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Azupogo F, Abizari AR, Feskens EJM, Verhoef H, Brouwer ID. Ten2Twenty-Ghana: a randomised controlled trial on the efficacy of multiple micronutrient-fortified biscuits on the micronutrient status of adolescent girls. Br J Nutr 2024; 131:707-719. [PMID: 37795629 PMCID: PMC10803820 DOI: 10.1017/s0007114523002234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/23/2023] [Accepted: 10/02/2023] [Indexed: 10/06/2023]
Abstract
Adolescent girls are an important target group for micronutrient interventions particularly in Sub-Saharan Africa where adolescent pregnancy and micronutrient deficiencies are common. When consumed in sufficient amounts and at levels appropriate for the population, fortified foods may be a useful strategy for this group, but little is known about their effectiveness and timing (regarding menarche), particularly in resource-poor environments. We evaluated the effect of consuming multiple micronutrient-fortified biscuits (MMB), sold in the Ghanaian market, 5 d/week for 26 weeks compared with unfortified biscuits (UB) on the micronutrient status of female adolescents. We also explored to what extent the intervention effect varied before or after menarche. Ten2Twenty-Ghana was a 26-week double-blind, randomised controlled trial among adolescent girls aged 10-17 years (n 621) in the Mion District, Ghana. Biomarkers of micronutrient status included concentrations of Hb, plasma ferritin (PF), soluble transferrin receptor (TfR) and retinol-binding protein (RBP), including body-iron stores. Intention-to-treat analysis was supplemented by protocol-specific analysis. We found no effect of the intervention on PF, TfR and RBP. MMB consumption did not affect anaemia and micronutrient deficiencies at the population level. MMB consumption increased the prevalence of vitamin A deficiency by 6·2 % (95 % CI (0·7, 11·6)) among pre-menarche girls when adjusted for baseline micronutrient status, age and height-for-age Z-score, but it decreased the prevalence of deficient/low vitamin A status by -9·6 % (95 % CI (-18·9, -0·3)) among post-menarche girls. Consuming MMB available in the market did not increase iron status in our study, but reduced the prevalence of deficient/low vitamin A status in post-menarcheal girls.
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Affiliation(s)
- Fusta Azupogo
- Department of Family and Consumer Sciences, Faculty of Agriculture, Food and Consumer Sciences, University for Development Studies, Tamale, 1882, Ghana
- Institute for Global Nutrition, University of California, Davis, USA
| | - Abdul-Razak Abizari
- Formerly of the Department of Nutritional Sciences, School of Allied Health Sciences, University for Development Studies, Tamale, Ghana
| | - Edith J. M. Feskens
- Division of Human Nutrition and Health, Wageningen University and Research, Wageningen, The Netherlands
| | - Hans Verhoef
- Division of Human Nutrition and Health, Wageningen University and Research, Wageningen, The Netherlands
| | - Inge D. Brouwer
- Division of Human Nutrition and Health, Wageningen University and Research, Wageningen, The Netherlands
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Sandalinas F, Filteau S, Joy EJM, Segovia de la Revilla L, MacDougall A, Hopkins H. Measuring the impact of malaria infection on indicators of iron and vitamin A status: a systematic literature review and meta-analysis. Br J Nutr 2023; 129:87-103. [PMID: 35260210 PMCID: PMC9816655 DOI: 10.1017/s0007114522000757] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/17/2022] [Accepted: 02/28/2022] [Indexed: 01/21/2023]
Abstract
Inflammation and infections such as malaria affect estimates of micronutrient status. Medline, Embase, Web of Science, Scopus and the Cochrane library were searched to identify studies reporting mean concentrations of ferritin, hepcidin, retinol or retinol binding protein in individuals with asymptomatic or clinical malaria and healthy controls. Study quality was assessed using the US National Institute of Health tool. Random effects meta-analyses were used to generate summary mean differences. In total, forty-four studies were included. Mean ferritin concentrations were elevated by: 28·2 µg/l (95 % CI 15·6, 40·9) in children with asymptomatic malaria; 28·5 µg/l (95 % CI 8·1, 48·8) in adults with asymptomatic malaria; and 366 µg/l (95 % CI 162, 570) in children with clinical malaria compared with individuals without malaria infection. Mean hepcidin concentrations were elevated by 1·52 nmol/l (95 % CI 0·92, 2·11) in children with asymptomatic malaria. Mean retinol concentrations were reduced by: 0·11 µmol/l (95 % CI -0·22, -0·01) in children with asymptomatic malaria; 0·43 µmol/l (95 % CI -0·71, -0·16) in children with clinical malaria and 0·73 µmol/l (95 % CI -1·11, -0·36) in adults with clinical malaria. Most of these results were stable in sensitivity analyses. In children with clinical malaria and pregnant women, difference in ferritin concentrations were greater in areas with higher transmission intensity. We conclude that biomarkers of iron and vitamin A status should be statistically adjusted for malaria and the severity of infection. Several studies analysing asymptomatic infections reported elevated ferritin concentrations without noticeable elevation of inflammation markers, indicating a need to adjust for malaria status in addition to inflammation adjustments.
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Affiliation(s)
- Fanny Sandalinas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Suzanne Filteau
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Edward J. M. Joy
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Amy MacDougall
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Heidi Hopkins
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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3
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Ensuring the Efficacious Iron Fortification of Foods: A Tale of Two Barriers. Nutrients 2022; 14:nu14081609. [PMID: 35458169 PMCID: PMC9031268 DOI: 10.3390/nu14081609] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 02/01/2023] Open
Abstract
Iron fortification of foods has always been a challenge. This is because iron fortification compounds vary widely in relative absorption; because many foods undergo unacceptable changes in color or flavor from the addition of iron; and because many of the iron-fortified foods contain potent inhibitors of iron absorption. These technical barriers have largely been overcome, and efficacious iron-fortified foods, that maintain or improve the iron status of women or children in long-term feeding studies, can be designed. Commercially fortified infant foods are efficacious, and other commercial iron-fortified foods targeted at women and children will provide a useful amount of iron provided the fortification level is adjusted according to the relative absorption of the iron compound. Technologies for the large-scale fortification of wheat and maize flour are also well established, and iron fortification of rice, using the recently developed extruded premix technique, is showing great promise. However, some important knowledge gaps still remain, and further research and development is needed in relation to iron (and iodine)-fortified salt and iron-fortified liquid milk. The usefulness of less-soluble iron compounds, such as ferrous fumarate, to fortify foods for infants and young children in low- and middle-income countries (LMICs) also needs further investigation. A more formidable barrier to efficacious iron-fortified food has been reported in recent years. This is the infection-initiated inflammation barrier, which inhibits iron absorption in response to infection. This barrier is particularly important in LMICs where infections such as malaria and HIV are widespread, and gastrointestinal infections are common due to poor quality water supplies and sanitation. Another source of inflammation in such countries is the high prevalence of obesity in women. Most countries in sub-Saharan Africa have high inflammation which not only decreases the efficacy of iron-fortified and iron-biofortified foods but complicates the monitoring of large-scale iron fortification programs. This is because iron deficiency anemia cannot be differentiated from the more prominent anemia of inflammation and because inflammation confounds the measurement of iron status. There is an urgent need to better quantify the impact of inflammation on the efficacy of iron-fortified foods. However, at present, in LMICs with high inflammation exposure, infection control, cleaner water, improved sanitation, and a decrease in obesity prevalence will undoubtedly have a greater impact on iron status and anemia than the iron fortification of foods.
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Kaboré B, Post A, Berendsen MLT, Diallo S, Lompo P, Derra K, Rouamba E, Jacobs J, Tinto H, de Mast Q, van der Ven AJ. Red blood cell homeostasis in children and adults with and without asymptomatic malaria infection in Burkina Faso. PLoS One 2020; 15:e0242507. [PMID: 33253198 PMCID: PMC7703889 DOI: 10.1371/journal.pone.0242507] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/02/2020] [Indexed: 11/30/2022] Open
Abstract
Asymptomatic malaria infections may affect red blood cell (RBC) homeostasis. Reports indicate a role for chronic hemolysis and splenomegaly, however, the underlying processes are incompletely understood. New hematology analysers provide parameters for a more comprehensive analysis of RBC hemostasis. Complete blood counts were analysed in subjects from all age groups (n = 1118) living in a malaria hyperendemic area and cytokines and iron biomarkers were also measured. Subjects were divided into age groups (<2 years, 2–4, 5–14 and ≥15 years old) and clinical categories (smear-negative healthy subjects, asymptomatic malaria and clinical malaria). We found that hemoglobin levels were similar in smear-negative healthy children and asymptomatic malaria children but significantly lower in clinical malaria with a maximum difference of 2.2 g/dl in children <2 years decreasing to 0.1 g/dl in those aged ≥15 years. Delta-He, presenting different hemoglobinization of reticulocytes and RBC, levels were lower in asymptomatic and clinial malaria, indicating a recent effect of malaria on erythropoiesis. Reticulocyte counts and reticulocyte production index (RPI), indicating the erythropoietic capacity of the bone marrow, were higher in young children with malaria compared to smear-negative subjects. A negative correlation between reticulocyte counts and Hb levels was found in asymptomatic malaria (ρ = -0.32, p<0.001) unlike in clinical malaria (ρ = -0.008, p = 0.92). Free-Hb levels, indicating hemolysis, were only higher in clinical malaria. Phagocytozing monocytes, indicating erythophagocytosis, were highest in clinical malaria, followed by asymptomatic malaria and smear-negative subjects. Circulating cytokines and iron biomarkers (hepcidin, ferritin) showed similar patterns. Pro/anti-inflammatory (IL-6/IL-10) ratio was higher in clinical than asymptomatic malaria. Cytokine production capacity of ex-vivo whole blood stimulation with LPS was lower in children with asymptomatic malaria compared to smear-negative healthy children. Bone marrow response can compensate the increased red blood cell loss in asymptomatic malaria, unlike in clinical malaria, possibly because of limited level and length of inflammation. Trial registration: Prospective diagnostic study: ClinicalTrials.gov identifier: NCT02669823. Explorative cross-sectional field study: ClinicalTrials.gov identifier: NCT03176719.
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Affiliation(s)
- Berenger Kaboré
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
- * E-mail: (BK); (AJV)
| | - Annelies Post
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mike L. T. Berendsen
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- Open Patient Data Explorative Network, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Salou Diallo
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | | | - Karim Derra
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Eli Rouamba
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine (ITM), Antwerp, Belgium
- Department of Microbiology and Immunology, University of Leuven (KU Leuven), Leuven, Belgium
| | - Halidou Tinto
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
- Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Quirijn de Mast
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Andre J. van der Ven
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- * E-mail: (BK); (AJV)
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5
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Restrepo-Gallego M, Díaz LE, Rondó PHC. Classic and emergent indicators for the assessment of human iron status. Crit Rev Food Sci Nutr 2020; 61:2827-2840. [PMID: 32619106 DOI: 10.1080/10408398.2020.1787326] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Iron deficiency is the leading cause of anemia, a significant global public health problem. Different methods exist for assessing iron nutritional status, including laboratory tests that focus on storage, transportation, and iron functional compartment parameters. Classical markers such as bone marrow, serum iron, ferritin, hemoglobin, erythrocyte parameters, transferrin, transferrin receptors, and zinc protoporphyrin are discussed in this review. Additional parameters calculated from these indicators, including transferrin saturation, ferritin index and Thomas plot, and some emergent parameters such as hepcidin, erythroferrone, and low hemoglobin density are also discussed. There is no a single indicator for assessing iron nutritional status. Therefore, the use of more than one indicator may be the best practice to obtain the correct diagnosis, also considering the influence of inflammation/infection on many of these indicators. The constant validation of the current parameters, the improvement of assessment methods, and the identification of new indicators will be the key to refine the assessment of iron nutritional status and the right choice of treatment for its improvement.
