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Donkor WES, Adu-Afarwuah S, Wegmüller R, Bentil H, Petry N, Rohner F, Wirth JP. Complementary Feeding Indicators in Relation to Micronutrient Status of Ghanaian Children Aged 6-23 Months: Results from a National Survey. Life (Basel) 2021; 11:969. [PMID: 34575118 PMCID: PMC8468967 DOI: 10.3390/life11090969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Optimal complementary feeding is critical for adequate growth and development in infants and young children. The associations between complementary feeding and growth have been studied well, but less is known about the relationship between complementary feeding and micronutrient status. METHODS Using data from a national cross-sectional survey conducted in Ghana in 2017, we examined how multiple WHO-recommended complementary feeding indicators relate to anemia and the micronutrient status of children aged 6-23 months. RESULTS In total, 42%, 38%, and 14% of the children met the criteria for minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD), respectively. In addition, 71% and 52% of the children consumed iron-rich foods and vitamin A-rich foods, respectively. The prevalence of anemia, iron deficiency (ID), iron deficiency anemia (IDA) and vitamin A deficiency (VAD) was 46%, 45%, 27%, and 10%, respectively. Inverse associations between MMF and socio-economic status were found, and MMF was associated with an increased risk of ID (55%; p < 0.013) and IDA (38%; p < 0.002). CONCLUSION The pathways connecting complementary feeding and micronutrient status are complex. Findings related to MMF should be further investigated to ensure that complementary feeding programs account for the potential practice of frequent feeding with nutrient-poor foods.
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Affiliation(s)
| | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon P.O. Box LG 25, Ghana; (S.A.-A.); (H.B.)
| | - Rita Wegmüller
- GroundWork, 7306 Fläsch, Switzerland; (R.W.); (N.P.); (F.R.); (J.P.W.)
| | - Helena Bentil
- Department of Nutrition and Food Science, University of Ghana, Legon P.O. Box LG 25, Ghana; (S.A.-A.); (H.B.)
| | - Nicolai Petry
- GroundWork, 7306 Fläsch, Switzerland; (R.W.); (N.P.); (F.R.); (J.P.W.)
| | - Fabian Rohner
- GroundWork, 7306 Fläsch, Switzerland; (R.W.); (N.P.); (F.R.); (J.P.W.)
| | - James P. Wirth
- GroundWork, 7306 Fläsch, Switzerland; (R.W.); (N.P.); (F.R.); (J.P.W.)
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2
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Menshawey R, Menshawey E, Alserr AHK, Abdelmassih AF. Low iron mitigates viral survival: insights from evolution, genetics, and pandemics-a review of current hypothesis. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2020; 21:75. [PMID: 38624521 PMCID: PMC7738201 DOI: 10.1186/s43042-020-00114-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/20/2020] [Indexed: 12/21/2022] Open
Abstract
Background Upon re-examination of our human history, evolutionary perspectives, and genetics, a prevailing iron deficiency phenotype appears to have evolved to protect the human race from extinction. Body In this review, we summarize the evolutionary and genetic perspectives pointing towards the hypothesis that low iron mitigates infection. The presence of infection promotes the generation of resistance alleles, and there are some evolutionary and genetic clues that suggest the presence of an iron deficiency phenotype that may have developed to protect against infection. Examples include the relative paucity of iron overload genes given the essential role of iron, as well as the persistence of iron deficiency among populations in spite of public health efforts to treat it. Additional examination of geographic areas with severe iron deficiency in the setting of pandemics including H1N1, SARS, and COVID-19 reveals that areas with higher prevalence of iron deficiency are less affected. RNA viruses have several evolutionary adaptations which suggest their absolute need for iron, and this dependency may be exploited during treatment. Conclusion RNA viruses pose a unique challenge to modern healthcare, with an average of 2-3 new pathogens being discovered yearly. Their overarching requirements for iron, along with human evolutionary and genetic adaptations which favored an iron deficiency phenotype, ultimately suggest the potential need for iron control in these infections.
