
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Pike V, Zlotkin S. Excess micronutrient intake: defining toxic effects and upper limits in vulnerable populations. Ann N Y Acad Sci 2018; 1446:21-43. [PMID: 30569544 DOI: 10.1111/nyas.13993] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 10/21/2018] [Accepted: 11/06/2018] [Indexed: 12/17/2022]
Abstract
Excessive micronutrient intake causes a variety of adverse health effects, depending on dose and duration. The risk of excess intake carries significant implications for micronutrient delivery interventions, particularly when such programs are overlapping. To minimize risk and provide public health guidance, several countries and the Food and Agriculture Organization of the United Nations/World Health Organization have set upper intake levels (ULs) for various life-stage populations using the risk assessment framework. However, there is a lack of international consensus on the actual ULs due to variability in application of this framework and a scarcity of evidence from which to draw upon, especially for children. Often ULs for children are established through a downward weight-based extrapolation from adult ULs, which is not always appropriate. The published ULs of nine organizations are compared, recent population nutrient intake evidence is presented, and the toxic effects of key minerals and vitamins are reviewed. Finally, the evidence for toxicity and setting of ULs for each nutrient is discussed including a comment on our degree of confidence in the strength of existing individual ULs. Challenges with risk assessment and opportunities for strengthening the definition of ULs are discussed.
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Affiliation(s)
- Vanessa Pike
- The Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stanley Zlotkin
- The Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.,The Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,The Munk School of Global Affairs and Public Policy, University of Toronto, Toronto, Ontario, Canada
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18
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Ford JL, Green JB, Green MH. A Population-Based (Super-Child) Approach for Predicting Vitamin A Total Body Stores and Retinol Kinetics in Children Is Validated by the Application of Model-Based Compartmental Analysis to Theoretical Data. Curr Dev Nutr 2018; 2:nzy071. [PMID: 30488046 PMCID: PMC6252344 DOI: 10.1093/cdn/nzy071] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 07/05/2018] [Accepted: 08/16/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Public health nutritionists need accurate and feasible methods to assess vitamin A status and to evaluate efficacy of interventions, especially in children. The application of population-based designs to tracer kinetic data is an effective approach that reduces sample burden for each child. OBJECTIVES Objectives of the study were to use theoretical data to validate a population-based (super-child) approach for estimating group mean vitamin A total body stores (TBS) and retinol kinetics in children and to use population-based data to improve individual TBS predictions using retinol isotope dilution (RID). METHODS We generated plasma retinol kinetic data from 6 h to 56 d for 50 theoretical children with high vitamin A intakes, assigning values within physiologically reasonable ranges for state variables and kinetic parameters ("known values"). Mean data sets for all subjects at extensive (n = 36) and reduced (n = 11) sampling times, plus 5 data sets for reduced numbers (5/time, except all at 4 d) and times, were analyzed using Simulation, Analysis and Modeling software. Results were compared with known values; population RID coefficients were used to calculate TBS for individuals. RESULTS For extensive and reduced data sets including all subjects, population TBS predictions were within 1% of the known value. For 5 data sets reflecting numbers and times being used in ongoing super-child studies, predictions were within 1-17% of the known group value. Using RID equation coefficients from population modeling, TBS predictions at 4 d were within 25% of the known value for 66-80% of subjects and reflected the range of assigned values; when ranked, predicted and assigned values were significantly correlated (Rs = 0.93, P < 0.0001). Results indicate that 7 d may be better than 4 d for applying RID in children. For all data sets, predictions for kinetic parameters reflected the range of known values. CONCLUSION The population-based (super-child) approach provides a feasible experimental design for quantifying retinol kinetics, accurately estimating group mean TBS, and predicting TBS for individuals reasonably well.