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Affiliation(s)
| | - Luis E Díaz
- Doctorate Program in Bioscience, La Sabana University, Chía, Colombia
| | - Patrícia H C Rondó
- Department of Nutrition, School of Public Health, University of São Paulo, São Paulo, Brazil
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6
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Suchdev PS, Trehan I. Optimizing iron supplementation for children with severe malaria. Am J Clin Nutr 2020; 111:939-940. [PMID: 32140703 DOI: 10.1093/ajcn/nqaa041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Parminder S Suchdev
- Department of Pediatrics, Emory University, Atlanta, GA, USA.,Emory Global Health Institute, Emory University, Atlanta, GA, USA
| | - Indi Trehan
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
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7
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Abstract
BACKGROUND Iron deficiency (ID) is a major public health burden in African children and accurate prevalence estimates are important for effective nutritional interventions. However, ID may be incorrectly estimated in Africa because most measures of iron status are altered by inflammation and infections such as malaria. Through the current study, we have assessed different approaches to the prediction of iron status and estimated the burden of ID in African children. METHODS We assayed iron and inflammatory biomarkers in 4853 children aged 0-8 years from Kenya, Uganda, Burkina Faso, South Africa, and The Gambia. We described iron status and its relationship with age, sex, inflammation, and malaria parasitemia. We defined ID using the WHO guideline (ferritin < 12 μg/L or < 30 μg/L in the presence of inflammation in children < 5 years old or < 15 μg/L in children ≥ 5 years old). We compared this with a recently proposed gold standard, which uses regression-correction for ferritin levels based on the relationship between ferritin levels, inflammatory markers, and malaria. We further investigated the utility of other iron biomarkers in predicting ID using the inflammation and malaria regression-corrected estimate as a gold standard. RESULTS The prevalence of ID was highest at 1 year of age and in male infants. Inflammation and malaria parasitemia were associated with all iron biomarkers, although transferrin saturation was least affected. Overall prevalence of WHO-defined ID was 34% compared to 52% using the inflammation and malaria regression-corrected estimate. This unidentified burden of ID increased with age and was highest in countries with high prevalence of inflammation and malaria, where up to a quarter of iron-deficient children were misclassified as iron replete. Transferrin saturation < 11% most closely predicted the prevalence of ID according to the regression-correction gold standard. CONCLUSIONS The prevalence of ID is underestimated in African children when defined using the WHO guidelines, especially in malaria-endemic populations, and the use of transferrin saturation may provide a more accurate approach. Further research is needed to identify the most accurate measures for determining the prevalence of ID in sub-Saharan Africa.
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Houghton LA, Trilok-Kumar G, McIntosh D, Haszard JJ, Harper MJ, Reid M, Erhardt J, Bailey K, Gibson RS. Multiple micronutrient status and predictors of anemia in young children aged 12-23 months living in New Delhi, India. PLoS One 2019; 14:e0209564. [PMID: 30735503 PMCID: PMC6368289 DOI: 10.1371/journal.pone.0209564] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 12/07/2018] [Indexed: 02/07/2023] Open
Abstract
Anemia has been identified as a severe public health concern among young children in India, however, information on the prevalence of anemia attributed to micronutrient deficiencies is lacking. We aimed to assess multiple micronutrient status (iron, zinc, selenium, vitamin A, vitamin D, folate and vitamin B12) in young Indian children and to investigate the role of these seven micronutrients and other non-nutritional factors on hemoglobin concentrations and anemia. One-hundred and twenty children aged 12 to 23 months were included in a cross-sectional nutritional assessment survey, of which 77 children provided a blood sample. Hemoglobin (Hb), serum ferritin, soluble transferrin receptor (sTfR), total body iron, zinc, selenium, retinol binding protein (RBP), folate, vitamin B12 and 25-hydroxyvitamin D (25(OH)D) were measured, and adjusted for inflammation using C-reactive protein (CRP) and α-1-acid glycoprotein (AGP), where appropriate. Predictors for hemoglobin and anemia were identified in multiple regression models. Most of the children were classified as anemic, of which 86 to 93% was associated with iron deficiency depending on the indicator applied. Deficiencies of folate (37%), and notably vitamin D (74%) were also common; fewer children were classified with deficiencies of vitamin B12 (29%), zinc (25%), and vitamin A (17%) and selenium deficiency was nearly absent. Multiple micronutrient deficiencies were common with over half (57%) deficient in three or more micronutrients, and less than 10% of children were classified with adequate status for all the micronutrients measured. Iron status was found to be the only nutritional factor statistically significantly inversely associated with anemia (P = 0.003) in multivariate analysis after controlling for sex. A coordinated multi-micronutrient program is urgently needed to combat the co-existing micronutrient deficiencies in these young children to improve micronutrient status and reduce the high burden of childhood anemia.
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Affiliation(s)
- Lisa A. Houghton
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
- * E-mail:
| | - Geeta Trilok-Kumar
- Department of Biochemistry, Institute of Home Economics, University of Delhi, New Delhi, India
| | - Deborah McIntosh
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - Jillian J. Haszard
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - Michelle J. Harper
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - Malcolm Reid
- Department of Chemistry, University of Otago, Dunedin, New Zealand
| | | | - Karl Bailey
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - Rosalind S. Gibson
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
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9
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Diallo S, Roberts SA, Gies S, Rouamba T, Swinkels DW, Geurts-Moespot AJ, Ouedraogo S, Ouedraogo GA, Tinto H, Brabin BJ. Malaria early in the first pregnancy: Potential impact of iron status. Clin Nutr 2019; 39:204-214. [PMID: 30737046 DOI: 10.1016/j.clnu.2019.01.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/11/2019] [Accepted: 01/12/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Low iron stores may protect from malaria infection, therefore improving iron stores in early pregnancy in line with current recommendations could increase malaria susceptibility. To test this hypothesis we compared iron biomarkers and red cell indices in nulliparae and primigravidae who participated in a randomized controlled trial of long-term weekly iron supplementation. METHODS Cross-sectional and longitudinal data analysis from a randomized controlled trial of long-term weekly iron supplementation in rural Burkina Faso. Malaria parasitaemia was monitored and biomarkers and red cell indices measured at study end-points: plasma ferritin, transferrin receptor (sTfR), zinc protoporphyrin, hepcidin, sTfR/log10 ferritin ratio, body iron, haemoglobin, red cell distribution width; mean corpuscular haemoglobin concentration/volume, and C-reactive protein. Correlation coefficients between biomarkers and red cell indices were determined. A regression correction approach based on ferritin was used to estimate iron body stores, allowing for inflammation. Body iron differences were compared between nulliparae and primigravidae, and the association determined of iron biomarkers and body iron stores with malaria. RESULTS Iron and haematological indices of 972 nulliparae (mean age 16.5 years) and 314 primigravidae (median gestation 18 weeks) were available. Malaria prevalence was 54.0% in primigravidae and 41.8% in nulliparae (relative risk 1.28, 95% CI 1.13-1.45, P < 0.001), anaemia prevalence 69.7% and 43.4% (P < 0.001), and iron deficient erythropoiesis (low body iron) 8.0% and 11.7% (P = 0.088) respectively. Unlike other biomarkers the sTfR/log10 ferritin ratio showed no correlation with inflammation as measured by CRP. Most biomarkers indicated reduced iron deficiency in early pregnancy, with the exception of haemoglobin. Body iron increased by 0.6-1.2 mg/kg in early gestation, did not differ by malaria status in nulliparae, but was higher in primigravidae with malaria (6.5 mg/kg versus 5.0 mg/kg; relative risk 1.53, 95% CI 0.67-2.38, P < 0.001). CONCLUSION In primigravidae, early pregnancy haemoglobin was not a good indicator of requirement for iron supplementation, which could be detrimental given the association of better iron status with increased malaria infection. TRIAL REGISTRATION clinicaltrials.gov:NCT01210040. Until placed in a public repository, data relating to the current study can be requested from the corresponding author and will be made available following an end user data agreement and sponsor approval.
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Affiliation(s)
- Salou Diallo
- Clinical Research Unit of Nanoro (URCN/IRSS), Nanoro, Burkina Faso.
| | - Stephen A Roberts
- Centre for Biostatistics, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC), Oxford Road, University of Manchester, Manchester, M139PL, UK.
| | - Sabine Gies
- Department of Biomedical Sciences, Prince Leopold Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium; Medical Mission Institute, Würzburg, Germany.
| | | | - Dorine W Swinkels
- Department of Laboratory Medicine (TLM 830), Radboud University Nijmegen Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands; Hepcidinanalysis.com, Geert Grooteplein 10 (830), 6525 GA, Nijmegen, the Netherlands.
| | | | | | | | - Halidou Tinto
- Clinical Research Unit of Nanoro (URCN/IRSS), Nanoro, Burkina Faso.
| | - Bernard J Brabin
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L35QA, England, UK; Institute of Infection and Global Health, University of Liverpool, UK; Global Child Health Group, Academic Medical Centre, University of Amsterdam, the Netherlands.
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10
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Garcia-Casal MN, Pasricha SR, Martinez RX, Lopez-Perez L, Peña-Rosas JP. Are Current Serum and Plasma Ferritin Cut-offs for Iron Deficiency and Overload Accurate and Reflecting Iron Status? A Systematic Review. Arch Med Res 2018; 49:405-417. [DOI: 10.1016/j.arcmed.2018.12.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 12/06/2018] [Indexed: 12/11/2022]
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11
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MacDonell SO, Miller JC, Harper MJ, Reid MR, Haszard JJ, Gibson RS, Houghton LA. A comparison of methods for adjusting biomarkers of iron, zinc, and selenium status for the effect of inflammation in an older population: a case for interleukin 6. Am J Clin Nutr 2018; 107:932-940. [PMID: 29767675 DOI: 10.1093/ajcn/nqy052] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/02/2018] [Indexed: 01/21/2023] Open
Abstract
Background Older people are at risk of micronutrient deficiencies, which can be under- or overestimated in the presence of inflammation. Several methods have been proposed to adjust for the effect of inflammation; however, to our knowledge, none have been investigated in older adults in whom chronic inflammation is common. Objective We investigated the influence of various inflammation-adjustment methods on micronutrient biomarkers associated with anemia in older people living in aged-care facilities in New Zealand. Design Blood samples were collected from 289 New Zealand aged-care residents aged >65 y. Serum ferritin, soluble transferrin receptor (sTfR), total body iron (TBI), plasma zinc, and selenium as well as the inflammatory markers high-sensitivity C-reactive protein (CRP), α1-acid glycoprotein (AGP), and interleukin 6 (IL-6) were measured. Four adjustment methods were applied to micronutrient concentrations: 1) internal correction factors based on stages of inflammation defined by CRP and AGP, 2) external correction factors derived from the literature, 3) a regression correction model in which reference CRP and AGP were set to the maximum of the lowest decile, and 4) a regression correction model in which reference IL-6 was set to the maximum of the lowest decile. Results Forty percent of participants had elevated concentrations of CRP, AGP, or both, and 37% of participants had higher than normal concentrations of IL-6. Adjusted geometric mean values for serum ferritin, sTfR, and TBI were significantly lower (P < 0.001), and plasma zinc and selenium were significantly higher (P < 0.001), than the unadjusted values regardless of the method applied. The greatest inflammation adjustment was observed with the regression correction that used IL-6. Subsequently, the prevalence of zinc and selenium deficiency decreased (-13% and -14%, respectively; P < 0.001), whereas iron deficiency remained unaffected. Conclusions Adjustment for inflammation should be considered when evaluating micronutrient status in this aging population group; however, the approaches used require further investigation, particularly the influence of adjustment for IL-6.
