Are boys more vulnerable to stunting? Examining risk factors, differential sensitivity, and measurement issues in Zambian infants and young children

BACKGROUND

Stunting remains a considerable public health problem globally, and sex differences in prevalence have been documented. While many risk factors for stunting have been identified, few studies examine how these factors may contribute to sex differences. We test whether: (1) boys and girls are differentially exposed to stunting risk factors, (2) boys and girls respond differently to similar exposures, and (3) these associations are sensitive to the growth measures used.

METHODS

Data comes from 7486 Zambian infants, aged 0-23 months, participating in the SUN (Scaling Up Nutrition) 2.0 Program baseline survey. Surveys and dietary recalls were collected from primary caregivers, and anthropometry was collected for caregivers and children. Stunting was defined as height-for-age z-score (HAZ) <-2. Descriptive statistics and adjusted multilevel logistic regression models controlling for age and province were used to identify sex differences in exposures and risk factors for stunting, respectively. Interaction terms between exposure and infant sex were added to test for sex differences in response. Sensitivity testing with alternate measures of infant size, including height-for-age difference (HAD), was conducted.

RESULTS

Boys were more likely to be stunted than girls (34.5% vs. 25.7%, respectively). Numerous maternal, care giving, diet, and household characteristics were associated with the risk of stunting, but few sex differences were seen in exposure to these factors. Only one risk factor-maternal marital status-showed evidence of moderation by sex at the p < 0.05 level, while a limited number of risk factors did so at the p < 0.10 level. At all ages, boys were longer than girls, and there were no sex-specific differences in the patterns of HAZ or HAD with age. Results were robust to alternate specifications.

CONCLUSIONS

Our results show that Zambian boys have lower mean HAZ scores than girls and a greater prevalence of stunting throughout the first two years We do not find strong evidence that infant feeding practices, environmental exposures, or care giving differ consistently between boys and girls or that boys and girls respond differently to these exposures. Our results instead indicate that further investigation of prenatal factors and/or measurement issues is needed.

Aetiology of diarrhoea in children aged zero to nine years in low- and middle-income countries: A systematic review

Background

While diarrhoeal disease remains a leading cause of death in children aged <5 years in low- and middle-income countries (LMICs), it also poses significant health risks for older children, underscoring the importance of our study focusing on children aged <10 years. In this systematic review, we assessed common diarrhoea aetiologies in children aged <10 years in LMICs.

Methods

We identified relevant articles in PubMed, Embase, and Web of Science using pre-defined search criteria. We included case series and case-control studies of children aged <10 years with non-bloody, bloody, acute, persistent, and chronic diarrhoea. Articles that evaluated two or more diarrhoea pathogens in LMICs conducted between 1 January 1990 and 31 July 2020 were eligible for inclusion. We stratified combined data from case series and case-control studies by age and World Health Organization (WHO) regions.

Results

76 studies published between 1990-2020 were eligible for inclusion. Among these, eight were case-control studies. 56 papers focused only on children aged <5 years, while 20 also included children aged ≥5 years. The most common viral pathogens among <5 years old children were rotavirus, norovirus, adenovirus, and astrovirus. Bacterial pathogens included Escherichia coli, Salmonella enterica, Shigella species, and Campylobacter species, while parasitic pathogens included Cryptosporidium, Giardia, and Entamoeba species. Rotavirus was the most common viral pathogen among children across all age groups and every WHO region. Escherichia coli was prevalent in all age groups and was responsible for most diarrhoea cases in the African Region. Among parasitic pathogens, Entamoeba species and Giardia were prevalent in children aged three to five years, with the former a major cause of diarrhoea in the Eastern Mediterranean Region. Similarly, in children aged six to 10 years, bacterial pathogens, including Escherichia coli, Salmonella, and Shigella, suggest a continued significance of these pathogens beyond the age of five. Common viral pathogens for this group were rotavirus, norovirus, and sapovirus, although the number of studies for this age group is limited.

Conclusions

Escherichia coli, rotavirus, and Entamoeba species were the most common pathogens responsible for diarrhoea in children aged <5 years in LMICs. Future research should focus on characterising the pathogens responsible for causing diarrhoea in children aged six to 10 years stratified by geographic area of residence, i.e. WHO region and urban vs rural. Case-control or cohort studies covering a full 12-month period to account for seasonality are needed for a more accurate picture of diarrhoea aetiology among children.

Registration

PROSPERO (CRD42020204005).

International Trends in Zinc Treatment for Diarrhea

BACKGROUND

Diarrhea is a leading cause of death among children <5 years of age and can have long-term adverse consequences for human development. The World Health Organization has recommended the therapeutic use of zinc for the treatment of diarrhea, along with oral rehydration solutions, since 2004. We studied recent trends in the use of zinc to treat diarrhea in 23 low- and middle-income countries.

METHODS

A repeated cross-sectional design of 46 Demographic and Health Surveys from 23 countries was used to estimate the average annual change in zinc treatment across recent years. The earlier surveys were conducted in different years from 2009 to 2014, and the latest surveys were conducted in different years from 2015 to 2023, with an average gap of 6 years between surveys. A diarrhea episode during the 2 weeks before the survey and the treatment of diarrhea using zinc and oral rehydration solutions among children <5 years old was identified using an interview with mothers.

RESULTS

In the pooled sample, the treatment of diarrhea in children <5 years of age using zinc increased from 2% in the earlier surveys to 27% in the more recent surveys, or an average annual increase of 4 percentage points (pp). The prevalence of zinc treatment increased in all 23 countries, ranging from 9 pp per year on average in Sierra Leone to 1 pp in Cambodia.

CONCLUSIONS

A large increase in the use of therapeutic zinc to treat diarrhea in children was observed in recent years. However, coverage remains incomplete.

Modeled impacts of bouillon fortification with micronutrients on child mortality in Senegal, Burkina Faso, and Nigeria

Micronutrient interventions can reduce child mortality. By applying Micronutrient Intervention Modeling methods in Senegal, Burkina Faso, and Nigeria, we estimated the impacts of bouillon fortification on apparent dietary adequacy of vitamin A and zinc among children and folate among women. We then used the Lives Saved Tool to predict the impacts of bouillon fortification with ranges of vitamin A, zinc, and folic acid concentrations on lives saved among children 6-59 months of age. Fortification at 250 µg vitamin A/g and 120 µg folic acid/g was predicted to substantially reduce vitamin A- and folate-attributable deaths: 65% for vitamin A and 92% for folate (Senegal), 36% for vitamin A and 74% for folate (Burkina Faso), and >95% for both (Nigeria). Zinc fortification at 5 mg/g would avert 48% (Senegal), 31% (Burkina Faso), and 63% (Nigeria) of zinc-attributable deaths. The addition of all three nutrients at 30% of Codex nutrient reference values in 2.5 g bouillon was predicted to save an annual average of 293 child lives in Senegal (3.5% of deaths from all causes among children 6-59 months of age), 933 (2.1%) in Burkina Faso, and 18,362 (3.7%) in Nigeria. These results, along with evidence on program feasibility and costs, can help inform fortification program design discussions.

Efficacy of Zinc Fortified and Fermented Wheat Flour (EZAFFAW): A randomized controlled trial protocol

BACKGROUND

Zinc deficiency poses significant health risks, particularly in low-income settings. This study aims to evaluate the impact of agronomically zinc biofortified (fermented and non-fermented) and post-harvest wheat flour flatbread on zinc status and metabolic health in adolescents and adult women in rural Pakistan.

METHODS

A four-arm triple-blind randomized controlled trial will be conducted in a rural district of Pakistan. Participants (adolescents aged 10-19 and adult women aged 20-40) will be assigned to receive fermented or unfermented high zinc agronomically biofortified wheat flour flatbread, post-harvest zinc-fortified wheat flour flatbread, or low zinc conventional whole wheat flour flatbread. The meal would be served once a day, six days a week for six months. The study aims to enroll 1000 participants and will be analyzed based on the intention-to-treat principle. The trial is registered with number NCT06092515.

OUTCOMES

Primary outcomes will include serum zinc concentration and metabolic markers, while secondary outcomes include anthropometric measurements, blood pressure, and dietary intake.

CONCLUSION

This trial will provide valuable insights into the efficacy of agronomically zinc biofortified wheat flour in improving zinc status and metabolic health. Findings may inform public health strategies to combat zinc deficiency in resource-limited settings.

Recommendations for India-specific multiple micronutrient supplement through expert consultation

Background & objectives Reducing maternal anaemia and enhancing feto-maternal health to achieve desired birth outcomes is a major health concern in India. Micronutrient deficiencies during pregnancy may impact fetal growth and neonatal outcomes. There is increasing interest in using multiple micronutrient supplement (MMS) during pregnancy. However, the World Health Organization (WHO) recommends use of MMS containing Iron and Folic Acid (IFA) in the context of "rigorous research". Against this backdrop, an Indian Council of Medical Research (ICMR)-led MMS design expert group met over six months to review the evidence and decide on the formulation of an India-specific MMS supplement for pregnant mothers for potential use in a research setting. Methods The India-MMS design expert group conducted a series of meetings to assess the available evidence regarding the prevalence of micronutrient deficiencies in pregnant women in India, the health benefits of supplementing with different micronutrients during pregnancy, as well as nutrient interactions within the MMS formulation. Based on these considerations, the expert group reached a consensus on the composition of the MMS tailored for pregnant women in India. Results The India-specific MMS formulation includes five minerals and 10 vitamins, similar to the United Nations International Multiple Micronutrient Antenatal Preparation (UNIMMAP) composition. However, the quantities of all vitamins and minerals except Zinc, Vitamin E, and Vitamin B6 differ. Interpretation & conclusions This report provides an overview of the process adopted, the evidence evaluated, and the conclusions from the expert working group meetings to finalize an MMS supplement in pregnancy for the Indian context to be used in a research setting.