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Affiliation(s)
- Rahma Menshawey
- Faculty of Medicine, Kasr al Ainy, Cairo University, Geziret Elroda, Manial, Cairo, 11562 Egypt
| | - Esraa Menshawey
- Faculty of Medicine, Kasr al Ainy, Cairo University, Geziret Elroda, Manial, Cairo, 11562 Egypt
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3
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Murshed M, Dkhil MA, Al-Shaebi EM, Qasem MAA, Mares MM, Aljawdah HMA, Alojayri G, Abdel-Gaber R, Al-Quraishy S. Biosynthesized silver nanoparticles regulate the iron status in the spleen of Plasmodium chabaudi-infected mice. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2020; 27:40054-40060. [PMID: 32651798 DOI: 10.1007/s11356-020-10027-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/06/2020] [Indexed: 06/11/2023]
Abstract
Malaria is a dangerous disease affecting millions around the globe. Biosynthesized nanoparticles are used against a variety of diseases including malaria worldwide. Here, silver nanoparticles (AgNPs) synthesized from the leaf extracts of Indigofera oblongifolia have been used in the treatment of mice infected with Plasmodium chabaudi to evaluate the expression of iron regulatory genes in the spleen. Infrared spectroscopy was used to identify the expected classes of compounds in the extract. AgNPs were able to decrease the parasitemia nearly similar to the used reference drug, chloroquine. In addition, AgNPs significantly decreased the spleen index after infection. Moreover, the iron distribution was increased after the treatment. Finally, AgNPs could regulate the mice spleen iron regulatory genes, Lipocalin 2 (Lcn2), transferrin receptor 1 (TFR1) and hepcidin antimicrobial peptide (Hamp). Taken together, our findings indicate that AgNPs have antimalarial activity and can control the state of iron in spleen. We need further investigations to determine mechanisms of action of the AgNPs.
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Affiliation(s)
- Mutee Murshed
- Department of Zoology, College of Science, King Saud University, P.O. Box: 2455, Riyadh, 11451, Saudi Arabia
| | - Mohamed A Dkhil
- Department of Zoology, College of Science, King Saud University, P.O. Box: 2455, Riyadh, 11451, Saudi Arabia.
- Department of Zoology and Entomology, Faculty of Science, Helwan University, Cairo, 11795, Egypt.
| | - Esam M Al-Shaebi
- Department of Zoology, College of Science, King Saud University, P.O. Box: 2455, Riyadh, 11451, Saudi Arabia
| | - Mahmood A A Qasem
- Department of Zoology, College of Science, King Saud University, P.O. Box: 2455, Riyadh, 11451, Saudi Arabia
| | - Mohammed M Mares
- Department of Zoology, College of Science, King Saud University, P.O. Box: 2455, Riyadh, 11451, Saudi Arabia
| | - Hossam M A Aljawdah
- Department of Zoology, College of Science, King Saud University, P.O. Box: 2455, Riyadh, 11451, Saudi Arabia
| | - Ghada Alojayri
- Department of Zoology, College of Science, King Saud University, P.O. Box: 2455, Riyadh, 11451, Saudi Arabia
| | - Rewaida Abdel-Gaber
- Department of Zoology, College of Science, King Saud University, P.O. Box: 2455, Riyadh, 11451, Saudi Arabia
- Department of Zoology, Faculty of Science, Cairo University, Cairo, Egypt
| | - Saleh Al-Quraishy
- Department of Zoology, College of Science, King Saud University, P.O. Box: 2455, Riyadh, 11451, Saudi Arabia
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4
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Lemoine A, Tounian P. Childhood anemia and iron deficiency in sub-Saharan Africa – risk factors and prevention: A review. Arch Pediatr 2020; 27:490-496. [DOI: 10.1016/j.arcped.2020.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 04/15/2020] [Accepted: 08/13/2020] [Indexed: 12/17/2022]
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Abstract