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Affiliation(s)
- Sue O MacDonell
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - Jody C Miller
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand.,Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, CA
| | - Michelle J Harper
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - Malcolm R Reid
- Trace Element Centre, Department of Chemistry, University of Otago, Dunedin, New Zealand
| | - Jillian J Haszard
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - Rosalind S Gibson
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - Lisa A Houghton
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
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12
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Lynch S, Pfeiffer CM, Georgieff MK, Brittenham G, Fairweather-Tait S, Hurrell RF, McArdle HJ, Raiten DJ. Biomarkers of Nutrition for Development (BOND)-Iron Review. J Nutr 2018; 148:1001S-1067S. [PMID: 29878148 PMCID: PMC6297556 DOI: 10.1093/jn/nxx036] [Citation(s) in RCA: 159] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 05/27/2017] [Accepted: 11/07/2017] [Indexed: 12/20/2022] Open
Abstract
This is the fifth in the series of reviews developed as part of the Biomarkers of Nutrition for Development (BOND) program. The BOND Iron Expert Panel (I-EP) reviewed the extant knowledge regarding iron biology, public health implications, and the relative usefulness of currently available biomarkers of iron status from deficiency to overload. Approaches to assessing intake, including bioavailability, are also covered. The report also covers technical and laboratory considerations for the use of available biomarkers of iron status, and concludes with a description of research priorities along with a brief discussion of new biomarkers with potential for use across the spectrum of activities related to the study of iron in human health.The I-EP concluded that current iron biomarkers are reliable for accurately assessing many aspects of iron nutrition. However, a clear distinction is made between the relative strengths of biomarkers to assess hematological consequences of iron deficiency versus other putative functional outcomes, particularly the relationship between maternal and fetal iron status during pregnancy, birth outcomes, and infant cognitive, motor and emotional development. The I-EP also highlighted the importance of considering the confounding effects of inflammation and infection on the interpretation of iron biomarker results, as well as the impact of life stage. Finally, alternative approaches to the evaluation of the risk for nutritional iron overload at the population level are presented, because the currently designated upper limits for the biomarker generally employed (serum ferritin) may not differentiate between true iron overload and the effects of subclinical inflammation.
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Affiliation(s)
| | - Christine M Pfeiffer
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Michael K Georgieff
- Division of Neonatology, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN
| | - Gary Brittenham
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY
| | - Susan Fairweather-Tait
- Department of Nutrition, Norwich Medical School, Norwich Research Park, University of East Anglia, Norwich NR4 7JT, UK
| | - Richard F Hurrell
- Institute of Food, Nutrition and Health, Swiss Federal Institute of Technology, Zurich, Switzerland
| | - Harry J McArdle
- Rowett Institute of Nutrition and Health, University of Aberdeen, Aberdeen AB21 9SB, UK
| | - Daniel J Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH)
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13
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Abstract
Measurement of serum ferritin (SF) is currently the laboratory test recommended for diagnosing iron deficiency. In the absence of an associated disease, a low SF value is an early and highly specific indicator of iron deficiency. The WHO criteria proposed to define depleted storage iron are 12μg/L for children under 5 years and 15μg/L for those over 5 years. A higher threshold of 30μg/L is used in the presence of infection or inflammation. Iron deficiency anemia, with typical low mean corpuscular volume and mean corpuscular hemoglobin, is only present at the end stage of iron deficiency. Other diagnostic tests for iron deficiency including iron parameters (low serum iron, increased total iron-binding capacity, low transferrin saturation) and erythrocyte traits (low mean corpuscular volume, increased zinc protoporphyrin) provide little additional diagnostic value over SF. In children, serum soluble transferrin receptor (sTfR) has been reported to be a sensitive indicator of iron deficiency and is relatively unaffected by inflammation. On the other hand, sTfR is directly related to extent of erythroid activity and not commonly used in clinical practice. In population surveys, approaches based on combinations of markers have been explored to improve the specificity and sensitivity of diagnostic. In addition to Hb value determination, a combination of parameters (among transferrin saturation, zinc protoporphyrin, mean corpuscular volume or serum ferritin) was generally used to assess iron deficiency. More recently sTfR/ ferritin index were evaluated, sTfR in conjunction with SF allowing to better distinguishing iron deficiency from inflammatory anemia. Also, hepcidin measurements appeared an interesting marker for diagnosing iron deficiency and identifying individuals in need of iron supplementation in populations where inflammatory or infectious diseases are frequently encountered. Reticulocyte Hb content (CHr) determination is an early parameter of iron deficiency erythropoiesis. CHr can be measured with several automated hematology analyzers and so, used for individual's iron status assessment. In addition to Hb concentration determination, individual's iron status is commonly assessed in the pediatric clinical practice by the SF measurement accompanied by the determination of C-reactive protein for detection of a simultaneous acute infection and/or inflammation.
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Affiliation(s)
- I Thuret
- Service d'onco-hématologie pédíatrique, CHU Timone Enfants, centre de référence des thalassémies, 264, rue Saint-Pierre, 13005 Marseille, France.
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Barffour MA, Schulze KJ, Coles CL, Chileshe J, Kalungwana N, Siamusantu W, Arguello M, Moss WJ, West KP, Palmer AC. Malaria exacerbates inflammation-associated elevation in ferritin and soluble transferrin receptor with only modest effects on iron deficiency and iron deficiency anaemia among rural Zambian children. Trop Med Int Health 2017; 23:53-62. [PMID: 29121448 DOI: 10.1111/tmi.13004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE In 4- to 8-year-old Zambian children (n = 744), we evaluated the effects of adjusting for inflammation (α1-acid glycoprotein >1 g/l), with or without additional adjustment for malaria, on prevalence estimates of iron deficiency (ID) and iron deficiency anaemia (IDA) during low malaria (LowM) and high malaria (HighM) transmission seasons. METHODS To estimate adjustment factors, children were classified as: (i) reference (malaria negative without inflammation), (ii) inflammation without malaria (I), (iii) malaria without inflammation (M) and (iv) inflammation with malaria (IM). We estimated the unadjusted ID or IDA prevalence, and then adjusted for inflammation alone (IDI or IDAI ) or inflammation and malaria (IDIM or IDAIM ). RESULTS Mean ferritin was 38 (reference), 45 (I), 43 (M) and 54 μg/l (IM) in LowM, increasing to 44, 56, 96 and 167 μg/l, respectively, in HighM. Corresponding mean sTfR was 6.4, 6.9, 7.9 and 8.4 mg/l in LowM, increasing to 8.2, 9.2. 8.7 and 9.7 mg/l in HighM. Ferritin-based ID, IDI and IDIM were 7.8%, 8.7% or 9.1%, respectively, in LowM and 4.6%, 10.0% or 11.7%, respectively, in HighM. Corresponding soluble transferrin receptor (sTfR)-based estimates were 27.0%, 24.1% and 19.1%, respectively, in LowM, increasing to 53.6%, 46.5% and 45.3%, respectively, in HighM. Additional adjustment for malaria resulted in a ~1- to 2-percentage point change in IDA, depending on biomarker and season. CONCLUSIONS In this population, malaria substantially increased ferritin and sTfR concentrations, with modest effects on ID and IDA prevalence estimates.
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Affiliation(s)
- Maxwell A Barffour
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kerry J Schulze
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Christian L Coles
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | - Margia Arguello
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - William J Moss
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Keith P West
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amanda C Palmer
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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15
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Chen Z, Zhu B, Ou C, Li Y. Serum ferritin and primary lung cancer. Oncotarget 2017; 8:92643-92651. [PMID: 29190945 PMCID: PMC5696211 DOI: 10.18632/oncotarget.21518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 09/04/2017] [Indexed: 01/10/2023] Open
Abstract
Existing research yields conflicting results regarding the relation between iron deficiency and high serum ferritin (SF) levels in primary lung cancer patients. We investigated the concentrations of SF, hemoglobin (Hb) and transferrin (TRF) in 569 male primary lung cancer patients and 252 female primary lung cancer patients. We grouped the subjects according to gender, smoking status, menopausal status, pathological type, stage, and TNM stage. The levels of SF and TRF were correlated with T stage in male patients (p<0.01). The levels of SF and TRF were correlated with menopausal status in female patients (p<0.01). Hb was correlated with smoking status, pathological type, stage, and TNM stages in male patients(p<0.01), but in female patients, Hb was not correlated with these grouping factors(p>0.05). The levels of SF may be regulated by different mechanisms and may be of different physiological significance in different populations.
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Affiliation(s)
- Zhongqing Chen
- Department of Clinical Laboratory, Guangxi Medical University Affiliated Tumor Hospital, Nanning 530021, Guangxi Province, P.R. China
| | - Bo Zhu
- Department of Clinical Laboratory, Guangxi Medical University Affiliated Tumor Hospital, Nanning 530021, Guangxi Province, P.R. China
| | - Chao Ou
- Experimental Research Department, Guangxi Medical University Affiliated Tumor Hospital, Nanning 530021, Guangxi Province, P.R. China
| | - Yuxuan Li
- Department of Hepatobiliary Surgery, Guangxi Medical University Affiliated Tumor Hospital, Nanning 530021, Guangxi Province, P.R. China
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16
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Glinz D, Wegmüller R, Ouattara M, Diakité VG, Aaron GJ, Hofer L, Zimmermann MB, Adiossan LG, Utzinger J, N'Goran EK, Hurrell RF. Iron Fortified Complementary Foods Containing a Mixture of Sodium Iron EDTA with Either Ferrous Fumarate or Ferric Pyrophosphate Reduce Iron Deficiency Anemia in 12- to 36-Month-Old Children in a Malaria Endemic Setting: A Secondary Analysis of a Cluster-Randomized Controlled Trial. Nutrients 2017; 9:E759. [PMID: 28708072 PMCID: PMC5537873 DOI: 10.3390/nu9070759] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/08/2017] [Accepted: 07/11/2017] [Indexed: 12/23/2022] Open
Abstract
Iron deficiency anemia (IDA) is a major public health problem in sub-Saharan Africa. The efficacy of iron fortification against IDA is uncertain in malaria-endemic settings. The objective of this study was to evaluate the efficacy of a complementary food (CF) fortified with sodium iron EDTA (NaFeEDTA) plus either ferrous fumarate (FeFum) or ferric pyrophosphate (FePP) to combat IDA in preschool-age children in a highly malaria endemic region. This is a secondary analysis of a nine-month cluster-randomized controlled trial conducted in south-central Côte d'Ivoire. 378 children aged 12-36 months were randomly assigned to no food intervention (n = 125; control group), CF fortified with 2 mg NaFeEDTA plus 3.8 mg FeFum for six days/week (n = 126; FeFum group), and CF fortified with 2 mg NaFeEDTA and 3.8 mg FePP for six days/week (n = 127; FePP group). The outcome measures were hemoglobin (Hb), plasma ferritin (PF), iron deficiency (PF < 30 μg/L), and anemia (Hb < 11.0 g/dL). Data were analyzed with random-effect models and PF was adjusted for inflammation. The prevalence of Plasmodium falciparum infection and inflammation during the study were 44-66%, and 57-76%, respectively. There was a significant time by treatment interaction on IDA (p = 0.028) and a borderline significant time by treatment interaction on iron deficiency with or without anemia (p = 0.068). IDA prevalence sharply decreased in the FeFum (32.8% to 1.2%, p < 0.001) and FePP group (23.6% to 3.4%, p < 0.001). However, there was no significant time by treatment interaction on Hb or total anemia. These data indicate that, despite the high endemicity of malaria and elevated inflammation biomarkers (C-reactive protein or α-1-acid-glycoprotein), IDA was markedly reduced by provision of iron fortified CF to preschool-age children for 9 months, with no significant differences between a combination of NaFeEDTA with FeFum or NaFeEDTA with FePP. However, there was no overall effect on anemia, suggesting most of the anemia in this setting is not due to ID. This trial is registered at clinicaltrials.gov (NCT01634945).