Potential Complementary Effect of Zinc and Alkalihalobacillus clausii on Gut Health and Immunity: A Narrative Review

A balanced microbiota-microorganisms that live in the gut-is crucial in the early years of a child's life, while dysbiosis-altered microbiota-has been linked to the development of various diseases. Probiotics, such as Alkalihalobacillus clausii, are commonly used to restore the balance of gut microbiota and have shown additional antimicrobial and immunomodulatory properties. Intake of micronutrients can affect the structure and function of the gut barrier and of the microbiota by having multiple effects on cellular metabolism (e.g., immunomodulation, gene expression, and support structure proteins). An inadequate zinc intake increases the risk of deficiency and associated immune dysfunctions; it is responsible for an increased risk of developing gastrointestinal diseases, respiratory infections, and stunting. Paediatric zinc deficiency is a public health concern in many countries, especially in low-income areas. Currently, zinc supplementation is used to treat childhood diarrhoea. This review examines how combining A. clausii and zinc could improve dysbiosis, gut health, and immunity. It suggests that this combination could be used to prevent and treat infectious diseases and diarrhoea in children up to adolescence.

A blueprint for fortification planning and programming: Lessons learned from an analytical review of existing fortification frameworks

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.

Soil micronutrients linked to human health in India

Trace soil minerals are a critical determinant of both crop productivity and the mineral concentration of crops, therefore potentially impacting the nutritional status of human populations relying on those crops. We link health data from nearly 0.3 million children and one million adult women across India with over 27 million soil tests drawn from a nationwide soil health program. We find that soil zinc availability is positively associated with children's linear height growth, and soil iron availability is positively associated with hemoglobin levels. The link between soil zinc and childhood stunting is particularly robust-a one standard deviation increase in satisfactory soil zinc tests is associated with approximately 11 fewer children stunted per 1000. We also find that this zinc-stunting relationship is strongest in wealthier households. Our results suggest that soil mineral availability impacts human nutritional status and health in at least some areas of India, and that agronomic fortification may be a beneficial intervention.

Nutritional Strategies for the Prevention and Management of Cow's Milk Allergy in the Pediatric Age

Cow's milk allergy (CMA) is one of the most common pediatric food allergies. The prevalence and severity of CMA have increased dramatically in the last decades, under the pressure of environmental factors in genetically predisposed individuals. Among the environmental influences, nutritional factors play a crucial role. Diet is the most modifiable factor, representing a potential target for the prevention and treatment of CMA. In this review, we report the most scientific-based nutritional strategies for preventing and managing pediatric CMA. In addition, we propose the most complete supplement of compounds able to prevent nutrient deficiencies in CMA pediatric patients and to positively influence the disease course.

Insulin-like Growth Factor 1 (IGF1), IGF Binding Protein-3 (IGFBP3) and Growth Response to Daily Zinc Supplementation: A Randomized Trial in Rural Laotian Children

OBJECTIVES

To assess (a) the impact of daily preventive zinc tablets (7 mg; PZ), zinc-containing multiple micronutrient powder (10 mg zinc, and 13 other micronutrients; MNP) or placebo, delivered for 9 months, on Insulin-like Growth Factor 1 (IGF1) and IGF Binding Protein 3 (IGFBP3) among Laotian children 6-23 months, and (b) whether the effects of PZ and MNP on length-for-age z-scores (LAZ) and weight-for-age z-scores (WAZ) are modified by baseline IGF1 and IGFBP3.

DESIGN

A double-blind, placebo-controlled trial (N = 419).

METHODS

Plasma IGF1 and IGFBP3 concentrations at baseline and 36 weeks were analyzed by automated chemiluminescent assay. Anthropometry was assessed at baseline, at 18 and 36 weeks. Intervention effects were estimated using ANCOVA.

RESULTS

At 36 weeks, geometric mean IGF1 (~39.0-39.2 ng/mL; p = 0.99) and IGFBP3 (2038-2076 ng/mL; p = 0.83) did not differ by group. At 18 weeks (but not at 36 weeks), LAZ in the PZ group (-1.45) was higher than the MNP (-1.70) and control (-1.55) groups (p = 0.01) among children in the highest baseline IGF1 tertile (p for interaction = 0.006). At 36 weeks (but not at 18 weeks), WAZ in the PZ group (-1.55) was significantly higher than the MNP (-1.75) and control (-1.65) groups (p = 0.03), among children in the lowest baseline IGFBP3 tertile (p for interactions = 0.06).

CONCLUSIONS

Although IGF1 and IGFBP3 did not respond to PZ and MNP, baseline IGF1 and IGFBP3 significantly modified the impact of PZ on linear and ponderal growth, suggesting that IGF1 bioavailability may drive catch-up growth in zinc-supplemented children.

Zinc supplementation for preventing mortality, morbidity, and growth failure in children aged 6 months to 12 years

BACKGROUND

Zinc deficiency is prevalent in low- and middle-income countries, and is considered a significant risk factor for morbidity, mortality, and linear growth failure. The effectiveness of preventive zinc supplementation in reducing prevalence of zinc deficiency needs to be assessed.

OBJECTIVES

To assess the effects of zinc supplementation for preventing mortality and morbidity, and for promoting growth, in children aged 6 months to 12 years.

SEARCH METHODS

A previous version of this review was published in 2014. In this update, we searched CENTRAL, MEDLINE, Embase, five other databases, and one trials register up to February 2022, together with reference checking and contact with study authors to identify additional studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of preventive zinc supplementation in children aged 6 months to 12 years compared with no intervention, a placebo, or a waiting list control. We excluded hospitalized children and children with chronic diseases or conditions. We excluded food fortification or intake, sprinkles, and therapeutic interventions.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies, extracted data, and assessed the risk of bias. We contacted study authors for missing information and used GRADE to assess the certainty of evidence. The primary outcomes of this review were all-cause mortality; and cause-specific mortality, due to all-cause diarrhea, lower respiratory tract infection (LRTI, including pneumonia), and malaria. We also collected information on a number of secondary outcomes, such as those related to diarrhea and LRTI morbidity, growth outcomes and serum levels of micronutrients, and adverse events.

MAIN RESULTS

We included 16 new studies in this review, resulting in a total of 96 RCTs with 219,584 eligible participants. The included studies were conducted in 34 countries; 87 of them in low- or middle-income countries. Most of the children included in this review were under five years of age. The intervention was delivered most commonly in the form of syrup as zinc sulfate, and the most common dose was between 10 mg and 15 mg daily. The median duration of follow-up was 26 weeks. We did not consider that the evidence for the key analyses of morbidity and mortality outcomes was affected by risk of bias. High-certainty evidence showed little to no difference in all-cause mortality with preventive zinc supplementation compared to no zinc (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.84 to 1.03; 16 studies, 17 comparisons, 143,474 participants). Moderate-certainty evidence showed that preventive zinc supplementation compared to no zinc likely results in little to no difference in mortality due to all-cause diarrhea (RR 0.95, 95% CI 0.69 to 1.31; 4 studies, 132,321 participants); but probably reduces mortality due to LRTI (RR 0.86, 95% CI 0.64 to 1.15; 3 studies, 132,063 participants) and mortality due to malaria (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 42,818 participants); however, the confidence intervals around the summary estimates for these outcomes were wide, and we could not rule out a possibility of increased risk of mortality. Preventive zinc supplementation likely reduces the incidence of all-cause diarrhea (RR 0.91, 95% CI 0.90 to 0.93; 39 studies, 19,468 participants; moderate-certainty evidence) but results in little to no difference in morbidity due to LRTI (RR 1.01, 95% CI 0.95 to 1.08; 19 studies, 10,555 participants; high-certainty evidence) compared to no zinc. There was moderate-certainty evidence that preventive zinc supplementation likely leads to a slight increase in height (standardized mean difference (SMD) 0.12, 95% CI 0.09 to 0.14; 74 studies, 20,720 participants). Zinc supplementation was associated with an increase in the number of participants with at least one vomiting episode (RR 1.29, 95% CI 1.14 to 1.46; 5 studies, 35,192 participants; high-certainty evidence). We report a number of other outcomes, including the effect of zinc supplementation on weight and serum markers such as zinc, hemoglobin, iron, copper, etc. We also performed a number of subgroup analyses and there was a consistent finding for a number of outcomes that co-supplementation of zinc with iron decreased the beneficial effect of zinc.

AUTHORS' CONCLUSIONS

Even though we included 16 new studies in this update, the overall conclusions of the review remain unchanged. Zinc supplementation might help prevent episodes of diarrhea and improve growth slightly, particularly in children aged 6 months to 12 years of age. The benefits of preventive zinc supplementation may outweigh the harms in regions where the risk of zinc deficiency is relatively high.

Impacts of micronutrient intervention programs on effective coverage and lives saved: Modeled evidence from Cameroon

Policymakers are committed to improving nutritional status and to saving lives. Some micronutrient intervention programs (MIPs) can do both, but not to the same degrees. We apply the Micronutrient Intervention Modeling tool to compare sets of MIPs for (1) achieving dietary adequacy separately for zinc, vitamin A (VA), and folate for children and women of reproductive age (WRA), and (2) saving children's lives via combinations of MIPs. We used 24-h dietary recall data from Cameroon to estimate usual intake distributions of zinc and VA for children 6-59 months and of folate for WRA. We simulated the effects on dietary inadequacy and lives saved of four fortified foods and two VA supplementation (VAS) platforms. We estimated program costs over 10 years. To promote micronutrient-specific dietary adequacy, the economic optimization model (EOM) selected zinc- and folic acid-fortified wheat flour, VA-fortified edible oils, and bouillon cubes, and VAS via Child Health Days in the North macroregion. A different set of cost-effective MIPs emerged for reducing child mortality, shifting away from VA and toward more zinc for children and more folic acid for WRA. The EOM identified more efficient sets of MIPs than the business-as-usual MIPs, especially among programs aiming to save lives.

Soil zinc deficiency and child stunting: Evidence from Nepal

We examine the negative child health impacts of soil zinc (Zn) deficiency in Nepal. Soil Zn deficiency limits both crop yields and the Zn concentration in food crops, leading many to speculate that it underlies human Zn deficiency and child stunting, globally and particularly in South Asia. We find strong evidence that soil Zn deficiency does have a causal impact on child stunting in Nepal's Tarai region, the breadbasket of the country. Using causal bounds, we find that a 1 part per million increase in plant-available soil Zn - achievable with application of Zn-enriched fertilizer - decreases child stunting by between 1 and 7.5 percentage points. Multiple statistical sensitivity tests indicate that this relationship is unlikely to be manufactured by omitted, relevant variables.