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Affiliation(s)
- Jennifer Lynn Ford
- Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, PA
| | - Joanne Balmer Green
- Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, PA
| | - Michael H Green
- Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, PA
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19
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Low breastmilk vitamin A concentration is prevalent in rural Ethiopia. Eur J Clin Nutr 2018; 73:1110-1116. [DOI: 10.1038/s41430-018-0334-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 09/03/2018] [Accepted: 09/21/2018] [Indexed: 02/06/2023]
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20
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Garcia‐Casal MN, Mowson R, Rogers L, Grajeda R. Risk of excessive intake of vitamins and minerals delivered through public health interventions: objectives, results, conclusions of the meeting, and the way forward. Ann N Y Acad Sci 2018; 1446:5-20. [DOI: 10.1111/nyas.13975] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/03/2018] [Accepted: 09/08/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Maria Nieves Garcia‐Casal
- Evidence and Programme Guidance Unit, Department of Nutrition for Health and Development World Health Organization Geneva Switzerland
| | - Robin Mowson
- Nutrition and Social Determinants the Pan American Health Organization Washington DC
| | - Lisa Rogers
- Evidence and Programme Guidance Unit, Department of Nutrition for Health and Development World Health Organization Geneva Switzerland
| | - Ruben Grajeda
- Nutrition and Social Determinants the Pan American Health Organization Washington DC
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21
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Greene MD, Kabaghe G, Musonda M, Palmer AC. Retail Sugar From One Zambian Community Does Not Meet Statutory Requirements for Vitamin A Fortification. Food Nutr Bull 2017; 38:594-598. [PMID: 28978232 DOI: 10.1177/0379572117733841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Industrial food fortification is a major strategy to improve dietary micronutrient intakes and prevent deficiencies. Zambia introduced mandatory sugar fortification with vitamin A, at a target of 10 mg/kg, in 1998. Representative surveys conducted since that time do not support marked improvement in vitamin A status. OBJECTIVE To describe vitamin A concentrations in retail sugar, as well as vendor practices, perceptions of fortified foods, and sugar use practices. METHODS We conducted a census of sugar vendors in one Zambian community, capturing information on vendors, available brands and packaging options, and storage conditions. We purchased all brands and package types of sugar available at each vendor. In a 15% subsample, we conducted semi-structured interviews with vendor-consumer pairs. We tested 50% of sugar samples at random for vitamin A using an iCheck portable fluorimeter. RESULTS The distribution of vitamin A in sugar in market samples was highly skewed, with a median of 3.1 mg/kg (25th-75th percentiles: 1.8-5.5) and a range from 0.2 to 29.9 mg/kg. Only 11.3% of samples met the 10 mg/kg statutory requirement. Sugar was primarily repackaged and sold in small quantities, with rapid turnover of stocks. Perceptions of fortification by vendors and consumers were generally positive. CONCLUSIONS Vitamin A in fortified sugar fell well below statutory requirements. Our data point to challenges at regional depot and/or poor adherence to fortification standards at the factory level. A renewed commitment to monitoring and enforcement will be required for Zambia to benefit from a food fortification strategy.
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Affiliation(s)
- Matthew D Greene
- 1 Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gladys Kabaghe
- 2 National Food and Nutrition Commission, Lusaka, Zambia
| | - Mofu Musonda
- 2 National Food and Nutrition Commission, Lusaka, Zambia
| | - Amanda C Palmer
- 1 Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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22
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Sheftel J, Gannon BM, Davis CR, Tanumihardjo SA. Provitamin A-biofortified maize consumption increases serum xanthophylls and 13C-natural abundance of retinol in Zambian children. Exp Biol Med (Maywood) 2017; 242:1508-1514. [PMID: 28836851 DOI: 10.1177/1535370217728500] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Plants that undergo C4 photosynthesis, such as maize, are enriched in the stable isotope of carbon (13C) compared with other dietary plants and foods. Consumption of maize that has been biofortified to contain elevated levels of provitamin A carotenoids (orange maize) increased the abundance of 13C in serum retinol of Mongolian gerbils. We evaluated this method in humans to determine if it has potential for further use in intervention effectiveness studies. A random subset of samples from a two-month randomized controlled feeding trial of rural three- to five-year old Zambian children were used to determine the impact of orange maize intake on serum carotenoid concentrations ( n = 88) and 13C-natural abundance in serum retinol ( n = 77). Concentrations of β-cryptoxanthin (a xanthophyll provitamin A carotenoid) and the dihydroxy xanthophylls lutein and zeaxanthin, which do not have vitamin A activity, were elevated in children consuming orange maize compared with those consuming a white maize control ( P < 0.001), while β-carotene was not different ( P > 0.3). Furthermore, 13C natural abundance was higher after two months' intervention in the orange maize group compared with the white maize group ( P = 0.049). Predictions made from equations developed in the aforementioned gerbil study estimated that maize provided 11% (2-21%, 95% confidence interval) of the recent dietary vitamin A to these children. These results demonstrate that orange maize is efficacious at providing retinol to the vitamin A pool in children through provitamin A carotenoids, as monitored by the change in 13C enrichment, which was not reflected in serum β-carotene concentrations. Further effectiveness studies in countries who have adopted orange maize should consider determining differences in retinol 13C-enrichment among target groups in addition to profiling serum xanthophyll carotenoids with specific emphasis on zeaxanthin. Impact statement Maize biofortified with provitamin A carotenoids (orange) has been released in some African markets. Responsive and sensitive methods to evaluate dissemination effectiveness are needed. This study investigated methods to evaluate effectiveness of orange maize consumption using serum from Zambian children fed orange maize for two months. Many varieties of orange maize contain higher amounts of the xanthophyll carotenoids in addition to β-carotene compared with typical varieties. This study uniquely showed higher concentrations of the maize xanthophylls lutein, zeaxanthin, and β-cryptoxanthin in children who consumed orange maize compared with white. Furthermore, maize is a C4 plant and is therefore naturally enriched with 13C. Higher 13C was detected in the serum retinol of the orange maize consumers with no change in serum β-carotene concentration suggesting preferential bioconversion to retinol. The combined analyses of serum zeaxanthin specifically and 13C-natural abundance of retinol could prove useful in effectiveness studies between orange maize adopters and non-adopters.