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Affiliation(s)
- Dominik Glinz
- Laboratory of Human Nutrition, Institute of Food, Nutrition, and Health, ETH Zurich, CH-8092 Zurich, Switzerland.
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, CH-4031 Basel, Switzerland.
- University of Basel, CH-4003 Basel, Switzerland.
| | - Rita Wegmüller
- Laboratory of Human Nutrition, Institute of Food, Nutrition, and Health, ETH Zurich, CH-8092 Zurich, Switzerland.
| | - Mamadou Ouattara
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, 01 BP V34 Abidjan, Cote d'Ivoire.
- Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, 01 BP 1303 Abidjan, Côte d'Ivoire.
| | - Victorine G Diakité
- Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, 01 BP 1303 Abidjan, Côte d'Ivoire.
- Département de Sociologie, Université Alassane Ouattara, 01 BP V18 Bouaké, Côte d'Ivoire.
| | - Grant J Aaron
- Global Alliance for Improved Nutrition, CH-1202 Geneva, Switzerland.
| | - Lorenz Hofer
- Swiss Tropical and Public Health Institute, CH-4051 Basel, Switzerland.
| | - Michael B Zimmermann
- Laboratory of Human Nutrition, Institute of Food, Nutrition, and Health, ETH Zurich, CH-8092 Zurich, Switzerland.
| | - Lukas G Adiossan
- Hôpital Général de Taabo, Taabo Cité, BP 700 Toumodi, Côte d'Ivoire.
| | - Jürg Utzinger
- University of Basel, CH-4003 Basel, Switzerland.
- Swiss Tropical and Public Health Institute, CH-4051 Basel, Switzerland.
| | - Eliézer K N'Goran
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, 01 BP V34 Abidjan, Cote d'Ivoire.
- Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, 01 BP 1303 Abidjan, Côte d'Ivoire.
| | - Richard F Hurrell
- Laboratory of Human Nutrition, Institute of Food, Nutrition, and Health, ETH Zurich, CH-8092 Zurich, Switzerland.
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17
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Engle-Stone R, Williams TN, Nankap M, Ndjebayi A, Gimou MM, Oyono Y, Tarini A, Brown KH, Green R. Prevalence of Inherited Hemoglobin Disorders and Relationships with Anemia and Micronutrient Status among Children in Yaoundé and Douala, Cameroon. Nutrients 2017; 9:E693. [PMID: 28671630 PMCID: PMC5537808 DOI: 10.3390/nu9070693] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 06/19/2017] [Accepted: 06/26/2017] [Indexed: 02/06/2023] Open
Abstract
Information on the etiology of anemia is necessary to design effective anemia control programs. Our objective was to measure the prevalence of inherited hemoglobin disorders (IHD) in a representative sample of children in urban Cameroon, and examine the relationships between IHD and anemia. In a cluster survey of children 12-59 months of age (n = 291) in Yaoundé and Douala, we assessed hemoglobin (Hb), malaria infection, and plasma indicators of inflammation and micronutrient status. Hb S was detected by HPLC, and α⁺thalassemia (3.7 kb deletions) by PCR. Anemia (Hb < 110 g/L), inflammation, and malaria were present in 45%, 46%, and 8% of children. A total of 13.7% of children had HbAS, 1.6% had HbSS, and 30.6% and 3.1% had heterozygous and homozygous α⁺thalassemia. The prevalence of anemia was greater among HbAS compared to HbAA children (60.3 vs. 42.0%, p = 0.038), although mean Hb concentrations did not differ, p = 0.38). Hb and anemia prevalence did not differ among children with or without single gene deletion α⁺thalassemia. In multi-variable models, anemia was independently predicted by HbAS, HbSS, malaria, iron deficiency (ID; inflammation-adjusted ferritin <12 µg/L), higher C-reactive protein, lower plasma folate, and younger age. Elevated soluble transferrin receptor concentration (>8.3 mg/L) was associated with younger age, malaria, greater mean reticulocyte counts, inflammation, HbSS genotype, and ID. IHD are prevalent but contribute modestly to anemia among children in urban Cameroon.
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Affiliation(s)
- Reina Engle-Stone
- Department of Nutrition, University of California, Davis, CA 95616, USA; or
| | | | - Martin Nankap
- Helen Keller International, Cameroon, BP 14227 Yaoundé, Cameroon; (M.N.); (A.N.); (A.T.)
| | - Alex Ndjebayi
- Helen Keller International, Cameroon, BP 14227 Yaoundé, Cameroon; (M.N.); (A.N.); (A.T.)
| | | | - Yannick Oyono
- Centre Pasteur du Cameroun, BP 1274 Yaoundé, Cameroon;
| | - Ann Tarini
- Centre Pasteur du Cameroun, BP 1274 Yaoundé, Cameroon;
| | - Kenneth H. Brown
- Department of Nutrition, University of California, Davis, CA 95616, USA; or
- Bill & Melinda Gates Foundation, Seattle, WA 98102, USA
| | - Ralph Green
- Department of Medical Pathology and Laboratory Medicine, UC Davis Medical Center, Sacramento, CA 95817, USA;
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18
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Namaste SML, Rohner F, Huang J, Bhushan NL, Flores-Ayala R, Kupka R, Mei Z, Rawat R, Williams AM, Raiten DJ, Northrop-Clewes CA, Suchdev PS. Adjusting ferritin concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Am J Clin Nutr 2017; 106:359S-371S. [PMID: 28615259 PMCID: PMC5490647 DOI: 10.3945/ajcn.116.141762] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: The accurate estimation of iron deficiency is important in planning and implementing interventions. Ferritin is recommended as the primary measure of iron status, but interpretability is challenging in settings with infection and inflammation.Objective: We assessed the relation between ferritin concentrations and inflammation and malaria in preschool children (PSC) (age range: 6-59 mo) and women of reproductive age (WRA) (age range: 15-49 y) and investigated adjustment algorithms to account for these effects.Design: Cross-sectional data from 15 surveys for PSC (n = 27,865) and 8 surveys for WRA (24,844), from the Biomarkers Reflecting the Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed individually and combined with the use of a meta-analysis. Several approaches were explored to estimate depleted iron stores (ferritin concentration <12 μg/L in PSC and <15 μg/L in WRA) in inflammation and malaria settings as follows: 1) increase ferritin-concentration cutoff to <30 μg/L; 2) exclude individuals with C-reactive protein (CRP) concentrations >5 mg/L or α-1-acid glycoprotein (AGP) concentrations >1 g/L; 3) apply arithmetic correction factors; and 4) use a regression correction approach.Results: Depleted iron-store estimates incrementally increased as CRP and AGP deciles decreased (4% compared with 30%, and 6% compared with 29% from highest compared with lowest CRP deciles for pooled PSC and WRA, respectively, with similar results for AGP). Depending on the approach used to adjust for inflammation (CRP plus AGP), the estimated prevalence of depleted iron stores increased by 7-25 and 2-8 absolute median percentage points for PSC and WRA, respectively, compared with unadjusted values. Adjustment for malaria in addition to CRP and AGP did not substantially change the estimated prevalence of depleted iron stores.Conclusions: Our results lend support for the use of internal regression correction to estimate the prevalence of depleted iron stores in regions with inflammation. This approach appears to mathematically reflect the linear relation of ferritin concentrations with acute-phase proteins. More research is warranted to validate the proposed approaches, but this study contributes to the evidence base to guide decisions about how and when to adjust ferritin for inflammation.
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Affiliation(s)
- Sorrel ML Namaste
- Strengthening Partnerships, Results, and Innovations in Nutrition Globally, Arlington, VA;,Helen Keller International, Washington, DC
| | | | - Jin Huang
- Department of Oncology, Johns Hopkins University, Baltimore, MD
| | - Nivedita L Bhushan
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC
| | | | | | | | - Rahul Rawat
- Poverty Health and Nutrition Division, International Food Policy Research Institute, Dakar, Senegal
| | | | - Daniel J Raiten
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD; and
| | | | - Parminder S Suchdev
- Nutrition Branch, CDC, Atlanta, GA;,Emory University, Department of Pediatrics, Atlanta, GA
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19
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Namaste SML, Aaron GJ, Varadhan R, Peerson JM, Suchdev PS. Methodologic approach for the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Am J Clin Nutr 2017; 106:333S-347S. [PMID: 28615254 PMCID: PMC5490643 DOI: 10.3945/ajcn.116.142273] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: The Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project is a multiagency and multicountry collaboration that was formed to improve micronutrient assessment and to better characterize anemia.Objectives: The aims of the project were to 1) identify factors associated with inflammation, 2) assess the relations between inflammation, malaria infection, and biomarkers of iron and vitamin A status and compare adjustment approaches, and 3) assess risk factors for anemia in preschool children (PSC) and women of reproductive age (WRA).Design: The BRINDA database inclusion criteria included surveys that 1) were conducted after 2004, 2) had target groups of PSC, WRA, or both, and 3) used a similar laboratory methodology for the measurement of ≥1 biomarker of iron [ferritin or soluble transferrin receptor or vitamin A status (retinol-binding protein or retinol)] and ≥1 biomarker of inflammation (α-1-acid glycoprotein or C-reactive protein). Individual data sets were standardized and merged into a BRINDA database comprising 16 nationally and regionally representative surveys from 14 countries. Collectively, the database covered all 6 WHO geographic regions and contained ∼30,000 PSC and 27,000 WRA. Data were analyzed individually and combined with the use of a meta-analysis.Results: The methods that were used to standardize the BRINDA database and the analytic approaches used to address the project's research questions are presented in this article. Three approaches to adjust micronutrient biomarker concentrations in the presence of inflammation and malaria infection are presented, along with an anemia conceptual framework that guided the BRINDA project's anemia analyses.Conclusions: The BRINDA project refines approaches to interpret iron and vitamin A biomarker values in settings of inflammation and malaria infection and suggests the use of a new regression approach as well as proposes an anemia framework to which real-world data can be applied. Findings can inform guidelines and strategies to prevent and control micronutrient deficiencies and anemia globally.