Effects of Different Doses, Forms, and Frequencies of Zinc Supplementation on Biomarkers of Iron and Zinc Status among Young Children in Dhaka, Bangladesh

Young children in resource-constrained settings are susceptible to zinc deficiency and its deleterious health effects. The objective of this secondary analysis was to evaluate the effects of the following six interventions on biomarkers of iron and zinc status among a subgroup of young children in Dhaka, Bangladesh, who participated in the Zinc in Powders Trial (ZiPT): (1) standard micronutrient powders (MNPs) containing 4.1 mg zinc and 10 mg iron, daily; (2) high-zinc (10 mg) and low-iron (6 mg) (HiZn LoFe) MNP, daily; (3) HiZn (10 mg) and LoFe (6 mg)/HiZn (10 mg) and no-iron MNPs on alternating days; (4) dispersible zinc tablet (10 mg), daily; (5) dispersible zinc tablet (10 mg), daily for 2 weeks at enrollment and at 12 weeks; (6) placebo powder, daily. At the end of the 24 week intervention period, children in the daily dispersible zinc tablet group exhibited a mean serum zinc concentration (SZC) of 92.5 μg/dL, which was significantly higher than all other groups except the HiZn LoFe MNP alternating group (81.3 μg/dL). MNPs containing 10 mg and 6 mg of iron had a similar impact on biomarkers of iron status, with no evidence of an adverse interaction with zinc.

Study of Serum Ferritin, Zinc, and Copper Levels in Children With Helicobacter pylori Gastritis and the Effect of the Treatment

OBJECTIVES

This study aimed to assess serum iron, zinc, and copper in symptomatic children with Helicobacter pylori infection, to correlate their serum levels with the degree of gastritis, and to evaluate the effect of H. pylori treatment on their levels.

METHODS

This study was carried out on 70 children with upper gastrointestinal tract symptoms. H. pylori infection was diagnosed by the H. pylori antigen test in the stool and histopathologic findings during upper gastrointestinal endoscopy. Patients were divided into 2 groups; H. pylori -positive and H. pylori -negative groups. Hemoglobin, serum ferritin, transferrin (sTfR), zinc, and copper were assessed in all included children.

RESULTS

The hemoglobin level, serum ferritin, and zinc were significantly lower in H. pylori -positive patients compared to H. pylori -negative patients. However, the serum copper level was comparable between the 2 groups. After treatment, the hemoglobin level, serum ferritin, and serum zinc significantly increased in H. pylori -positive patients, especially in those who responded to treatment compared to their levels before treatment. There was a significant negative correlation between the severity of histopathologic abnormalities and hemoglobin level, serum ferritin, and zinc levels, but a significant positive relation with sTfR concentrations in H. pylori -positive patients.

CONCLUSIONS

H. pylori -infected children had low serum ferritin and zinc levels but high sTfR level with no effect on serum copper levels. After treatment, hemoglobin, serum ferritin, and zinc levels significantly improved in H. pylori -positive patients. Gastric histologic findings correlated significantly with hemoglobin, serum ferritin, zinc, and sTfR levels.

Zinc Kinetics Correlate With Length-for-Age z Scores in Bangladeshi Infants

OBJECTIVES

Stunting [length-for-age z score (LAZ) &lt;-2] has multiple causes and is prevalent in areas with low dietary zinc (Zn) intake. Zinc kinetics from non-stunted infants were used in a published model for predicting linear growth; here, we directly measure zinc kinetics in stunted infants.

METHODS

Zinc kinetics were determined in 9-month-old Bangladeshi infants (n = 10), who were non-wasted [weight-for-length z score (WLZ) &gt; -2], ranging in LAZ from -2.9 to -0.43. Stable isotopes were administered 2 hours after a meal as oral ( 70 Zn) and intravenous ( 67 Zn) tracers. After isotope administration, blood was sampled within 5 hours and all urine and feces were collected for 24 hours. Urine was sampled twice-daily out to 9 days. Data were analyzed by compartmental modeling. Daily zinc intake was estimated by the model as the sum of zinc used for growth plus that lost via urine and feces. Zinc absorbed (the amount required to maintain steady state) was the sum of zinc used for growth plus urine and endogenous fecal excretions.

RESULTS

The LAZ score correlated with serum zinc concentration ( R = 0.77, P = 0.001), urinary zinc excretion ( R = 0.66, P = 0.010), and fractional zinc absorption from calculated daily intake ( R = 0.58, P = 0.030). In stunted infants (n = 8), the amount of zinc absorbed did not increase with calculated zinc intake unlike published values for non-stunted infants.

CONCLUSIONS

Zinc kinetics in Bangladeshi infants correlate with LAZ and show that malabsorption of supplemental sources of zinc may occur in stunted infants.

Daily preventive zinc supplementation increases the antibody response against pathogenic Escherichia coli in children with zinc insufficiency: a randomised controlled trial

Zinc deficiency impairs the antibody-mediated immune response and is common in children from lower-income countries. This study aimed to investigate the impact of different zinc supplementation regimens (7, 10 or 20 mg/day elemental zinc)—therapeutic dispersible zinc tablets (TZ), daily multiple micronutrient powder (MNP), daily preventive zinc tablets (PZ) and placebo powder (control)—and compare between baseline and endline antibody production against pathogenic Escherichia coli in Laotian children (aged 6–23 months). Fifty representative plasma samples of each treatment group were randomly selected from 512 children to determine anti-E. coli IgG antibody levels and avidity. Of the 200 children, 78.5% had zinc deficiency (plasma zinc concentration < 65 µg/dL) and 40% had anaemia before receiving zinc supplementation. aAfter receiving the TZ, MNP or PZ regimen, the plasma anti-E. coli IgG levels were significantly increased compared with baseline; the effect on the antibody level was more pronounced in children with zinc deficiency. Interestingly, there was increased anti-E. coli IgG avidity in the control and PZ groups. This study suggests that PZ might be the optimal zinc supplementation regimen to increase both the quantity and quality of antibody responses in children with zinc deficiency. Clinical trial registration: https://clinicaltrials.gov/ct2/show/NCT02428647 (NCT02428647, 29/04/2015).

Basis for changes in the disease burden estimates related to vitamin A and zinc deficiencies in the 2017 and 2019 Global Burden of Disease Studies

BACKGROUND

The Global Burden of Disease (GBD) Study provides estimates of death and disability from eighty-seven risk factors, including some micronutrient deficiencies.

OBJECTIVES

To review methodological changes that led to large differences in the disease burden estimates for vitamin A and Zn deficiencies between the GBD 2017 and 2019 Studies.

METHODS

GBD publications were reviewed; additional information was provided by GBD researchers.

RESULTS

Vitamin A deficiency prevalence is based on plasma retinol concentration, whereas the estimate for Zn deficiency prevalence uses dietary adequacy as a proxy. The estimated global prevalence of vitamin A deficiency for children aged 1-4 years in the year 2017 decreased from 0·20 (95 % CI 0·17, 0·24) in GBD 2017 to 0·16 (95 % CI 0·15, 0·19) in GBD 2019, while the global prevalence of Zn deficiency did not change between the two studies (0·09 (95 % CI 0·04, 0·17) and 0·09 (95 % CI 0·03, 0·18)). New to 2019 was that meta-analyses were performed using Meta Regression - Bayesian, Regularized, Trimmed, a method developed for GBD. Due to this and multiple other methodological changes, the estimated number of deaths due to vitamin A deficiency dropped from 233 000 (179 000-294 000) to 24 000 (3000-50 000) from GBD 2017 to 2019, and for Zn deficiency from 29 000 (1000-77 000) to 2800 (700-6500), respectively.

CONCLUSION

The changes in the estimated disease burdens due to vitamin A and Zn deficiencies in the GBD reports from 2017 to 2019 are due primarily to changes in the analytical methods employed, so may not represent true changes in disease burden. Additional effort is needed to validate these results.

Cost-effectiveness of zinc supplementation for prevention of childhood diarrhoea in Tanzania

OBJECTIVE

To assess the cost-effectiveness of prophylactic Zn supplementation for preventing diarrhoea in young children in Tanzania.

DESIGN

Cost-effectiveness analysis using decision-analytic modelling. Cost-effectiveness ratios were calculated as the incremental cost (2019 USD) per disability-adjusted life year (DALY) averted, from a societal perspective, and with a 3 % discount rate applied to future outcomes. Sensitivity analyses were performed to test the robustness of results to alternative assumptions.

SETTING

Tanzania.

PARTICIPANTS

A hypothetical cohort of 10 000 children aged 6 weeks to 18 months.

RESULTS

The intervention costs of Zn supplementation were estimated as $109 800 (95 % uncertainty interval: 61 716, 171 507). Zn supplementation was estimated to avert 2200 (776, 3737) diarrhoeal episodes, 14 080 (4692, 25 839) sick days, 1584 (522, 2927) outpatient visits, 561 (160-1189) inpatient bed days, 0·51 (0·15, 1·03) deaths and 19·3 (6·1, 37·5) DALY (discounted at 3 % per year). Zn supplementation reduced diarrhoea care costs by $12, 887 (4089, 25 058). The incremental cost per DALY averted was $4950 (1678, 17 933). Incremental cost-effectiveness ratios (ICER) estimated from a health system perspective were similar to the results from the societal perspective. ICER were substantially lower (more favourable) when future outcomes were not discounted, but all ICER were above contemporary thresholds for cost-effectiveness in this setting.

CONCLUSION

Prophylactic Zn reduced diarrhoea incidence and associated healthcare utilisation; however, it did not appear to be cost-effective for prevention of childhood diarrhoea in the scenario examined in this study. Reducing intervention costs, or identifying high risk groups for intervention targeting, may be needed to improve cost-effectiveness in this setting.