PURPOSE OF REVIEW Anaemia affects up to 50% of pregnancies worldwide, and is associated with maternal and neonatal morbidity and mortality. Prevention and management of anaemia remains a priority. Despite this, there is ongoing debate on the optimal approach to identifying anaemia in pregnant women and the best strategies for prevention and management. The objective of this review is to describe the current landscape of haemoglobin testing in pregnancy in low and high-income countries. RECENT FINDINGS Current definitions of anaemia in pregnancy comprise a laboratory threshold of haemoglobin below which treatment is offered. Haemoglobin measurement is not sensitive in detecting iron deficiency - the most common cause of maternal anaemia. Furthermore, these historical thresholds were derived from heterogeneous populations comprising men and women. Women with anaemia in pregnancy are offered iron therapy, without testing for the underlying cause. This may be appropriate in high-income settings, where iron deficiency is the likely cause, but may not address the complex causes of anaemia in other geographical areas. SUMMARY Current thresholds of haemoglobin defining anaemia in pregnancy are under review. Further research and policy should focus on optimal strategies to identify women at risk of anaemia from all causes.
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Cusick SE, Opoka RO, Ssemata AS, Georgieff MK, John CC. Delayed iron improves iron status without altering malaria risk in severe malarial anemia. Am J Clin Nutr 2020; 111:1059-1067. [PMID: 32005992 PMCID: PMC7198296 DOI: 10.1093/ajcn/nqaa004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/07/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND WHO guidelines recommend concurrent iron and antimalarial treatment in children with malaria and iron deficiency, but iron may not be well absorbed or utilized during a malaria episode. OBJECTIVES We aimed to determine whether starting iron 28 d after antimalarial treatment in children with severe malaria and iron deficiency would improve iron status and lower malaria risk. METHODS We conducted a randomized clinical trial on the effect of immediate compared with delayed iron treatment in Ugandan children 18 mo-5 y of age with 2 forms of severe malaria: cerebral malaria (CM; n = 79) or severe malarial anemia (SMA; n = 77). Asymptomatic community children (CC; n = 83) were enrolled as a comparison group. Children with iron deficiency, defined as zinc protoporphyrin (ZPP) ≥ 80 µmol/mol heme, were randomly assigned to receive a 3-mo course of daily oral ferrous sulfate (2 mg · kg-1 · d-1) either concurrently with antimalarial treatment (immediate arm) or 28 d after receiving antimalarial treatment (delayed arm). Children were followed for 12 mo. RESULTS All children with CM or SMA, and 35 (42.2%) CC, were iron-deficient and were randomly assigned to immediate or delayed iron treatment. Immediate compared with delayed iron had no effect in any of the 3 study groups on the primary study outcomes (hemoglobin concentration and prevalence of ZPP ≥ 80 µmol/mol heme at 6 mo, malaria incidence over 12 mo). However, after 12 mo, children with SMA in the delayed compared with the immediate arm had a lower prevalence of iron deficiency defined by ZPP (29.4% compared with 65.6%, P = 0.006), a lower mean concentration of soluble transferrin receptor (6.1 compared with 7.8 mg/L, P = 0.03), and showed a trend toward fewer episodes of severe malaria (incidence rate ratio: 0.39; 95% CI: 0.14, 1.12). CONCLUSIONS In children with SMA, delayed iron treatment did not increase hemoglobin concentration, but did improve long-term iron status over 12 mo without affecting malaria incidence.This trial was registered at clinicaltrials.gov as NCT01093989.