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Affiliation(s)
- Sorrel ML Namaste
- Strengthening Partnerships, Results, and Innovations in Nutrition Globally, Arlington, VA;,Helen Keller International, Washington, DC
| | - Grant J Aaron
- Global Alliance for Improved Nutrition, Geneva, Switzerland
| | - Ravi Varadhan
- Department of Oncology, Johns Hopkins University, Baltimore, MD
| | - Janet M Peerson
- Department of Nutrition, University of California, Davis, Davis, CA
| | - Parminder S Suchdev
- Nutrition Branch, CDC, Atlanta, GA; and,Department of Pediatrics and Global Health, Emory University, Atlanta, GA
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20
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Engle-Stone R, Aaron GJ, Huang J, Wirth JP, Namaste SM, Williams AM, Peerson JM, Rohner F, Varadhan R, Addo OY, Temple V, Rayco-Solon P, Macdonald B, Suchdev PS. Predictors of anemia in preschool children: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Am J Clin Nutr 2017; 106:402S-415S. [PMID: 28615260 PMCID: PMC5490650 DOI: 10.3945/ajcn.116.142323] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: A lack of information on the etiology of anemia has hampered the design and monitoring of anemia-control efforts.Objective: We aimed to evaluate predictors of anemia in preschool children (PSC) (age range: 6-59 mo) by country and infection-burden category.Design: Cross-sectional data from 16 surveys (n = 29,293) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed separately and pooled by category of infection burden. We assessed relations between anemia (hemoglobin concentration <110 g/L) and severe anemia (hemoglobin concentration <70 g/L) and individual-level (age, anthropometric measures, micronutrient deficiencies, malaria, and inflammation) and household-level predictors; we also examined the proportion of anemia with concomitant iron deficiency (defined as an inflammation-adjusted ferritin concentration <12 μg/L). Countries were grouped into 4 categories on the basis of risk and burden of infectious disease, and a pooled multivariable logistic regression analysis was conducted for each group.Results: Iron deficiency, malaria, breastfeeding, stunting, underweight, inflammation, low socioeconomic status, and poor sanitation were each associated with anemia in >50% of surveys. Associations between breastfeeding and anemia were attenuated by controlling for child age, which was negatively associated with anemia. The most consistent predictors of severe anemia were malaria, poor sanitation, and underweight. In multivariable pooled models, child age, iron deficiency, and stunting independently predicted anemia and severe anemia. Inflammation was generally associated with anemia in the high- and very high-infection groups but not in the low- and medium-infection groups. In PSC with anemia, 50%, 30%, 55%, and 58% of children had concomitant iron deficiency in low-, medium-, high-, and very high-infection categories, respectively.Conclusions: Although causal inference is limited by cross-sectional survey data, results suggest anemia-control programs should address both iron deficiency and infections. The relative importance of factors that are associated with anemia varies by setting, and thus, country-specific data are needed to guide programs.
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Affiliation(s)
| | - Grant J Aaron
- Global Alliance for Improved Nutrition, Geneva, Switzerland
| | - Jin Huang
- Division of Biostatistics and Bioinformatics, Department of Oncology, Johns Hopkins University, Baltimore, MD
| | | | - Sorrel Ml Namaste
- Strengthening Partnerships, Results, and Innovations in Nutrition Globally, Arlington, VA
| | | | - Janet M Peerson
- Department of Nutrition, University of California, Davis, CA
| | | | - Ravi Varadhan
- Division of Biostatistics and Bioinformatics, Department of Oncology, Johns Hopkins University, Baltimore, MD
| | - O Yaw Addo
- Department of Global Health, Rollins School of Public Health, Atlanta, GA
| | - Victor Temple
- School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - Pura Rayco-Solon
- Department of Nutrition for Health and Development, WHO, Geneva, Switzerland
| | | | - Parminder S Suchdev
- Department of Pediatrics, Emory University, Atlanta, GA;
- Department of Global Health, Rollins School of Public Health, Atlanta, GA
- Nutrition Branch, CDC, Atlanta, GA
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21
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Rohner F, Namaste SML, Larson LM, Addo OY, Mei Z, Suchdev PS, Williams AM, Sakr Ashour FA, Rawat R, Raiten DJ, Northrop-Clewes CA. Adjusting soluble transferrin receptor concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Am J Clin Nutr 2017; 106:372S-382S. [PMID: 28615256 PMCID: PMC5490651 DOI: 10.3945/ajcn.116.142232] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: Iron deficiency is thought to be one of the most prevalent micronutrient deficiencies globally, but an accurate assessment in populations who are frequently exposed to infections is impeded by the inflammatory response, which causes iron-biomarker alterations.Objectives: We assessed the relation between soluble transferrin receptor (sTfR) concentrations and inflammation and malaria in preschool children (PSC) (age range: 6-59 mo) and women of reproductive age (WRA) (age range: 15-49 y) and investigated adjustment algorithms to account for these effects.Design: Cross-sectional data from the Biomarkers Reflecting the Inflammation and Nutritional Determinants of Anemia (BRINDA) project from 11,913 PSC in 11 surveys and from 11,173 WRA in 7 surveys were analyzed individually and combined with the use of a meta-analysis. The following 3 adjustment approaches were compared with estimated iron-deficient erythropoiesis (sTfR concentration >8.3 mg/L): 1) the exclusion of individuals with C-reactive protein (CRP) concentrations >5 mg/L or α-1-acid glycoprotein (AGP) concentrations >1 g/L, 2) the application of arithmetic correction factors, and 3) the use of regression approaches.Results: The prevalence of elevated sTfR concentrations incrementally decreased as CRP and AGP deciles decreased for PSC and WRA, but the effect was more pronounced for AGP than for CRP. Depending on the approach used to adjust for inflammation, the estimated prevalence of iron-deficient erythropoiesis decreased by 4.4-14.6 and 0.3-9.5 percentage points in PSC and WRA, respectively, compared with unadjusted values. The correction-factor approach yielded a more modest reduction in the estimated prevalence of iron-deficient erythropoiesis than did the regression approach. Mostly, adjustment for malaria in addition to AGP did not significantly change the estimated prevalence of iron-deficient erythropoiesis.Conclusions: sTfR may be useful to assess iron-deficient erythropoiesis, but inflammation influences its interpretation, and adjustment of sTfR for inflammation and malaria should be considered. More research is warranted to evaluate the proposed approaches in different settings, but this study contributes to the evidence on how and when to adjust sTfR for inflammation and malaria.
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Affiliation(s)
| | - Sorrel ML Namaste
- Strengthening Partnerships, Results, and Innovations in Nutrition Globally, Arlington, VA;,Helen Keller International, Washington, DC
| | | | | | | | | | | | | | - Rahul Rawat
- International Food Policy Research Institute, Washington, DC
| | - Daniel J Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD; and
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22
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Mei Z, Namaste SML, Serdula M, Suchdev PS, Rohner F, Flores-Ayala R, Addo OY, Raiten DJ. Adjusting total body iron for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Am J Clin Nutr 2017; 106:383S-389S. [PMID: 28615255 PMCID: PMC5490648 DOI: 10.3945/ajcn.116.142307] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Total body iron (TBI) that is calculated from ferritin and soluble transferrin receptor (sTfR) allows for the evaluation of the full range of iron status from deficiency to excess. However, both ferritin and sTfR are affected by inflammation and malaria, which may require a statistical adjustment. TBI has been used to assess iron status in the United States, but its use worldwide and in settings with inflammation has been limited.Objective: We examine whether inflammation-adjusted ferritin and sTfR concentrations affect TBI values and the prevalence of low TBI (<0 mg/kg) in preschool children (PSC) (age range: 6-59 mo) and women of reproductive age (WRA) (age range: 15-49 y).Design: Cross-sectional data for PSC (8 surveys; n = 8413) and WRA (4 surveys; n = 4258) from the Biomarkers Reflecting the Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed individually and combined. TBI and the prevalence of low TBI were compared following 3 adjustment approaches for ferritin and sTfR: 1) the exclusion of individuals with inflammation (C-reactive protein concentration >5 mg/L or α-1-acid glycoprotein concentration >1 g/L), 2) the application of arithmetic correction factors, and 3) the use of regression correction.Results: Regardless of the method that was used to adjust ferritin and sTfR for inflammation, the adjusted mean TBI decreased in both PSC and WRA compared with unadjusted values. Subsequently, inflammation-adjusted TBI increased the prevalence of low TBI by a median of 4-14 percentage points (pps) in PSC and 1-3 pps in WRA compared with unadjusted TBI. The regression approach resulted in a greater median increase than was achieved with the exclusion or correction-factor approaches, and accounting for malaria in addition to inflammation did not have an added effect on the prevalence estimates.Conclusion: The prevalence of low TBI is underestimated if it is not adjusted by inflammation, particularly in children living in areas with a high prevalence of inflammation.
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Affiliation(s)
| | - Sorrel ML Namaste
- Strengthening Partnerships, Results, and Innovations in Nutrition Globally, Arlington, VA;,Helen Keller International, Washington, DC
| | | | | | | | | | | | - Daniel J Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD
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23
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Abstract
Studies of prévalence in iron deficiency separate iron depletion (defined as decreased blood ferritin) and iron deficiency anemia (defined as blood decrease in both ferritin and hemoglobin). In Europe, most studies are outdated. Prevalence of iron depletion varies from 7 to 18 % and 24 to 36% in toddlers and adolescents, respectively. Prevalence of iron deficiency anemia varies from 2 to 8.5% and 7 to 10% in toddlers and adolescents. In French speaking African countries, Demography Health Surveys show that 80% of children aged 0 to 2 years are anemic, severely for 5 to 9% of them.
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Affiliation(s)
- C Dupont
- Service d'explorations fonctionnelles digestives, hôpital Necker-Enfants malades, 149, rue de Sèvres, 75015 Paris, France.
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Abizari AR, Azupogo F, Brouwer ID. Subclinical inflammation influences the association between vitamin A- and iron status among schoolchildren in Ghana. PLoS One 2017; 12:e0170747. [PMID: 28152069 PMCID: PMC5289472 DOI: 10.1371/journal.pone.0170747] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 01/10/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVE In resource-poor settings, micronutrient deficiencies such as vitamin A deficiency may co-exist with iron-deficiency. In this study we assessed the iron and vitamin A status of schoolchildren and the association between vitamin A and iron status. METHODS A cross-sectional design using the baseline data of a dietary intervention trial conducted among randomly selected 5-12 years old schoolchildren (n = 224) from 2 rural schools in northern Ghana. Hemoglobin (Hb), serum ferritin (SF) and serum transferrin receptor (sTfR) concentrations were used as measures of iron status. Retinol binding protein (RBP) was used as a measure of vitamin A status. Subclinical inflammation (SCI) was measured using C-reactive protein (CRP) and α1-acid glycoprotein (AGP) concentrations. We examined the cross-sectional association between vitamin A and iron status biomarkers with multiple linear regressions. RESULTS The proportions of schoolchildren with anemia (WHO criteria), iron-deficiency (ID, SF <15μg/l and/or sTfR >8.5mg/l) and iron-deficiency anemia (IDA, concurrent anemia and ID) were 63.8%, 68.3% and 46.4% respectively. Low or marginal vitamin A status (0.70 μmol/l ≤ RBP < 1.05μmol/l) was present in 48.2% while 37.5% of the schoolchildren had vitamin A deficiency (VAD, RBP <0.70 μmol/l). The prevalence of SCI as well as concurrent VAD and ID were 48.7% and 25% respectively. RBP was associated with Hb (β = 7.2, P = 0.05) but not SF (β = 20.7, P = 0.33) and sTfR concentration (β = 12.0, P = 0.63). In the presence of SCI, RBP was not associated with hemoglobin status but a significant positive association was observed among children without SCI. CONCLUSIONS The study shows that RBP is significantly associated with Hb concentration but not with SF and sTfR. The observed relationship between RBP and Hb is only significant in the absence of SCI.