Global Burden and Trends of Norovirus-Associated Diseases From 1990 to 2019: An Observational Trend Study

Introduction

As an important pathogen causing diarrheal diseases, the burden and change in the death rate of norovirus-associated diseases (NADs) globally are still unknown.

Methods

Based on global disease burden data from 1990 to 2019, we analyzed the age-standardized death rate (ASDR) of NADs by age, region, country, and Socio-Demographic Index (SDI) level. The discrete Poisson model was applied in the analysis of NADs' spatiotemporal aggregation, the Joinpoint regression model to analyze the trend of death burden of NADs over 30 years, and a generalized linear model to identify the risk factors for the death rate from NADs.

Results

The ASDR of NADs significantly decreased by a factor of approximately 2.7 times, from 5.02 (95% CI: 1.1, 11.34) in 1990 to 1.86 (95% CI: 0.36, 4.16) in 2019 [average annual percent change (AAPC) = −3.43, 95% CI: −3.56, −3.29]. The death burden of NADs in 2019 was still highest in African regions despite a great decline in recent decades. However, the ASDR in high SDI countries presented an uptrend [0.12 (95% CI: 0.03, 0.26) in 1990 and 0.24 (95% CI: 0.03, 0.53) in 2019, AAPC = 2.52, 95% CI: 2.02–3.03], mainly observed in the elderly over 70 years old. Compared to children under 5 years old, the 2019 death rate of elderly individuals over 80 years old was much higher in high SDI countries. The generalized linear model showed that factors of the number of physicians (RR = 0.67), the proportions of children under 14 years old (RR = 1.21), elderly individuals over 65 years old (RR = 1.13), educational level (RR = 1.03) and urbanization proportion (RR = 1.01) influenced the ASDR of NADs.

Conclusions

The death burden of NADs has remained high in developing regions over the last three decades and has increased among the elderly in countries with high SDI levels, even though the global trend in NAD-associated deaths has decreased significantly in the past three decades. More effective public health policies against NADs need to be implemented in high SDI regions and for the elderly.

Different Doses, Forms, and Frequencies of Zinc Supplementation for the Prevention of Diarrhea and Promotion of Linear Growth among Young Bangladeshi Children: A Six-Arm, Randomized, Community-Based Efficacy Trial

BACKGROUND

Children in resource-limited settings remain vulnerable to zinc deficiency and its consequences.

OBJECTIVES

To evaluate the effects of different doses, durations, and frequencies of zinc supplementation on the incidence of diarrhea and change in linear growth among young children.

METHODS

We conducted a randomized, partially double-blind, controlled, 6-arm, community-based efficacy trial in Dhaka, Bangladesh. Children aged 9-11 mo were randomly assigned to receive 1 of the following interventions for 24 wk: 1) standard micronutrient powder (MNP) containing 4.1 mg zinc and 10 mg iron, daily; 2) high-zinc (10 mg), low-iron (6 mg) (HiZn LoFe) MNP, daily; 3) HiZn (10 mg) LoFe (6 mg)/HiZn (10 mg), no-iron MNPs on alternating days; 4) dispersible zinc tablet (10 mg), daily; 5) dispersible zinc tablet (10 mg), daily for 2 wk at enrollment and 12 wk; 6) placebo powder, daily. Primary outcomes were incidence of diarrhea and change in length-for-age z-score (LAZ) over the 24-wk intervention period. Home visits were conducted twice weekly to assess diarrhea and other morbidity. Incidence and prevalence outcomes were compared among groups with Poisson regression; continuous outcomes were compared using ANCOVA.

RESULTS

A total of 2886 children were enrolled between February 2018 and July 2019. The mean incidence and prevalence of diarrhea among all participants was 1.21 episodes per 100 d and 3.76 d per 100 d, respectively. There were no differences in the incidence or prevalence of diarrhea across intervention groups. The decline in LAZ was slightly smaller among children in the daily HiZn LoFe MNP group compared with the placebo powder group (P < 0.05).

CONCLUSIONS

The dose of zinc in MNPs as well as the duration and frequency of supplementation evaluated in this trial were not effective in reducing diarrhea; however, the daily HiZn LoFe MNP formulation offered modest improvements in linear growth among young children. This trial was registered at clinicaltrials.gov as NCT03406793.

Association between zinc and body composition: An integrative review

BACKGROUND

Zinc deficiency is related to lean body mass reduction, fat deposition, and obesity. Zinc acts in catalytic, structural, and regulatory functions, being an essential micronutrient to humans. It is crucial for maintaining lean body mass, synthesizing nucleic acids and proteins, and forming new tissues. Pre-existing zinc deficiency may contribute to obesity due to its relationship with fat deposition associated with short stature. This integrative review aims to analyze the association between zinc and body composition, hitherto very poorly established in previous studies.

MATERIAL AND METHODS

The electronic databases utilized in this review were PubMed and Web of Science. We identified titles and abstracts from 1178 articles relating to zinc and body composition that were published in the last ten years. After duplicates were removed, the reference lists of relevant reviews were checked, and 47 articles were obtained by manual search.

MAIN FINDINGS AND CONCLUSIONS

The articles were transversal or longitudinal studies, clinical trials, randomized controlled trials, reviews, systematic reviews, and meta-analysis. Although there was heterogeneity among the methodologies, the existence of an association between zinc and body composition was predominant among the studies. All articles concluded that zinc had positive effects on proteogenesis. Moreover, zinc metabolism is dysregulated in obese individuals, whose mechanisms remain controversial.

Nutritional evaluation of complementary porridge formulated from orange-fleshed sweet potato, amaranth grain, pumpkin seed, and soybean flours

Supplementing breastmilk with poor energy and nutrient-dense complementary foodstuffs for young children and infants has resulted in malnutrition, poor growth, and retardation of infant development in many sub-Saharan African countries. Ensuring nutrient adequacy for infants because of their lower consumption requires energy and nutrient-dense food. In this context, the nutritional composition of porridge from complementary flour blends of locally available foodstuffs (orange-fleshed sweet potato, pumpkin seeds, amaranth grains, and soybeans) was carried out. Complementary flours formulated from flour blends of pumpkin seeds, extrusion cooked soybean, and orange-fleshed sweet potato, as well as germinated and extrusion cooked amaranth grains, resulted in varieties of complementary porridges (SAPO1-SAPO5). From these, proximate composition, mineral content (sodium, iron, magnesium, calcium, phosphorus, and zinc), vitamin contents (A and C), and nutrient density of the formulated complementary porridge were determined. Results showed that all the formulated complementary porridge were able to meet the stipulated standards of energy and nutrient (zinc, iron, vitamin A, and protein) densities. Flour blend ratio, germination process, and extrusion cooking significantly (p < .05) influenced the targeted nutrients of interest, as well as the nutrient and energy densities of the formulated complementary porridge. Specifically, the formulated complementary porridge with 40% amaranth grain, 25% orange-fleshed sweet potato, 20% soybean, and 15% pumpkin seed composite mixture had 76.92% compliance level with recommended standards, which assure adequate nutrient complementation to breastfeeding. The present study provides a valuable insight that complementary foods from locally obtainable foodstuffs are potential solutions for mitigating childhood malnutrition and adequate complementation to breastfeeding by proffering the needed energy and nutrient densities required for the immunity, well-being, growth, and development of young children and infants, without fortification.

Daily supplementation of a multiple micronutrient powder improves folate but not thiamine, riboflavin, or vitamin B12 status among young Laotian children: a randomized controlled trial

PURPOSE

To assess the effects of intervention with a daily multiple micronutrient powder (MNP) on thiamine, riboflavin, folate, and B₁₂ status among young Laotian children.

METHODS

Children (n = 1704) aged 6-23 mo, participating in a double-blind placebo-controlled randomized trial were individually randomized to receive daily either MNP (containing 0.5 mg of thiamine, 0.5 mg riboflavin, 150 μg folic acid, and 0.9 μg vitamin B₁₂ along with 11 other micronutrients) or placebo and followed for ~ 36 weeks. In a randomly selected sub-sample of 260 children, erythrocyte thiamine diphosphate (eThDP), plasma folate and B₁₂ concentrations, and erythrocyte glutathione reductase activation coefficient (EGRac; riboflavin biomarker) were assessed at baseline and endline.

RESULTS

There was no treatment effect on endline eThDP concentrations (110.6 ± 8.9 nmol/L in MNP vs. 109.4 ± 8.9 nmol/L in placebo group; p = 0.924), EGRac (1.46 ± 0.3 vs. 1.49 ± 0.3; p = 0.184) and B₁₂ concentrations (523.3 ± 24.6 pmol/L vs. 515.9 ± 24.8 pmol/L; p = 0.678). Likewise, the prevalence of thiamine, riboflavin, and B₁₂ deficiencies did not differ significantly between the two groups. However, endline folate concentration was significantly higher in the MNP compared to the placebo group (28.2 ± 0.8 nmol/L vs 19.9 ± 0.8 nmol/L, respectively; p < 0.001), and correspondingly, the prevalence of folate deficiency was significantly lower in the MNP group (1.6% vs 17.4%; p = 0.015).

CONCLUSIONS

Compared to a placebo, daily MNP for 9 months increased only folate but not thiamine, riboflavin, or B₁₂ status in young Laotian children.

TRIAL REGISTRATION

The trial was registered at www.

CLINICALTRIALS

gov (NCT02428647) on April 29 2015.

Effect of Zinc Supplementation in Children Less Than 5 Years on Diarrhea Attacks: A Randomized Controlled Trial

Recurrent infections and weak immunity were found to be linked with zinc deficiency especially in children. The goal of this study is to measure the level of blood zinc in children aged 6 months to less than 5 years old, and to assess the effect of 4 months of daily zinc supplements on the incidence and the severity of diarrheal morbidity. A randomized controlled trial study was conducted in Pediatric Outpatient Clinic in Ain Shams University Hospital on 140 children less than 5 years old who are apparently healthy. Random assignment of the sampled children to group receiving zinc (70 children) or group receiving placebo (70 children) was done. A questionnaire containing questions about occurrence of diarrhea was used during follow up. Serum zinc at baseline was measured. The mean age was 25.26 ± 15.7 months. Mean of serum zinc was 51.08 μg/dL, with 70% had low baseline serum zinc level. Cumulative incidence of diarrhea, number of diarrhea episodes per child and frequency of stools/day decreased significantly in zinc group (P < .05). Risk ratio was found to be 0.79, 95% CI: 0.64 to 0.97. we concluded that incidence of diarrhea and its severity reduced in children received zinc daily for 4 months.