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Affiliation(s)
- Jesse Sheftel
- Interdepartmental Graduate Program in Nutritional Sciences, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Bryan M Gannon
- Interdepartmental Graduate Program in Nutritional Sciences, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Christopher R Davis
- Interdepartmental Graduate Program in Nutritional Sciences, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Sherry A Tanumihardjo
- Interdepartmental Graduate Program in Nutritional Sciences, University of Wisconsin-Madison, Madison, WI 53706, USA
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23
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Ford JL, Green JB, Green MH. Should We Restrict Vitamin A Intake, a Minor Contributor to Plasma Retinol Turnover, When Using Retinol Isotope Dilution Equations to Estimate an Individual's Vitamin A Status, or Should Vitamin A Balance Be Maintained? J Nutr 2017; 147:1483-1486. [PMID: 28701388 DOI: 10.3945/jn.117.254441] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 06/02/2017] [Accepted: 06/07/2017] [Indexed: 11/14/2022] Open
Abstract
We discuss whether dietary vitamin A intake should be restricted or maintained at balance when retinol isotope dilution equations are applied to estimate an individual's vitamin A total body stores (TBS) after oral administration of a labeled dose of vitamin A. Although, at first glance, restriction makes sense as a way to prevent dilution of tracer in plasma, further investigation of the assumptions underlying the widely used isotope dilution equation presented by Olson's laboratory in 1989, as well as the compartmental modeling results presented in this article, indicate that, in fact, restriction leads to an incorrect prediction of TBS if steady state retinol isotope dilution equations are applied at the traditional time (21 d). Our results show that newly ingested vitamin A is a minor contributor to total plasma retinol turnover and that restriction of vitamin A intake leads to a higher plasma retinol specific activity than the value obtained when vitamin A input equals output (balance). When that higher specific activity is used in the traditional retinol isotope dilution equation, it results in a small but notable underestimation of vitamin A TBS. We conclude that, especially if blood is sampled at the traditional time, the most accurate results will be obtained when vitamin A balance is maintained. If sampling is done soon after dosing (e.g., 4 d), dietary intake has less effect on plasma retinol specific activity and thus on predictions of vitamin A status. Vitamin A status can also be estimated if intake is completely restricted and a different (non-steady state) equation is applied at an appropriate time after isotopic equilibrium has been reached.
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Affiliation(s)
- Jennifer Lynn Ford
- Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, PA
| | - Joanne Balmer Green
- Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, PA
| | - Michael H Green
- Department of Nutritional Sciences, College of Health and Human Development, The Pennsylvania State University, University Park, PA
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24
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Neufeld LM, Baker S, Garrett GS, Haddad L. Coverage and Utilization in Food Fortification Programs: Critical and Neglected Areas of Evaluation. J Nutr 2017; 147:1015S-1019S. [PMID: 28404835 PMCID: PMC5404214 DOI: 10.3945/jn.116.246157] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 12/22/2016] [Accepted: 02/16/2017] [Indexed: 12/04/2022] Open
Abstract
The need for evidence to inform nutrition program design and implementation has long been recognized, yet the generation and use of evidence for program decision making has lagged. The results of the coverage surveys reported in this supplement highlight some of the strengths and areas for improvement of current population-based (i.e., staple foods and condiments) and targeted (e.g., foods for infants and young children) fortification programs. Among other topics, the results identify a few striking successful fortification programs whereby the majority of the food vehicle used is fortifiable and fortified, and coverage is equitable among those classified as vulnerable and not. Other programs have great potential based on very high use of a fortifiable food vehicle, including in most cases among the vulnerable, but that potential is not currently reached because of low compliance with fortification requirements. Programs were also identified whereby the food vehicle has limited potential to make public health contributions to micronutrient intake, given the low proportions of the population who consume the food vehicle in general or who consume the fortifiable food vehicle. Four key lessons were learned: 1) the potential for impact of food fortification depends on the appropriate choice of food fortification vehicle but also on the proportion of the food vehicle consumed that is fortifiable; 2) the design of fortification programs should be informed by the magnitude and distribution of inadequate intake and deficiency and consumption of fortifiable foods, and part of micronutrient deficiency control strategies to ensure coordination with other programs; 3) effective quality control of fortification levels in foods urgently needs strengthening, including the many governance and other policy factors that influence the capacity, resources, and commitment to do this; 4) periodic review of the assumptions related to dietary patterns that underpin food fortification is needed to ensure continual safe and impactful programs.