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Affiliation(s)
- Abdul-Razak Abizari
- Department of Community Nutrition, School of Allied Health Sciences, University for Development Studies, Tamale, Ghana
| | - Fusta Azupogo
- Department of Family and Consumer Science, Faculty of Agriculture, University for Development Studies, Tamale, Ghana
| | - Inge D. Brouwer
- Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands
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Meltzer HM, Alexander J, Brantsæter AL, Borch-Iohnsen B, Ellingsen DG, Thomassen Y, Holmen J, Ydersbond TA. The impact of iron status and smoking on blood divalent metal concentrations in Norwegian women in the HUNT2 Study. J Trace Elem Med Biol 2016; 38:165-173. [PMID: 27108098 DOI: 10.1016/j.jtemb.2016.04.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/09/2016] [Accepted: 04/14/2016] [Indexed: 01/20/2023]
Abstract
Low iron (Fe) stores may result in increased absorption of divalent metals, in particular cadmium (Cd). We have previously shown that in non-smoking women participating in the Norwegian HUNT2 cohort study this also included other divalent metals, e.g. manganese (Mn) and cobalt (Co). The diet is the main source of metals in non-smoking individuals, whereas in smoking individuals tobacco smoke contributes significant amounts of Cd and lead (Pb). The aim of the present study was to investigate the impact of smoking on the relationship between low iron status and divalent metals. Blood concentrations of the divalent metals Cd, Mn, Co, Pb, copper (Cu) and zinc (Zn), determined using an Element 2 sector field mass spectrometer (ICP-MS), were investigated in smoking women of fertile age (range 21-55 years) (n=267) from the HUNT2 cohort. Among these, 82 were iron-deplete (serum ferritin<12μg/L) and 28 had iron deficiency anaemia (serum ferritin<12μg/L & Hb<120g/L). 150 (56%) women smoked 10 or more cigarettes daily, 101 (38%) had smoked for more than 20 years, and 107 (40%) had smoked for 11-20 years. Results from the smoking population were compared with results from our previous study in non-smoking women (n=448) of which 132 were previous smokers, all from the same cohort. Increasing concentrations of Cd in blood were observed for previous smokers, low-to-moderate smokers and high intensity smokers in all subgroups compared to never smokers, and according to age groups, education level, BMI and serum ferritin. Smokers had higher Pb concentrations than non-smokers in all subgroups, but less pronounced than for Cd. Smoking was not associated with Mn and Co concentrations in blood. In multiple regression models, low ferritin was associated with increased blood concentrations of Cd, Pb, Mn and Co. Ferritin was strongly associated with Cd at low smoking intensity, but was not a significant factor in heavy smokers, where intensity and duration of smoking emerged as main determinants. Ferritin associations with Co and Pb varied with tertiles of blood Cd. Ferritin emerged as the main determinant of blood Co and Mn, while for blood Pb, age and smoking intensity had higher impact. Cu and Zn remained within reference values and no significant associations with ferritin were found. Strong positive associations between blood concentrations of Pb, Mn, Cd and Co were observed, also when controlled for their common association with ferritin. Apart from these associations, the models showed no significant interactions between the divalent metals studied. Mild anaemia (110<Hb<120g/L) did not seem to have any effect independent of low ferritin. The results indicate that low serum ferritin facilitates absorption of certain divalent metal ions in female smokers as well as the previously shown effect in non-smokers. Even if smoking provides Pb and Cd, the mutual associations between Cd and other divalent metals in blood persisted in medium and heavy smokers. This indicates that the interrelationship between Cd and divalent metals not only reflect effects on the absorption, but possibly also on kinetic processes such as transportation in blood and other compartments, including excretion.
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Affiliation(s)
- H M Meltzer
- Norwegian Institute of Public Health, P.O. Box 4404 Nydalen, N-0403 Oslo, Norway.
| | - J Alexander
- Norwegian Institute of Public Health, P.O. Box 4404 Nydalen, N-0403 Oslo, Norway
| | - A L Brantsæter
- Norwegian Institute of Public Health, P.O. Box 4404 Nydalen, N-0403 Oslo, Norway
| | - B Borch-Iohnsen
- Institute of Basic Medical Sciences, Department of Nutrition, University of Oslo, P.O. Box 1046 Blindern, N-0317 Oslo, Norway
| | - D G Ellingsen
- National Institute of Occupational Health, P.O. Box 8149 Dep., N-0033 Oslo, Norway
| | - Y Thomassen
- National Institute of Occupational Health, P.O. Box 8149 Dep., N-0033 Oslo, Norway
| | - J Holmen
- HUNT Research Center, Department of Public Health and General Practice, Norwegian University of Science and Technology, Forskningsveien 2, N-7600, Levanger, Norway
| | - T A Ydersbond
- Statistics Norway, P.O. Box 8131 Dep., N-0033 Oslo, Norway
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26
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McCuskee S, Brickley EB, Wood A, Mossialos E. Malaria and macronutrient deficiency as correlates of anemia in young children: a systematic review of observational studies. Ann Glob Health 2016; 80:458-65. [PMID: 25960095 DOI: 10.1016/j.aogh.2015.01.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Anemia is a leading cause of pediatric mortality and impaired development and is highly prevalent in young children in sub-Saharan Africa. Populations most affected by anemia also often are at high risk for malaria and macronutrient deficiency, conditions that may exacerbate anemia. Due to its multifactorial etiology, anemia presents a significant global health challenge, and successful interventions targeting anemia require a greater understanding of the relative and interacting contributions of malaria and undernutrition. OBJECTIVES The aim of this study was to assess the associations of malaria and undernutrition, indicated by stunting and wasting, with anemia in young children using a systematic review of observational studies. METHODS Searches were conducted in MEDLINE and Scopus. Articles were screened and reviewed for inclusion by two reviewers. Studies published after 1990 that measured anemia, Plasmodium falciparum malaria, and stunting or wasting in children aged 5 years or under were included. FINDINGS Of 620 articles reviewed, 15 studies from 9 countries in sub-Saharan Africa were included. Statistical approaches and anemia measurement varied widely, so synthesis was qualitative. Thirteen studies found that malaria infection was associated with anemia or lowered hemoglobin; in these studies, malaria accounted for more of the variation in anemia than nutritional status. In contrast, only 7 of the 13 studies investigating stunting and 3 of the 6 studies investigating wasting as correlates of anemia observed statistically significant associations at α = 0.05. The role of nutrition in anemia may differ by country. CONCLUSIONS Observational epidemiologic studies consistently demonstrate that malaria is an important correlate of anemia in young children; however, the roles of stunting and wasting and interactions between malaria and nutrition require further investigation. Based on the current evidence, these findings suggest that global health strategies to reduce the burden of anemia should prioritize malaria prevention and support research on alternative causes of anemia that reflect local conditions.
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Affiliation(s)
- Sarah McCuskee
- LSE Health, London School of Economics and Political Science, London, UK.
| | - Elizabeth B Brickley
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland; Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Angela Wood
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Elias Mossialos
- LSE Health, London School of Economics and Political Science, London, UK
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27
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Martin-Prevel Y, Allemand P, Nikiema L, Ayassou KA, Ouedraogo HG, Moursi M, De Moura FF. Biological Status and Dietary Intakes of Iron, Zinc and Vitamin A among Women and Preschool Children in Rural Burkina Faso. PLoS One 2016; 11:e0146810. [PMID: 26991908 PMCID: PMC4798773 DOI: 10.1371/journal.pone.0146810] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 12/22/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Food-based approaches such as biofortification are meant to sustainably address micronutrient deficiencies in poor settings. Knowing more about micronutrient intakes and deficiencies is a prerequisite to designing and evaluating interventions. OBJECTIVE The objectives of the study were to assess biological status and dietary intakes of iron, zinc and vitamin A among women and children aged 36-59 months in rural Burkina Faso and to study relationships between intake and status to better inform future food-based interventions. DESIGN A cross-sectional survey was carried out in two rural provinces of Burkina Faso on a random cluster sample of 480 mother-child pairs. Dietary data was obtained by 24-hour recalls repeated on a random sub-selection of 37.5% of subjects to allow calculation of nutrient's probability of adequacy (PA). Biomarkers were measured on a sub-sample of 180 mother-child pairs. Blood samples were analyzed for hemoglobin, serum ferritin, soluble transferrin receptors (sTfR), C-reactive protein, alpha-1-glycoprotein, serum zinc concentration (SZnC) and retinol. For each micronutrient the relationship between biomarker and dietary intake was investigated by multiple linear regression models accounting for inflammatory biomarkers. RESULTS Mean PA for iron, zinc and vitamin A was 0.49, 0.87 and 0.21 among women and 0.61, 0.95 and 0.33 among children, respectively. Prevalence of anemia, corrected low serum ferritin and high sTfR was 37.6%, 4.0% and 77.5% among women and 72.1%, 1.5% and 87.6% among children, respectively. Prevalence of low SZnC and corrected low serum retinol was 39.4% and 12.0% among women and 63.7% and 24.8% among children, respectively. There was a tendency for a positive relationship between vitamin A intakes and serum retinol among women (β = 0.0003, P = 0.06). Otherwise, no link was found between micronutrients biomarkers and intakes. CONCLUSION Our study depicted different images of micronutrient deficiencies when based on dietary intakes or biomarkers results, thus highlighting the need for more suitable biomarkers and more precise measures of absorbable micronutrient intakes at the individual level. It thus points to challenges in the design and evaluation of future biofortification or other food-based interventions in rural areas of Burkina Faso.