This trial was registered at www.clinicaltrials.gov as NCT05002101.

The Role of Micronutrients and Toxic Metals in the Management of Epidemics in Cambodia

The illegal trade of wildlife in SE Asia has been identified as the likely cause of the COVID-19 pandemic. We reviewed 198 papers on the current COVID pandemic in Cambodia, diseases such as avian influenza and Nipah virus, most likely to develop into a new pandemic in Cambodia, and common features of disease that require mitigation. Artisanal goldmining uses pure mercury in the areas where wildlife is smuggled to China. Moreover, 30-40% of Cambodians are zinc deficient. High levels of arsenic in irrigation water (>1000 µg/L) are associated with very low levels of zinc in rice (5 µg/g) and rice is the primary staple food for the region. Brown rice from nine of 15 paddy fields in the arsenic zone of Cambodia had double the new guidelines of 100 µg/kg inorganic arsenic for children's food in the EU and USA. The combination of deficiencies of essential micronutrients like zinc and pervasive presence of arsenic and mercury has the potential to compromise the immunity of many Cambodians. Innovative solutions are suggested to improve micronutrient nutrition. Toxins that suppress the immune system must be better managed to reduce the virulence of pathogens. Cambodia was not likely the source of the COVID-19 but does have problems that could result in a new pandemic.

Zinc Supplementation with or without Additional Micronutrients Does Not Affect Peripheral Blood Gene Expression or Serum Cytokine Level in Bangladeshi Children

Preventive zinc supplementation provided as a stand-alone dispersible tablet, or via home fortification as multiple micronutrient powders (MNPs), has been considered a potential strategy to prevent zinc deficiency and improve health (including immune) outcomes among children in low- and middle-income countries. However, the impact of zinc supplementation on immune profiles has not been well characterized. We sought to define the effect of zinc supplementation on peripheral blood gene expression and cytokine levels among young children in Dhaka, Bangladesh. In a sub-study of a large randomized, controlled, community-based efficacy trial where children 9–11 months of age received one of the following interventions on a daily basis for 24 weeks: (1) MNPs containing 10 mg of zinc; (2) dispersible tablet containing 10 mg zinc; or (3) placebo powder, we used RNA sequencing to profile the peripheral blood gene expression, as well as highly sensitive multiplex assays to detect cytokine profiles. We profiled samples from 100 children enrolled in the parent trial (zinc MNPs 28, zinc tablets 39, placebo 33). We did not detect an effect from either zinc intervention on differential peripheral blood gene expression at the end of the intervention, or an effect from the intervention on changes in gene expression from baseline. We also did not detect an effect from either intervention on cytokine concentrations. Exploratory analysis did not identify an association between undernutrition (defined as stunting, underweight or wasting) and peripheral blood gene expression. Zinc interventions in children did not produce a gene expression or cytokine signature in the peripheral blood. However, this study demonstrates a proof of principle that sensitive multi-omic techniques can be applied to samples collected in field studies.

Nutrition-specific interventions for preventing and controlling anaemia throughout the life cycle: an overview of systematic reviews

BACKGROUND

Anaemia is a prevalent health problem worldwide. Some types are preventable or controllable with iron supplementation (pills or drops), fortification (sprinkles or powders containing iron added to food) or improvements to dietary diversity and quality (e.g. education or counselling).

OBJECTIVES

To summarise the evidence from systematic reviews regarding the benefits or harms of nutrition-specific interventions for preventing and controlling anaemia in anaemic or non-anaemic, apparently healthy populations throughout the life cycle.

METHODS

In August 2020, we searched MEDLINE, Embase and 10 other databases for systematic reviews of randomised controlled trials (RCTs) in anaemic or non-anaemic, apparently healthy populations. We followed standard Cochrane methodology, extracting GRADE ratings where provided. The primary outcomes were haemoglobin (Hb) concentration, anaemia, and iron deficiency anaemia (IDA); secondary outcomes were iron deficiency (ID), severe anaemia and adverse effects (e.g. diarrhoea, vomiting).

MAIN RESULTS

We included 75 systematic reviews, 33 of which provided GRADE assessments; these varied between high and very low. Infants (6 to 23 months; 13 reviews) Iron supplementation increased Hb levels and reduced the risk of anaemia and IDA in two reviews. Iron fortification of milk or cereals, multiple-micronutrient powder (MMNP), home fortification of complementary foods, and supplementary feeding increased Hb levels and reduced the risk of anaemia in six reviews. In one review, lipid-based nutrient supplementation (LNS) reduced the risk of anaemia. In another, caterpillar cereal increased Hb levels and IDA prevalence. Food-based strategies (red meat and fortified cow's milk, beef) showed no evidence of a difference (1 review). Preschool and school-aged children (2 to 10 years; 8 reviews) Daily or intermittent iron supplementation increased Hb levels and reduced the risk of anaemia and ID in two reviews. One review found no evidence of difference in Hb levels, but an increased risk of anaemia and ID for the intermittent regime. All suggested that zinc plus iron supplementation versus zinc alone, multiple-micronutrient (MMN)-fortified beverage versus control, and point-of-use fortification of food with iron-containing micronutrient powder (MNP) versus placebo or no intervention may increase Hb levels and reduce the risk of anaemia and ID. Fortified dairy products and cereal food showed no evidence of a difference on the incidence of anaemia (1 review). Adolescent children (11 to 18 years; 4 reviews) Compared with no supplementation or placebo, five types of iron supplementation may increase Hb levels and reduce the risk of anaemia (3 reviews). One review on prevention found no evidence of a difference in anaemia incidence on iron supplementation with or without folic acid, but Hb levels increased. Another suggested that nutritional supplementation and counselling reduced IDA. One review comparing MMN fortification with no fortification observed no evidence of a difference in Hb levels. Non-pregnant women of reproductive age (19 to 49 years; 5 reviews) Two reviews suggested that iron therapy (oral, intravenous (IV), intramuscular (IM)) increased Hb levels; one showed that iron folic acid supplementation reduced anaemia incidence; and another that daily iron supplementation with or without folic acid or vitamin C increased Hb levels and reduced the risk of anaemia and ID. No review reported interventions related to fortification or dietary diversity and quality. Pregnant women of reproductive age (15 to 49 years; 23 reviews) One review apiece suggested that: daily iron supplementation with or without folic acid increased Hb levels in the third trimester or at delivery and in the postpartum period, and reduced the risk of anaemia, IDA and ID in the third trimester or at delivery; intermittent iron supplementation had no effect on Hb levels and IDA, but increased the risk of anaemia at or near term and ID, and reduced the risk of side effects; vitamin A supplementation alone versus placebo, no intervention or other micronutrient might increase maternal Hb levels and reduce the risk of maternal anaemia; MMN with iron and folic acid versus placebo reduced the risk of anaemia; supplementation with oral bovine lactoferrin versus oral ferrous iron preparations increased Hb levels and reduced gastrointestinal side effects; MNP for point-of-use fortification of food versus iron and folic acid supplementation might decrease Hb levels at 32 weeks' gestation and increase the risk of anaemia; and LNS versus iron or folic acid and MMN increased the risk of anaemia. Mixed population (all ages; 22 reviews) Iron supplementation versus placebo or control increased Hb levels in healthy children, adults, and elderly people (4 reviews). Hb levels appeared to increase and risk of anaemia and ID decrease in two reviews investigating MMN fortification versus placebo or no treatment, iron fortified flour versus control, double fortified salt versus iodine only fortified salt, and rice fortification with iron alone or in combination with other micronutrients versus unfortified rice or no intervention. Each review suggested that fortified versus non-fortified condiments or noodles, fortified (sodium iron ethylenediaminetetraacetate; NaFeEDTA) versus non-fortified soy sauce, and double-fortified salt versus control salt may increase Hb concentration and reduce the risk of anaemia. One review indicated that Hb levels increased for children who were anaemic or had IDA and received iron supplementation, and decreased for those who received dietary interventions. Another assessed the effects of foods prepared in iron pots, and found higher Hb levels in children with low-risk malaria status in two trials, but no difference when comparing food prepared in non-cast iron pots in a high-risk malaria endemicity mixed population. There was no evidence of a difference for adverse effects. Anaemia and malaria prevalence were rarely reported. No review focused on women aged 50 to 65 years plus or men (19 to 65 years plus).

AUTHORS' CONCLUSIONS

Compared to no treatment, daily iron supplementation may increase Hb levels and reduce the risk of anaemia and IDA in infants, preschool and school-aged children and pregnant and non-pregnant women. Iron fortification of foods in infants and use of iron pots with children may have prophylactic benefits for malaria endemicity low-risk populations. In any age group, only a limited number of reviews assessed interventions to improve dietary diversity and quality. Future trials should assess the effects of these types of interventions, and consider the requirements of different populations.

Increasing the availability and utilization of reliable data on population micronutrient (MN) status globally: the MN Data Generation Initiative

Micronutrient (MN) deficiencies can produce a broad array of adverse health and functional outcomes. Young, preschool children and women of reproductive age in low- and middle-income countries are most affected by these deficiencies, but the true magnitude of the problems and their related disease burdens remain uncertain because of the dearth of reliable biomarker information on population MN status. The reasons for this lack of information include a limited understanding by policy makers of the importance of MNs for human health and the usefulness of information on MN status for program planning and management; insufficient professional capacity to advocate for this information and design and implement related MN status surveys; high costs and logistical constraints involved in specimen collection, transport, storage, and laboratory analyses; poor access to adequately equipped and staffed laboratories to complete the analyses reliably; and inadequate capacity to interpret and apply this information for public health program design and evaluation. This report describes the current situation with regard to data availability, the reasons for the lack of relevant information, and the steps needed to correct this situation, including implementation of a multi-component MN Data Generation Initiative to advocate for critical data collection and provide related technical assistance, laboratory services, professional training, and financial support.