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Affiliation(s)
| | - Shawn Baker
- Bill & Melinda Gates Foundation, Seattle, WA
| | - Greg S Garrett
- Global Alliance for Improved Nutrition, Geneva, Switzerland; and
| | - Lawrence Haddad
- Global Alliance for Improved Nutrition, Geneva, Switzerland; and
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25
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Using stable isotope techniques in nutrition assessments and tracking of global targets post-2015. Proc Nutr Soc 2017; 76:495-503. [PMID: 28347373 DOI: 10.1017/s0029665117000295] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Stable isotopes are non-radioactive, safe and are applied for various purposes in human health assessment in trace amounts that minimally disturb normal physiology. The International Atomic Energy Agency supports the use of stable isotope techniques to design and evaluate interventions addressing malnutrition in all its forms with focus on infant and young child feeding; maternal and adolescent nutrition; diet quality; prevention and control of non-communicable diseases; healthy ageing and gut function. These techniques can be used to objectively measure: (1) amount of human milk consumed and whether an infant is exclusively breastfed; (2) body composition in the context of re-feeding programmes for moderate and severe acute malnutrition and as an indicator of the risk for obesity; (3) bioavailability and bioconversion of pro-vitamin A and vitamin A body stores following vitamin A intervention programmes; (4) absorption and retention of iron, zinc and protein; (5) total energy expenditure for validation of physical activity measurement and dietary assessment tools and (6) diagnosis of Helicobacter pylori. Stable isotope techniques will be invaluable in the tracking of global targets on exclusive breast-feeding childhood obesity and anaemia among women. Efforts are underway to make nuclear techniques more affordable, field-friendly and less invasive, and to develop less sophisticated but precise equipment. Advocacy for the wide adoption of the techniques is needed.
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Wirth JP, Petry N, Tanumihardjo SA, Rogers LM, McLean E, Greig A, Garrett GS, Klemm RDW, Rohner F. Vitamin A Supplementation Programs and Country-Level Evidence of Vitamin A Deficiency. Nutrients 2017; 9:nu9030190. [PMID: 28245571 PMCID: PMC5372853 DOI: 10.3390/nu9030190] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 02/13/2017] [Accepted: 02/15/2017] [Indexed: 12/15/2022] Open
Abstract
Vitamin A supplementation (VAS) programs targeted at children aged 6–59 months are implemented in many countries. By improving immune function, vitamin A (VA) reduces mortality associated with measles, diarrhea, and other illnesses. There is currently a debate regarding the relevance of VAS, but amidst the debate, researchers acknowledge that the majority of nationally-representative data on VA status is outdated. To address this data gap and contribute to the debate, we examined data from 82 countries implementing VAS programs, identified other VA programs, and assessed the recentness of national VA deficiency (VAD) data. We found that two-thirds of the countries explored either have no VAD data or data that were >10 years old (i.e., measured before 2006), which included twenty countries with VAS coverage ≥70%. Fifty-one VAS programs were implemented in parallel with at least one other VA intervention, and of these, 27 countries either had no VAD data or data collected in 2005 or earlier. To fill these gaps in VAD data, countries implementing VAS and other VA interventions should measure VA status in children at least every 10 years. At the same time, the coverage of VA interventions can also be measured. We identified three countries that have scaled down VAS, but given the lack of VA deficiency data, this would be a premature undertaking in most countries without appropriate status assessment. While the global debate about VAS is important, more attention should be directed towards individual countries where programmatic decisions are made.
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Affiliation(s)
| | | | - Sherry A Tanumihardjo
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI 53706, USA.
| | - Lisa M Rogers
- Department of Nutrition for Health and Development, World Health Organization, 1207 Geneva, Switzerland.
| | - Erin McLean
- UNICEF Headquarters, New York, NY 10017, USA.
| | - Alison Greig
- Infant and Young Child Nutrition, Micronutrient Initiative, Ottawa, ON K2P 2K3, Canada.
| | - Greg S Garrett
- Global Alliance for Improved Nutrition, 1202 Geneva, Switzerland.
| | - Rolf D W Klemm
- Helen Keller International, New York, NY 10010, USA.
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
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Quadro L. A Gold Standard to Accurately Assess Vitamin A Status: Are We There Yet? J Nutr 2016; 146:1929-1930. [PMID: 27558576 PMCID: PMC6636398 DOI: 10.3945/jn.116.238311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 08/02/2016] [Indexed: 11/14/2022] Open
Affiliation(s)
- Loredana Quadro
- Department of Food Science and Rutgers Center for Lipid Research and New Jersey Institute for Food Nutrition and Health, Rutgers University, New Brunswick, NJ
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