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Affiliation(s)
- Yves Martin-Prevel
- Institut de Recherche pour le Développement, Research Unit 204 ‘Nutripass’, Montpellier, France
| | - Pauline Allemand
- Institut de Recherche pour le Développement, Research Unit 204 ‘Nutripass’, Montpellier, France
| | - Laetitia Nikiema
- Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso
| | - Kossiwavi A. Ayassou
- Institut de Recherche pour le Développement, Research Unit 204 ‘Nutripass’, Montpellier, France
| | | | - Mourad Moursi
- HarvestPlus, International Food Policy Research Institute, Washington, DC, United States of America
| | - Fabiana F. De Moura
- HarvestPlus, International Food Policy Research Institute, Washington, DC, United States of America
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28
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Nel E, Kruger HS, Baumgartner J, Faber M, Smuts CM. Differential ferritin interpretation methods that adjust for inflammation yield discrepant iron deficiency prevalence. MATERNAL & CHILD NUTRITION 2015; 11 Suppl 4:221-8. [PMID: 25721990 PMCID: PMC6860295 DOI: 10.1111/mcn.12175] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We reassessed the iron deficiency (ID) prevalence in a South African trial that formed part of the International Research on Infant Supplementation study by comparing four methods that account for the high prevalence of acute (28.6%) and chronic (41.8%) inflammation observed in the study. Serum ferritin (SF) was measured as marker of iron status in 192 apparently healthy, 4-13-month-old infants. Alpha-1 glycoprotein and C-reactive protein concentrations were determined to indicate chronic and acute inflammation, respectively. The ID prevalence was obtained by four methods that adjust for inflammation: (1) excluding infants with inflammation; (2) using a higher cut-off (SF < 30 μg L(-1) ); (3) using different cut-offs for infants with vs. without inflammation (SF < 30 μg L(-1) vs. SF < 12 μg L(-1) ); and (4) adjusting SF concentrations with correction factors (CFs) were compared with a reference method (SF < 12 μg L(-1) ) not accounting for inflammation. Using the higher SF cut-off method resulted in the highest ID prevalence (52.1%), followed by using two different cut-offs (31.8%), using CFs (21.9%) and excluding subjects with inflammation (17.6%). The CF method showed the best agreement with the reference method. Disregarding inflammation resulted in a significantly lower ID prevalence (17.2%). ID anaemia (IDA) prevalence ranged from 13.2% to 24.5%, with the lowest prevalence (12.0%) for the reference method. Our analysis highlights the challenge of assessing ID and IDA using only SF as marker of iron status in the presence of inflammation. We demonstrate the importance of measuring inflammation markers to account for their elevating effect on SF.
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Affiliation(s)
- Elsmari Nel
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | - Herculina S Kruger
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | - Jeannine Baumgartner
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | - Mieke Faber
- Non-communicable Diseases Research Unit, Medical Research Council, Tygerberg, South Africa
| | - Cornelius M Smuts
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
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29
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Diouf S, Folquet M, Mbofung K, Ndiaye O, Brou K, Dupont C, N'dri D, Vuillerod M, Azaïs-Braesco V, Tetanye E. [Prevalence and determinants of anemia in young children in French-speaking Africa. Role of iron deficiency]. Arch Pediatr 2015; 22:1188-97. [PMID: 26433575 DOI: 10.1016/j.arcped.2015.08.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 05/22/2015] [Accepted: 08/21/2015] [Indexed: 02/05/2023]
Abstract
Anemia and iron deficiency are major public health issues worldwide and particularly in Africa. Reliable information about their prevalence and associated factors is required to allow for effective actions. In this study, we used data from recent (2006-2012) large population health surveys, carried out in 11 French-speaking African countries (Benin, Burkina Faso, Cameroon, Congo Brazzaville, Ivory Coast, Gabon, Guinea, Mali, Niger, Democratic Republic of Congo, and Senegal). Hemoglobin (Hb) was assessed and demographic and health-related parameters were obtained from nation-representative samples of children aged 6-59 months. Anemia (Hb<11g/dL) was found in 72.4% of the children (60.2-87.8%), with no gender difference but a slightly lower incidence in older children (62% at age 4-5 years versus 85% at age 9 months), especially for the more severe forms (2.1% versus 8.7%, respectively). Anemia was only slightly but significantly affected by location (75.5% in rural areas versus 67.3% in towns), income (79.8% in lower quintile of income versus 62.3% in higher quintile), or maternal education (74.1% in children from non-educated mothers versus 62.4% in children whose mothers had secondary education). Nearly 50% of women of child-bearing age had anemia. In the countries that report this information, less than 50% (17-65%) of children consumed iron-rich foods regularly and only 12% (7.4-20.5%) received iron supplementation. Infection and parasitism are known to affect some markers of iron status, because of the inflammatory reaction, thereby making the diagnosis of iron deficiency difficult. In the study countries, acute respiratory diseases and diarrhea affected 6.2 and 15.6% of children aged between 6 and 59 months, respectively; their distribution according to age and location is very different from the one of anemia, which is also the case for the distribution of malaria. It is thus likely that a large part of the anemia observed in young children is due to iron deficiency, although further research is needed to confirm this. This fully justifies the nationwide programs of iron fortification of flour, currently undergoing in most countries of French-speaking Africa. Their formal evaluation is still pending but the initial data suggest some efficacy, although far from optimal. It is thus likely that a more holistic approach, including iron fortification, actions against undernutrition and parasitism in children, and actions in favor of improving young women's iron and nutritional status, together with appropriate communication and education objectives, would be more effective.
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Affiliation(s)
- S Diouf
- Institut de pédiatrie, université Cheikh Anta Diop, BP 5593, Dakar, Sénégal
| | - M Folquet
- Service de pédiatrie, CHU Cocody, université Houphouet Boigny, 25 BP 567, Abidjan 25, Côte d'Ivoire
| | - K Mbofung
- Biochimie et nutrition humaine, université de Bamenda, BP 516, Bamenda, Cameroun
| | - O Ndiaye
- Service de pédiatrie et néonatologie, CHU Abass Ndao, université Cheikh Anta Diop, BP 15872, Dakar, Sénégal
| | - K Brou
- Laboratoire de nutrition et sécurité alimentaire, université Nangui Abrogoua, 02 BP 801, Abidjan 02, Côte d'Ivoire
| | - C Dupont
- Service des explorations digestives et fonctionnelles, hôpital Necker, 149, rue de Sèvres, 75015 Paris, France
| | - D N'dri
- Recherche et développement, Danone Nutricia Africa & Overseas - Cocody, 2, plateaux Valllons, 28 BP 651, Abidjan, Côte d'Ivoire
| | - M Vuillerod
- Danone Nutricia Africa & Overseas, 383, rue Philippe-Héron, 69653 Villefranche-sur-Saône cedex, France
| | - V Azaïs-Braesco
- VAB-nutrition, 1, rue Claude-Danziger, 63100 Clermont-Ferrand, France.
| | - E Tetanye
- Université de Yaoundé, BP 2036, Yaoundé, Cameroun
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30
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Glinz D, Hurrell RF, Ouattara M, Zimmermann MB, Brittenham GM, Adiossan LG, Righetti AA, Seifert B, Diakité VG, Utzinger J, N'Goran EK, Wegmüller R. The effect of iron-fortified complementary food and intermittent preventive treatment of malaria on anaemia in 12- to 36-month-old children: a cluster-randomised controlled trial. Malar J 2015; 14:347. [PMID: 26377199 PMCID: PMC4573684 DOI: 10.1186/s12936-015-0872-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 08/25/2015] [Indexed: 11/29/2022] Open
Abstract
Background Iron deficiency (ID) and malaria co-exist in tropical regions and both contribute to high rates of anaemia in young children. It is unclear whether iron fortification combined with intermittent preventive treatment (IPT) of malaria would be an efficacious strategy for reducing anaemia in young children. Methods A 9-month cluster-randomised, single-blinded, placebo-controlled intervention trial was carried out in children aged 12–36 months in south-central Côte d’Ivoire, an area of intense and perennial malaria transmission. The study groups were: group 1: normal diet and IPT-placebo (n = 125); group 2: consumption of porridge, an iron-fortified complementary food (CF) with optimised composition providing 2 mg iron as NaFeEDTA and 3.8 mg iron as ferrous fumarate 6 days per week (CF-FeFum) and IPT-placebo (n = 126); group 3: IPT of malaria at 3-month intervals, using sulfadoxine-pyrimethamine and amodiaquine and no dietary intervention (n = 127); group 4: both CF-FeFum and IPT (n = 124); and group 5: consumption of porridge, an iron-fortified CF with the composition currently on the Ivorian market providing 2 mg iron as NaFeEDTA and 3.8 mg iron as ferric pyrophosphate 6 days per week (CF-FePP) and IPT-placebo (n = 127). The primary outcome was haemoglobin (Hb) concentration. Linear and logistic regression mixed-effect models were used for the comparison of the five study groups, and a 2 × 2 factorial analysis was used to assess treatment interactions of CF-FeFum and IPT (study groups 1–4). Results After 9 months, the Hb concentration increased in all groups to a similar extent with no statistically significant difference between groups. In the 2 × 2 factorial analysis after 9 months, no treatment interaction was found on Hb (P = 0.89). The adjusted differences in Hb were 0.24 g/dl (95 % CI −0.10 to 0.59; P = 0.16) in children receiving IPT and −0.08 g/dl (95 % CI −0.42 to 0.26; P = 0.65) in children receiving CF-FeFum. At baseline, anaemia (Hb <11.0 g/dl) was 82.1 %. After 9 months, IPT decreased the odds of anaemia (odds ratio [OR], 0.46 [95 % CI 0.23–0.91]; P = 0.023), whereas iron-fortified CF did not (OR, 0.85 [95 % CI 0.43–1.68]; P = 0.68), although ID (plasma ferritin <30 μg/l) was decreased markedly in children receiving iron fortified CF (OR, 0.19 [95 % CI 0.09–0.40]; P < 0.001). Conclusions IPT alone only modestly decreased anaemia, but neither IPT nor iron fortified CF significantly improved Hb concentration after 9 months. Additionally, IPT did not augment the effect of the iron fortified CF. CF fortified with highly bioavailable iron improved iron status but not Hb concentration, despite three-monthly IPT of malaria. Thus, further research is necessary to develop effective combination strategies to prevent and treat anaemia in malaria endemic regions. Trial registration: http://www.clinicaltrials.gov; identifier NCT01634945; registered on July 3, 2012. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0872-3) contains supplementary material, which is available to authorised users.
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Affiliation(s)
- Dominik Glinz
- Human Nutrition Laboratory, Institute of Food, Nutrition and Health, ETH Zurich, Schmelzbergstrasse 7, 8092, Zurich, Switzerland.
| | - Richard F Hurrell
- Human Nutrition Laboratory, Institute of Food, Nutrition and Health, ETH Zurich, Schmelzbergstrasse 7, 8092, Zurich, Switzerland.
| | - Mamadou Ouattara
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire.
| | - Michael B Zimmermann
- Human Nutrition Laboratory, Institute of Food, Nutrition and Health, ETH Zurich, Schmelzbergstrasse 7, 8092, Zurich, Switzerland.
| | - Gary M Brittenham
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, USA.
| | | | - Aurélie A Righetti
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Burkhardt Seifert
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
| | | | - Jürg Utzinger
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Eliézer K N'Goran
- Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire. .,Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Abidjan, Côte d'Ivoire.
| | - Rita Wegmüller
- Human Nutrition Laboratory, Institute of Food, Nutrition and Health, ETH Zurich, Schmelzbergstrasse 7, 8092, Zurich, Switzerland.