Effect of zinc supplementation on mortality in under 5-year children: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Several clinical trials evaluated the effect of zinc supplementation on mortality in children, but the results were inconsistent. We aimed to conduct a systematic review and meta-analysis on the impact of zinc supplementation on mortality in under 5-year children.

METHODS

A comprehensive search was conducted using the electronic (PubMed, Scopus, Web of Science) databases, and Google Scholar, up to June 2020. Randomized clinical trials (RCTs) that reported the effect of zinc supplementation on death incidence in under 5-year children were included in the analysis. Screening was performed based on title/abstract and full-text. A random effects model was applied to calculate the summary relative risk (SRR). Risk of Bias 2.0 tool was used to rate the quality of trials. The body of evidence was assessed by the GRADE approach.

RESULTS

Combining 30 RRs from 28 RCTs including 237,068 participants revealed that zinc supplementation has significantly reduced the risk of all-causes mortality by 16% in children (SRR: 0.84, 95% CI: 0.74, 0.96). A follow-up duration of less than 1 year after supplementation resulted in 54% reduced risk of mortality (0.46; 0.33, 0.63) with no heterogeneity between investigations. Subgroup analysis by zinc dosage showed that assigning ≥ 10 mg/d zinc to under five children and duration of less than 11 months of intervention decreased the risk of all-cause mortality by 44% (0.56; 0.42, 0.75) and 48% (0.52; 0.38, 0.72), respectively. In low birth weight (LBW) infants, zinc supplementation was reduced all-cause mortality by 52% (0.48; 0.23, 1.00). Zinc supplementation significantly reduced the risk of death from pneumonia (0.70: 0.64, 0.98) and infection (0.54; 0.39, 0.76), also changed the risk of mortality from diarrhea by 15% (0.85; 0.70, 1.03) and sepsis by 57% (0.43; 0.18, 1.02).

CONCLUSION

This meta-analysis on RCTs revealed that zinc supplementation in under 5-year children has significantly reduced the risk of all-cause mortality. Notable decreases were found in trials with a dose of 10 mg/d or more zinc supplementation, a maximum of 11 months of supplementation, a follow-up less than one year and especially in LBW infants.

Local Snacks and Virtual Nutrition Counseling Services Increasing Growth of Stunting Children

BACKGROUND: The conducive factor of stunting is the deficiency in nutrient intake due to the lack of quantity and quality of food consumed by the children. Children’s food consumption is strongly influenced by the mother’s nutritional knowledge and children’s feeding practices. AIM: The aims of this study were to determine the effect of providing local snacks in South Sulawesi with a substitute of snakehead fish flour (Tibus) and virtual nutrition counseling on the growth of stunting children. METHODS: The design of this study used a randomized pretest-posttest control design. The sample was divided in two groups using systematic random sampling. The first group was given local Tibus snacks and nutritional counseling virtually and the second group was only given virtual nutrition counseling. The intervention was carried out every day until 1 month. The sample of this research was mothers who have stunting children under five of age. RESULTS: Nutrition knowledge of mothers in group one increased significantly before and after intervention (63.78 ± 1.68 vs. 73.70 ±1.35 points), but this was not the case in group two. The increase in maternal nutritional knowledge was higher in group one than in group two, although it was not significant (p = 0.91). The comparison of the weight gain of children in group one versus group two was 0.37 ± 0.49 kg versus 0.07 ± 0.39 kg (p = 0.021). The increase in the height of the children in group one before and after was 84.15 ± 7.79 cm versus 85.97 ± 7.95 cm (p = 0.000). The ratio of the increase in the height of the children in group one and group two was 1.82 ± 0.94 cm versus 1.53 ± 0.68 cm (p = 0.402). CONCLUSIONS: Nutrition counseling virtual can increase nutrition knowledge. The providing of local snacks (Tibus) accompanied by virtual nutrition counseling can increase growth in body length and weight of stunting children. The efforts to accelerate prevention stunting in children under five can be done with utilization of local snacks.

Effect of zinc supplementation on hemogram parameters and circulating concentrations of homocysteine, vitamin B12, and folate in zinc-deficient children and adolescents

BACKGROUND

Zinc deficiency may exacerbate some pathologies and may also explain alterations in circulating concentrations of various molecules. Zinc has previously been reported to affect plasma concentrations of vitamin B₁₂, homocysteine, and folate; however, the current evidence is inconclusive. We aimed to evaluate plasma zinc, hemoglobin, red blood cell count, mean corpuscular volume, ferritin, vitamin B₁₂, folate, and homocysteine concentrations during and after zinc supplementation for treatment of zinc deficiency.

METHODS

This prospective, open-label, single-arm study included children who presented to outpatient clinics with symptoms of growth retardation, anorexia or frequent infections, and who were considered deficient based on plasma zinc concentrations (<70 mcg/dl). Zinc supplementation of 15 mg per day was administered to all participants, and fasting blood samples collected 3 months later were analyzed for plasma zinc, vitamin B₁₂, homocysteine, and folate concentrations.

RESULTS

Eighty-three children (27 males and 26 females) admitted to the outpatient clinics with anorexia, growth retardation, and complaints of frequent infections. The mean age of the children was 9.64 ± 5.05 (min-max, 1-15) years, and the mean plasma zinc concentration before zinc supplementation was 61.7 ± 6.3 mcg/dl. Zinc concentrations were significantly elevated after zinc sulfate supplementation for 3 months, at 107.1 ± 18.8 mcg/dl (p < 0.01). Hemoglobin (p < 0.01), mean corpuscular volume (p < 0.01), and ferritin (p = 0.049) levels were significantly increased after zinc supplementation, but no significant difference was found in red blood cell count (p = 0.83). Vitamin B₁₂ and homocysteine concentrations were significantly decreased after zinc treatment (743.5 ± 498.8 vs 373.3 ± 128 mcg/dl p < 0.01; and 11.2 ± 5.3 vs 6.7 ± 3.4 mcg/dl p < 0.01, respectively). However, the change in folate concentrations was not significant (p = 0.05).

CONCLUSIONS

Anemia was not detected in patients with zinc deficiency, but ferritin level significantly increased after zinc treatment. Therefore, it can be said that zinc therapy has a positive effect on iron absorption. Elevations in vitamin B₁₂ and homocysteine may be associated with zinc deficiency, and these elevations may in turn influence the prognoses of liver, kidney, cardiorespiratory, and neoplastic conditions. This can be corrected through appropriate zinc supplementation.

Multinutrient Biofortification of Maize (Zea mays L.) in Africa: Current Status, Opportunities and Limitations

Macro and micronutrient deficiencies pose serious health challenges globally, with the largest impact in developing regions such as subSaharan Africa (SSA), Latin America and South Asia. Maize is a good source of calories but contains low concentrations of essential nutrients. Major limiting nutrients in maize-based diets are essential amino acids such as lysine and tryptophan, and micronutrients such as vitamin A, zinc (Zn) and iron (Fe). Responding to these challenges, separate maize biofortification programs have been designed worldwide, resulting in several cultivars with high levels of provitamin A, lysine, tryptophan, Zn and Fe being commercialized. This strategy of developing single-nutrient biofortified cultivars does not address the nutrient deficiency challenges in SSA in an integrated manner. Hence, development of maize with multinutritional attributes can be a sustainable and cost-effective strategy for addressing the problem of nutrient deficiencies in SSA. This review provides a synopsis of the health challenges associated with Zn, provitamin A and tryptophan deficiencies and link these to vulnerable societies; a synthesis of past and present intervention measures for addressing nutrient deficiencies in SSA; and a discussion on the possibility of developing maize with multinutritional quality attributes, but also with adaptation to stress conditions in SSA.

Effects of therapeutic zinc supplementation for diarrhea and two preventive zinc supplementation regimens on the incidence and duration of diarrhea and acute respiratory tract infections in rural Laotian children: A randomized controlled trial

Background

Diarrhea and respiratory tract infections are leading causes of childhood morbidity and mortality. This individually randomized, double-blind placebo-controlled trial was designed to evaluate the effects of different zinc supplementation regimens on the incidence and duration of diarrhea and acute lower (ALRI) and upper (AURI) respiratory tract infections among rural Laotian children. The study included 3407 children, 6-23 months at enrollment.

Methods

Children were randomized to one of four study groups: therapeutic zinc supplements for diarrhea treatment (20 mg/d for 10 days with each episode; TZ), daily preventive zinc tablets (7 mg/d; PZ), daily multiple micronutrient powder (10 mg/d zinc, 6 mg/d iron and 13 other micronutrients; MNP), or daily placebo powder for 9 months. Incidence and duration of diarrhea (≥3 liquid stools/24 hours), ALRI (persistent cough with wheezing, stridor or chest in-drawing) and AURI (purulent nasal discharge with cough) were assessed by parental report during weekly home visits and analyzed using negative binomial models.

Results

Baseline mean age was 14.2 ± 5.1 months, and 71% had low plasma zinc (<65 μg/dL). Overall diarrhea incidence (0.61 ± 0.01 episodes/100 days at risk) and duration (2.12 ± 0.03 days/episode) did not differ by study group. Age modified the impact of the interventions on diarrhea incidence (P = 0.06) and duration (P = 0.01). In children >18 months, TZ reduced diarrhea incidence by 24% vs MNP (P = 0.035), and 36% vs Control (P = 0.004), but there was no difference with PZ. This patterned remained when analyses were restricted to diarrhea episode occurring after the first treatment with TZ. Also, in children >18 months, TZ reduced diarrhea duration by 15% vs PZ (P = 0.03), and 16% vs Control (P = 0.03), but there was no difference with MNP. There were no overall effects of study group on incidence of ALRI (overall mean 0.005 ± 0.001 episodes/100 days, P = 0.14) or AURI (overall mean 0.09 ± 0.01 episodes/100 days, P = 0.72).

Conclusions

There was no overall impact of TZ, PZ or MNP on diarrhea, ALRI and AURI. However, in children >18 months, TZ significantly reduced both the duration of diarrhea episodes and the incidence of future diarrhea episodes compared with placebo.

Trial registration

ClinicalTrials.gov: NCT02428647.

Effect of Zinc supplementation on child development: a systematic review and metaanalysis Protocol

Child development is one of the principal aspects of pediatrics. It is a multidimensional process, on which many factors may have different effects. Zinc is a nutritional trace element that has an essential role in neuronal activity and, consequently, in brain development. Since Zinc deficiency is prevalent in developing countries, some clinical trials were conducted to evaluate the impact of zinc supplementation on child development. Thus, we decided to run a systematic review in this area to identify the effectiveness of zinc supplements on child development.

This systematic review protocol will include randomized controlled trials studies (RCTs) in which zinc supplementation was used versus placebo or no intervention, zinc supplementation with other micronutrients versus the same micronutrients without zinc. We will evaluate the effect of zinc alone and zinc co-supplementation with iron on child development. We will search the Medline, Pubmed, EMBASE, ERIC, Psychinfo, the Cochrane Central Register of Controlled Trials (CENTRAL), clinicaltrials.gov, WHO International Clinical Trials Registry Platform (ICTRP), ISRCTN Registry CINAHL, Web of Science and Scopus databases. The clinicaltrials.gov and the Cochrane Library website will also be searched for randomized trials which were registered and completed but not published yet. Two researchers will independently screen titles and abstracts of citations and read the full texts of potentially relevant studies. The data extraction and quality assessment of the papers will be done independently. Any disagreements that arise between the reviewers in the above-mentioned steps will be resolved through discussion. We will report our findings based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and use the Cochrane Collaboration’s tool for assessing the risk of bias. We will aim to synthesize the results in a meta-analysis if the interventions are similar in methods. Based on the similarities and differences of primary studies, we will use the best statistical methods.

This is a protocol of systematic Review and meta-analysis of the effect of zinc supplementation on child development.

The strengths of this protocol after meta-analysis are as follows:

We will identify the strengths and weaknesses of each study.

We will also study if zinc alone and zinc co-supplementation with iron are useful for improving child development in terms of their age, their nutritional status, dose of the zinc supplementation, type of the zinc supplementation (salt), duration of the intervention and iron or other nutrient co supplementations.

We will assume that the measures used for the outcome will be heterogeneous between studies. We know that each study has its own quantity. We will use the random effect models for these heterogeneous data.

Plasma and Nail Zinc Concentrations, But Not Hair Zinc, Respond Positively to Two Different Forms of Preventive Zinc Supplementation in Young Laotian Children: a Randomized Controlled Trial

Plasma zinc concentrations (PZC) have been shown to significantly increase during zinc supplementation. This study investigated the effects of daily preventive zinc supplementation on hair and nail zinc concentrations compared with a control group. In a randomized controlled trial, 6- to 23-month-old children (n = 3407) in Lao PDR were randomly assigned to one of four groups and followed for ~ 36 weeks: daily preventive zinc dispersible tablet (7 mg/d; PZ), daily micronutrient powder (10 mg zinc/d; MNP), therapeutic zinc supplements for diarrhea treatment (20 mg/d for 10 days; TZ), or daily placebo powder (Control). Plasma, hair, and nail zinc concentrations were assessed in a sub-sample of participants (n = 457) at baseline and endline. At baseline, 75% of children had low PZC (< 65 μg/dL). At endline, geometric mean (95% CI) PZC were greater in the PZ and MNP groups compared with the TZ and control groups (P < 0.01), but hair zinc concentrations did not differ among groups (P = 0.99). Nail zinc concentrations were marginally higher in the PZ (115.8 (111.6, 119.9) μg/g) and the MNP (117.8 (113.3, 122.3) μg/g) groups than in the TZ group (110.4 (106.0, 114.8) μg/g; P = 0.055) at endline. This study does not support the use of hair zinc as a biomarker of zinc exposure in young children. However, it provides some evidence that zinc concentrations in nails may respond to supplemental zinc interventions and supports the need for collecting additional data on this emerging biomarker.

Potential role of neglected and underutilized plant species in improving women's empowerment and nutrition in areas of sub-Saharan Africa

In the context of the nutrition transition, women in sub-Sahara Africa are a critical target group from a nutrition standpoint, and they experience significant discrimination in food production. Food-based, women-centered strategies are recommended to address nutrient gaps, and to educate and empower women. In this context, local natural resources, such as neglected and underutilized plant species (NUS), may contribute to adding nutritional value, enriching diet diversity, and ensuring nutrition security. The aim of the current narrative review is to investigate the nutritional status of the sub-Saharan African population and the potential role of local agriculture strategies in improving food production and diet diversity and in expanding income-generating activities for women. The nutritional properties of the most important regional NUS are also discussed.

Serum level of some micronutrients in children infected with Helicobacter pylori

Background

Helicobacter pylori (H. pylori) proved to be highly prevalent all over the world. H. pylori may modify the absorption of many nutrients. Studies have suggested that, beyond iron, H. pylori infection may affect the homeostasis of other micronutrients such as vitamins and trace elements. Our study’s aim was to assess the effect of H. pylori infection on some blood micronutrient level including zinc, selenium, vitamin C, and vitamin B12 in children with chronic or recurrent unexplained dyspeptic symptoms and/or non-variceal hematemesis.

Results

A cross-sectional case-control study was carried out in 32 children (4–18 years) with chronic or recurrent unexplained dyspeptic symptoms and/or non-variceal hematemesis. Patients were divided according to the results histopathology and rapid urease test into two groups, H. pylori-positive patients (18 patients) and H. pylori-negative patients (14 patients). Another control group of 18 children was included. Serum levels of zinc, selenium, vitamin C, and vitamin B12 were measured in all children. Prevalence of H. pylori infection was 56.2%. The mean serum zinc levels were significantly lower in H. pylori-positive cases than in control group (84.2 ± 13.85 versus 94.6 ± 6.52 with P = 0.009) and lower than in H. pylori-negative cases but not statistically significant (84.2 ± 13.85 versus 92.2 ± 8.53 with P = 0.054). The mean serum vitamin C levels were significantly lower in H. pylori-positive cases than in negative cases and control group (220.7 ± 46.16 versus 305.1 ± 28.83 and 313.1 ± 31.43 with P < 0.0001). The mean serum vitamin B12 levels were significantly lower in H. pylori-positive cases than in negative cases and control group (167.8 ± 76.98 versus 290.1 ± 69.92 and 326.1 ± 38.67 with P < 0.0001). The mean serum selenium level was slightly higher in H. pylori-positive patients than in H. pylori-negative patients and control group but not statistically significant (118.2 ± 11.13 versus 112.1 ± 8.69 and 113.1 ± 13.76 with P = 0.096, 0.243 respectively).

Conclusion

Helicobacter pylori infection in children has a significant negative effect on the serum levels of zinc, vitamin C, and vitamin B12.

Calcium exacerbates the inhibitory effects of phytic acid on zinc bioavailability in rats

BACKGROUND

Complementary feeding of breastfed infants with foods high in bioavailable zinc (Zn) can help meet physiological requirements for Zn. Some infant cereals contain high concentrations of phytic acid (PA) and calcium (Ca) that may reduce absorbable Zn.

OBJECTIVES

This study measured PA, Zn and Ca concentrations in selected infant cereals sold in Canada and investigated the effects of dietary PA and Ca at concentrations present in infant cereals on Zn bioavailability in rats.

METHODS AND RESULTS

Male Sprague-Dawley rats (36-day old) were fed a control diet containing normal Zn (29.1 mg/kg) and Ca (4.95 g/kg) or six test diets (n = 12/diet group). Test diets were low in Zn (8.91-9.74 mg/kg) and contained low (2.16-2.17 g/kg), normal (5.00-5.11 g/kg) or high (14.6-14.9 g/kg) Ca without or with added PA (8 g/kg). After 2 weeks, rats were killed and Zn status of the rats was assessed. PA, Zn and Ca concentrations in infant cereals (n = 20) differed widely. PA concentrations ranged from undetectable to 16.0 g/kg. Zn and Ca concentrations ranged from 7.0-29.1 mg/kg and 0.8-13.4 g/kg, respectively. The [PA]/[Zn] and [PA × Ca]/[Zn] molar ratios in infants cereals with detectable PA (16 of 20 cereals) ranged from 22-75 and 0.9-14.9 mol/kg, respectively, predicting low Zn bioavailability. Body weight, body composition (lean and fat mass), right femur weight and length measurements and Zn concentrations in serum and femur indicated that diets higher in Ca had a more pronounced negative effect on Zn status of rats fed a PA-supplemented diet. Addition of PA to the diet had a greater negative effect on Zn status when Ca concentration in the diet was higher.

CONCLUSION

These results show that, in rats, higher concentrations of dietary Ca and PA interact to potentiate a decrease in bioavailable Zn and may suggest lower Zn bioavailability in infant cereals with higher PA and Ca concentrations.

Prevalence of Zinc Deficiency and the Effect of Zinc Supplementation on the Prevention of Acute Respiratory Infections

OBJECTIVE

Acute lower respiratory infections are an important cause of morbidity and mortality in developing countries. Recent randomized trials of zinc supplementation for the prevention of acute lower respiratory tract infections have revealed discrepant findings. The main aim of this study was to evaluate the prevalence of zinc deficiency and the effect of zinc supplementation on respiratory infections.

MATERIAL AND METHODS

A single center, prospective open-label interventional single-arm pre-post study of the effect of oral zinc supplementation in zinc deficient children aged 6 months to 5 years was done. A total of 465 healthy children of age 6 months to 5 years were enrolled in the study for estimation of the prevalence of zinc deficiency. Children having zinc deficiency were recruited to study the efficacy and safety of oral administration of 20 mg zinc for two weeks during a 6-month follow-up period.