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Iron deficiency in early pregnancy using serum ferritin and soluble transferrin receptor concentrations are associated with pregnancy and birth outcomes. Eur J Clin Nutr 2015; 70:358-63. [PMID: 26373962 DOI: 10.1038/ejcn.2015.157] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 07/29/2015] [Accepted: 07/31/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND/OBJECTIVES There are several biomarkers for measuring iron deficiency (ID) in pregnancy, but the prevalence of ID and its association with inflammation and adverse pregnancy outcomes is inconclusive. The aim of this work was to describe the prevalence and determinants of first trimester ID and associations with pregnancy and birth outcomes. SUBJECTS/METHODS A record-linkage cohort study of archived serum samples of women attending first trimester screening and birth and hospital data to ascertain maternal characteristics and pregnancy outcomes. Sera were analysed for iron stores (ferritin; μg/l), lack of iron in the tissues (soluble transferrin receptor (sTfR); nmol/l) and inflammatory (C-reactive protein (CRP); mg/dl) biomarkers. Total body iron (TBI) was calculated from serum ferritin (SF) and sTfR concentrations. Multivariate logistic regression analysed risk factors and pregnancy outcomes associated with ID using the definitions: SF<12 μg/l, TfR ⩾ 21.0 nmol/l, and TBI<0 mg/kg. RESULTS Of the 4420 women, the prevalence of ID based on ferritin, sTfR and TBI was 19.6, 15.3 and 15.7%, respectively. Risk factors of ID varied depending on which iron parameter was used and included maternal age <25 years, multiparity, socioeconomic disadvantage, high maternal body weight and inflammation. ID, defined by SF and TBI but not TfR, was associated with reduced risk of gestational diabetes mellitus (GDM). ID defined using TBI only was associated with increased risk of large-for-gestation-age (LGA) infants. CONCLUSIONS Nearly one in five Australian women begin pregnancy with ID. Further investigation of excess maternal weight and inflammation in the relationships between ID and GDM and LGA infants is needed.
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Chang Cojulun A, Bustinduy AL, Sutherland LJ, Mungai PL, Mutuku F, Muchiri E, Kitron U, King CH. Anemia Among Children Exposed to Polyparasitism in Coastal Kenya. Am J Trop Med Hyg 2015; 93:1099-105. [PMID: 26324733 DOI: 10.4269/ajtmh.15-0353] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 07/30/2015] [Indexed: 12/15/2022] Open
Abstract
Anemia represents a substantial problem for children living in areas with limited resources and significant parasite burden. We performed a cross-sectional study of 254 Kenyan preschool- and early school-age children in a setting endemic for multiple chronic parasitic infections to explore mechanisms of their anemia. Complete venous blood cell counts revealed a high prevalence of local childhood anemia (79%). Evaluating the potential links between low hemoglobin and socioeconomic factors, nutritional status, hemoglobinopathy, and/or parasite infection, we identified age < 9 years (odds ratio [OR]: 12.0, 95% confidence interval [CI]: 4.4, 33) and the presence of asymptomatic malaria infection (OR: 6.8, 95% CI: 2.1, 22) as the strongest independent correlates of having anemia. A total of 130/155 (84%) of anemic children with iron studies had evidence of iron-deficiency anemia (IDA), 16% had non-IDA; 50/52 of additionally tested anemic children met soluble transferrin-receptor (sTfR) criteria for combined anemia of inflammation (AI) with IDA. Children in the youngest age group had the greatest odds of iron deficiency (OR: 10.0, 95% CI: 3.9, 26). Although older children aged 9-11 years had less anemia, they had more detectable malaria, Schistosoma infection, hookworm, and proportionately more non-IDA. Anemia in this setting appears multifactorial such that chronic inflammation and iron deficiency need to be addressed together as part of integrated management of childhood anemia.
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Affiliation(s)
- Alicia Chang Cojulun
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio; Great Ormond Street NHS Trust, London, United Kingdom; Department of Environmental Sciences, Emory University, Atlanta, Georgia; Division of Vector Borne and Neglected Tropical Diseases, Ministry of Public Health and Sanitation, Nairobi, Kenya
| | - Amaya L Bustinduy
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio; Great Ormond Street NHS Trust, London, United Kingdom; Department of Environmental Sciences, Emory University, Atlanta, Georgia; Division of Vector Borne and Neglected Tropical Diseases, Ministry of Public Health and Sanitation, Nairobi, Kenya
| | - Laura J Sutherland
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio; Great Ormond Street NHS Trust, London, United Kingdom; Department of Environmental Sciences, Emory University, Atlanta, Georgia; Division of Vector Borne and Neglected Tropical Diseases, Ministry of Public Health and Sanitation, Nairobi, Kenya
| | - Peter L Mungai
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio; Great Ormond Street NHS Trust, London, United Kingdom; Department of Environmental Sciences, Emory University, Atlanta, Georgia; Division of Vector Borne and Neglected Tropical Diseases, Ministry of Public Health and Sanitation, Nairobi, Kenya
| | - Francis Mutuku
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio; Great Ormond Street NHS Trust, London, United Kingdom; Department of Environmental Sciences, Emory University, Atlanta, Georgia; Division of Vector Borne and Neglected Tropical Diseases, Ministry of Public Health and Sanitation, Nairobi, Kenya
| | - Eric Muchiri
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio; Great Ormond Street NHS Trust, London, United Kingdom; Department of Environmental Sciences, Emory University, Atlanta, Georgia; Division of Vector Borne and Neglected Tropical Diseases, Ministry of Public Health and Sanitation, Nairobi, Kenya
| | - Uriel Kitron
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio; Great Ormond Street NHS Trust, London, United Kingdom; Department of Environmental Sciences, Emory University, Atlanta, Georgia; Division of Vector Borne and Neglected Tropical Diseases, Ministry of Public Health and Sanitation, Nairobi, Kenya
| | - Charles H King
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio; Great Ormond Street NHS Trust, London, United Kingdom; Department of Environmental Sciences, Emory University, Atlanta, Georgia; Division of Vector Borne and Neglected Tropical Diseases, Ministry of Public Health and Sanitation, Nairobi, Kenya
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Wessells KR, Hess SY, Ouédraogo ZP, Rouamba N, Ouédraogo JB, Brown KH. Asymptomatic malaria infection affects the interpretation of biomarkers of iron and vitamin A status, even after adjusting for systemic inflammation, but does not affect plasma zinc concentrations among young children in Burkina Faso. J Nutr 2014; 144:2050-8. [PMID: 25411038 DOI: 10.3945/jn.114.200345] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Biomarkers of iron [plasma ferritin (pF)], vitamin A [retinol binding protein (RBP)], and zinc status [plasma zinc (pZn)] are affected by the acute phase response, independent of micronutrient status. OBJECTIVE The objective of these analyses was to assess how asymptomatic malaria infection affects the interpretation of these biomarkers after adjustment for elevated acute phase proteins (APPs). METHODS Soluble transferrin receptor (sTfR), pF, RBP, and pZn concentrations were measured among 451 asymptomatic children aged 6-23 mo in Burkina Faso and adjusted for elevated APP (C-reactive protein ≥5 mg/L and/or α-1-acid-glycoprotein ≥1 g/L) based on a 4-group categorical model. Plasma histidine-rich protein II (HRP2) concentrations ≥0.75 μg/L were considered indicative of current or recent malaria parasitemia. RESULTS Of the children in the study, 57.4% had at least 1 elevated APP, and 48.5% had elevated HRP2. After adjusting for APP, children with elevated HRP2 had higher pF (23.5 ± 1.5 μg/L vs. 11.1 ± 0.8 μg/L; P < 0.001) and lower RBP (0.79 ± 0.01 μmol/L vs. 0.92 ± 0.01 μmol/L; P < 0.001) than those without, but there were no differences in pZn among those with and without elevated HRP2 (64.9 ± 12.7 μg/dL vs. 64.9 ± 11.1 μg/dL; P = 0.98). Children with elevated HRP2 had higher sTfR than those without (17.6 ± 0.5 mg/L vs. 12.3 ± 0.4 mg/L; P < 0.0001). After adjusting for HRP2, along with APP, the estimated prevalence of iron deficiency (pF < 12 μg/L) increased from 38.7% to 50.6% and vitamin A deficiency (RBP < 0.84 μmol/L) decreased from 33.4% to 27.7%. CONCLUSIONS Asymptomatic malaria is associated with indicators of micronutrient status, even after adjusting for APP. Adjusting indicators of iron and vitamin A status based only on APP may inaccurately estimate the prevalence of micronutrient deficiencies in settings with a high prevalence of malaria and inflammation. This trial was registered at clinicaltrials.gov as NCT00944853.
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Affiliation(s)
- K Ryan Wessells
- Department of Nutrition, University of California, Davis, CA
| | - Sonja Y Hess
- Department of Nutrition, University of California, Davis, CA
| | | | - Noel Rouamba
- Health Sciences Research Institute, 01 BP 545 Bobo-Dioulasso 01, Burkina Faso
| | | | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, CA;
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The aetiology of anaemia during pregnancy: a study to evaluate the contribution of iron deficiency and common infections in pregnant Ugandan women. Public Health Nutr 2014; 18:1423-35. [DOI: 10.1017/s1368980014001888] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectiveTo describe the aetiology of anaemia in pregnant Ugandan women and explore Fe deficiency and common infections as contributors to anaemia in this population.DesignCross-sectional study in which Hb, ferritin, transferrin receptor (sTfR), C-reactive protein, α-1 acid glycoprotein, hepcidin, malaria, hookworm infestation, syphilis and Helicobacter pylori infection were assessed.SettingAntenatal care clinic at Kawempe Health Centre, Kampala, Uganda.SubjectsHIV-negative women (n 151) in their first or second pregnancy at 10–16 weeks’ gestation.ResultsThe prevalence of anaemia was 29·1 %. Fe deficiency was 40·4 % and 14·6 % based on ferritin <30 μg/l and on adjusted ferritin <12 μg/l respectively, and 6·6 % based on sTfR >8·3 μg/ml. The prevalence of Fe-deficiency anaemia was 9·3 % based on ferritin <30 μg/l, 6·6 % based on adjusted ferritin <12 μg/l and 4·3 % based on sTfR >8·3 μg/ml. Hepcidin concentration was positively correlated with ferritin concentration (n 151, r=0·578, P<0·00001). H. pylori infection was highly prevalent (70 %) while malaria, hookworm infestation and syphilis were not common. Of all women, 60·3 % had α-1 acid glycoprotein >1 g/l and/or C-reactive protein >5 mg/l. Malaria parasitaemia (OR=6·85; 95 % CI 1·25, 37·41, P=0·026) and Fe deficiency defined using sTfR (OR=5·58; 95 % CI 1·26, 24·80, P=0·024) were independently and positively associated with anaemia. Population-attributable risk factors for anaemia for raised C-reactive protein, Fe deficiency defined by sTfR >8·3 μg/ml and presence of malaria parasites were 41·6 (95 % CI 11·1, 72·2) %, 13·5 (95 % CI 2·0, 25·0) % and 12·0 (95 % CI 1·4, 22·6) %, respectively.ConclusionsInfections and inflammation are of greater significance than Fe deficiency in the aetiology of anaemia in pregnant Ugandan women during the first trimester.
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Righetti AA, Utzinger J, Koua AYG, Niamké S, Adiossan LG, Glinz D, Hurrell RF, Wegmüller R, N'Goran EK. In Response. Am J Trop Med Hyg 2013; 89:399-400. [PMID: 23926144 PMCID: PMC3741269 DOI: 10.4269/ajtmh.13-0168b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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