RESULTS

There were statistically significant differences between the zinc deficient and non-deficient groups according to modified Kuppuswamy categorization of family status and exclusive breast feeding. There was significant difference in the mid arm circumference between the zinc deficient and non-deficient groups (p<0.001). There was significant difference (p<0.001) in the number of episodes of acute upper respiratory infections (AURI), mean duration of AURI, and acute lower respiratory infections (ALRI) between the two groups. There was no significant difference in the ALRI episodes between the two groups. After zinc supplementation in zinc deficient children, there was significant decrease in the number of episodes and mean duration of AURI (p<0.001) and ALRI (p<0.001) within six months after supplementation as compared with the preceding six months before supplementation.

CONCLUSION

This study reveals that a short course of zinc supplementation may reduce the burden of AURI/ALRI among the zinc deficient children, but larger studies are needed.

Antimicrobial and micronutrient interventions for the management of infants under 6 months of age identified with severe malnutrition: a literature review

BACKGROUND

Infants under 6 months (U6M) contribute a significant proportion of the burden and mortality of severe malnutrition globally. Evidence of underlying aetiology in this population is sparse, but it is known that the group includes ex-preterm and low birthweight (LBW) infants. They represent a unique population given their dependence on breastmilk or a safe, secure alternative. Nutrition agencies and health providers struggle to make programming decisions on which interventions should be provided to this group based upon the 2013 WHO Guidelines for the 'Management of Severe Acute Malnutrition in Infants and Young Children' since there are no published interventional trial data focussed on this population. Interim guidance for this group might be informed by evidence of safety and efficacy in adjacent population groups.

METHODOLOGY

A narrative literature review was performed of systematic reviews, meta-analyses and randomised controlled trials of antimicrobial and micronutrient interventions (antibiotics, deworming, vitamin A, vitamin D, iron, zinc, folic acid and oral rehydration solution (ORS) for malnutrition) across the population groups of low birthweight/preterm infants, infants under 6 months, infants and children over 6 months with acute malnutrition or through supplementation to breastfeeding mothers. Outcomes of interest were safety and efficacy, in terms of mortality and morbidity.

RESULTS

Ninety-four articles were identified for inclusion within this review. None of these studied interventions exclusively in severely malnourished infants U6M. 64% reported on the safety of studied interventions. Significant heterogeneity was identified in definitions of study populations, interventions provided, and outcomes studied. The evidence for efficacy and safety across population groups is reviewed and presented for the interventions listed.

CONCLUSIONS

The direct evidence base for medical interventions for severely malnourished infants U6M is sparse. Our review identifies a specific need for accurate micronutrient profiling and interventional studies of micronutrients and oral fluid management of diarrhoea amongst infants U6M meeting anthropometric criteria for severe malnutrition. Indirect evidence presented in this review may help shape interim policy and programming decisions as well as the future research agenda for the management of infants U6M identified as malnourished.

Effects of Interspecific Chromosome Substitution in Upland Cotton on Cottonseed Micronutrients

Micronutrients are essential for plant growth and development, and important for human health nutrition and livestock feed. Therefore, the discovery of novel germplasm with significant variability or higher micronutrients content in crop seeds is critical. Currently, there is no information available on the effects of chromosome or chromosome arm substitution in cotton on cottonseed micronutrients. Thus, the objective of this study was to evaluate the effects of chromosome or chromosome arm substitution on the variability and levels of micronutrients B, Fe, Cu, Zn, Mn, and Ni in cottonseed from chromosome substitution (CS) cotton lines. Our hypothesis was that interspecific chromosome substitution in cotton can affect cottonseed micronutrients content, resulting in significant differences and variabilities of these nutrients among CS lines and between CS lines and the controls. Nine CS lines were grown in two-field experiments at two locations (in 2013 in South Carolina, USA; and in 2014 in Mississippi, USA). TM-1 (the recurrent parent of the CS line) and AM UA48 (cultivar) were used as control. The results showed significant variability among CS lines compared to the controls AM UA48 and TM-1. For example, in South Carolina (SC), B concentration in cottonseed ranged from 10.35 mg kg-1 in CS-M02 to 13.67 mg kg-1 in CS-T04. The concentration of Cu ranged from 4.81 mg kg-1 in CS-B08sh to 7.65 mg kg-1 in CS-T02, and CS-T02 was higher than both controls. The concentration of Fe ranged from 36.09 mg kg-1 to 56.69 mg kg-1 (an increase up to 57%), and six CS lines (CS-B02, CS-B08sh, CS-M02, CS-M04, CS-T02, and CS-T04) had higher concentration than both controls in 2013. In 2014 at the Mississippi location (MS), similar observation was found with CS lines for micronutrients content. The CS lines with higher concentrations of these micronutrients can be used as a genetic tool toward QTL identification for desired seed traits because these lines are genetically similar with TM-1, except the substituted chromosome or chromosome segment pairs from the alien species. Chromosome substitution provides an effective means for upland cotton improvement by targeted interspecific introgression, yielding CS lines that facilitate trait discovery, such as seed micronutritional qualities, due to increased isogenicity and markedly reduced complexity from epistatic interactions with non-target alien chromosomes. The positive correlation between B, Cu, and Fe at both locations, between Ni and Mn, between Zn and Cu, and between Zn and Ni at both locations signify the importance of a good agricultural and fertilizer management of these nutrients to maintain higher cottonseed nutrient content.

Daily Preventive Zinc Supplementation Decreases Lymphocyte and Eosinophil Concentrations in Rural Laotian Children from Communities with a High Prevalence of Zinc Deficiency: Results of a Randomized Controlled Trial

BACKGROUND

Zinc deficiency impairs immune function and is common among children in South-East Asia.

OBJECTIVES

The effect of zinc supplementation on immune function in young Laotian children was investigated.

METHODS

Children (n = 512) aged 6-23 mo received daily preventive zinc tablets (PZ; 7 mg Zn/d), daily multiple micronutrient powder (MNP; 10 mg Zn/d, 6 mg Fe/d, plus 13 other micronutrients), therapeutic dispersible zinc tablets only in association with diarrhea episodes (TZ; 20 mg Zn/d for 10 d after an episode), or daily placebo powder (control). These interventions continued for 9 mo. Cytokine production from whole blood cultures, the concentrations of T-cell populations, and a complete blood count with differential leukocyte count were measured at baseline and endline. Endline means were compared via ANCOVA, controlling for the baseline value of the outcome, child age and sex, district, month of enrollment, and baseline zinc status (below, or above or equal to, the median plasma zinc concentration).

RESULTS

T-cell cytokines (IL-2, IFN-γ, IL-13, IL-17), LPS-stimulated cytokines (IL-1β, IL-6, TNF-α, and IL-10), and T-cell concentrations at endline did not differ between intervention groups, nor was there an interaction with baseline zinc status. However, mean ± SE endline lymphocyte concentrations were significantly lower in the PZ than in the control group (5018 ± 158 compared with 5640 ± 160 cells/μL, P = 0.032). Interactions with baseline zinc status were seen for eosinophils (Pixn = 0.0036), basophils (Pixn = 0.023), and monocytes (P = 0.086) but a significant subgroup difference was seen only for eosinophils, where concentrations were significantly lower in the PZ than in the control group among children with baseline plasma zinc concentrations below the overall median (524 ± 44 compared with 600 ± 41 cells/μL, P = 0.012).

CONCLUSIONS

Zinc supplementation of rural Laotian children had no effect on cytokines or T-cell concentrations, although zinc supplementation affected lymphocyte and eosinophil concentrations. These cell subsets may be useful as indicators of response to zinc supplementation.This trial was registered at clinicaltrials.gov as NCT02428647.

Zinc deficiency in low- and middle-income countries: prevalence and approaches for mitigation

This review addresses the prevalence of zinc deficiency in Low- and Middle-income Countries (LMICs) and assesses the available strategies for its alleviation. The paucity of national-level data on the zinc deficiency in LMICs is partially a result of the lack of a reliable biomarker. Zinc deficiency appears to be a public health problem in almost all the LMICs, irrespective of the recommended indicators (plasma zinc concentration, dietary zinc adequacy and stunting prevalence) used. Based on plasma/serum zinc concentration (PZC), which is the most appropriate indicator at present, the prevalence of zinc deficiency in LMICs is of concern. Among the 25 countries for which national PZC data were available, 23 had a zinc deficiency prevalence of >20% for at least one physiological group. Zinc supplementation is largely restricted as an adjunct therapy for diarrhoea management in children, and the best platform and the most effective way of preventive zinc supplementation delivery remains to be established. Impact assessment for current zinc fortification programmes in LMICs and the effectiveness of zinc supplementation as part of a multi-micronutrient powder is to be determined. Dietary diversification, though promising for LMICs, is in the nascent stages of development at present. Inclusion of meat and animal products can be an important way of improving zinc status. Programmatic experience with the promotion of home processing techniques to increase absorbable zinc in the diet is lacking. Conventional biofortification techniques are gaining recognition in LMICs; however, transgenic biofortification as a strategy remains controversial.

Effect of Eel Biscuit Supplementation on Height of Children with Stunting Aged 36-60 Months: A Pilot Study

Background

Stunting is a major health problem in developing countries. Animal-based supplements can increase the height of children with stunting. This study was aimed at determining the effect of eel biscuit supplementation on increase in the height of children with stunting aged 36-60 months.

Methods

A pilot study with pretest-post-test design. The study was conducted in two villages in the Priangan Region, West Java Province, Indonesia. The participants were divided into two groups: intervention group (10 supplemented eel biscuit pieces) and control group (biscuits from the government's biscuit programme). A total of 56 children aged 36-60 months with the height-for-age z-score of <-2 SD were recruited voluntarily for sampling.

Results

The initial height-for-age z-score of the intervention group was -3.45 SD and that of the control group was -3.11 SD. After 3 months of supplemented eel biscuit consumption, the height-for-age z-score of the intervention group changed to -2.52 SD and that of the control group changed to -2.51 SD. The average shift of the height-for-age z-score after 3 months of supplemented eel biscuit consumption was 0.93 SD in the intervention group and 0.6 SD in the control group. There were significant differences in delta and percent increase in the height-for-age z-score between both groups.

Conclusions

Consumption of supplemented eel biscuits for 3 months increased the height-for-age z-score of children with stunting aged 36-60 months by 0.93 SD.