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Affiliation(s)
- Sarah E Cusick
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrew S Ssemata
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Michael K Georgieff
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Chandy C John
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, MN, USA
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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7
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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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8
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Osman KA, Zinsstag J, Tschopp R, Schelling E, Hattendorf J, Umer A, Ali S, Cercamondi CI. Nutritional status and intestinal parasites among young children from pastoralist communities of the Ethiopian Somali region. MATERNAL AND CHILD NUTRITION 2020; 16:e12955. [PMID: 32026575 PMCID: PMC7296781 DOI: 10.1111/mcn.12955] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 12/13/2019] [Accepted: 01/06/2020] [Indexed: 11/30/2022]
Abstract
Pastoralist children in the Ethiopian Somali Regional State (ESRS) are at high risk for undernutrition and intestinal parasitic infections (IPIs). We assessed the nutritional status and its association with IPIs in 500 children <5 years of age in a clustered cross‐sectional study in Adadle district, ESRS. Stool samples were microscopically examined for IPIs and biomarkers for iron and vitamin A status, anthropometry, and food variety score (FVS) were assessed. Median (interquartile range [IQR]) FVS was 2.0 (2.0, 4.0), and 35% of children were exclusively breastfed up to age 6 months. Prevalence of stunting, wasting, underweight and mid‐upper arm circumference (MUAC) <12.5 cm was 30, 34, 40, and 16%, respectively. Median (IQR) haemoglobin, ferritin, and retinol‐binding protein concentrations were 9.5 g dL‐1 (8.2, 10.9), 6.2 μg L‐1 (4.0, 10.2), and 0.8 μmol L−1 (0.67, 0.91), respectively. Prevalence of anaemia, iron, and vitamin A deficiency was 75, 91, and 30%, respectively. IPIs' prevalence was 47%; the most prevalent IPIs were Giardia lamblia (22%) and Ascaris lumbricoides (15%). Giardial infections but not A. lumbricoides increased the risk for MUAC <12.5 cm (adjusted odds ratio [aOR]: 3.50, 95% confidence interval [CI] [2.21, 5.54]). The odds for anaemia were 97% (aOR: 0.03, 95% CI [0.03, 0.07]) and 89% (aOR: 0.11, 95% CI [0.11, 0.23]) less for children with FVS >2 or with exclusive breastfeeding up to 6 months, respectively. Undernutrition and IPIs are alarmingly high in <5 years of age children in ESRS. Giardial infections and low nutritional adequacy of the diet seem to be major contributing factors to the precarious nutritional status and should be addressed by appropriate interventions.
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Affiliation(s)
- Kadra A Osman
- Jigjiga University One Health Initiative, Jigjiga University, Jigjiga, Ethiopia.,Human and Animal Health Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Jakob Zinsstag
- Human and Animal Health Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Rea Tschopp
- Human and Animal Health Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Esther Schelling
- Human and Animal Health Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Jan Hattendorf
- Human and Animal Health Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Abdurezak Umer
- Jigjiga University One Health Initiative, Jigjiga University, Jigjiga, Ethiopia.,Human and Animal Health Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Seid Ali
- Jigjiga University One Health Initiative, Jigjiga University, Jigjiga, Ethiopia.,Human and Animal Health Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Colin I Cercamondi
- Human Nutrition Laboratory, Swiss Federal Institute of Technology, Zürich, Switzerland
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9
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Onyegbutulem H, Pillatar B, Afiomah E, Sagay F, Amadi O, Dankyau M. Impacts of a pilot of community antiretroviral group initiative on HIV-positive patients in a tertiary health facility in Abuja, North Central Nigeria. NIGERIAN JOURNAL OF MEDICINE 2020. [DOI: 10.4103/njm.njm_69_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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10
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Bah A, Muhammad AK, Wegmuller R, Verhoef H, Goheen MM, Sanyang S, Danso E, Sise EA, Pasricha SR, Armitage AE, Drakesmith H, Cross JH, Moore SE, Cerami C, Prentice AM. Hepcidin-guided screen-and-treat interventions against iron-deficiency anaemia in pregnancy: a randomised controlled trial in The Gambia. Lancet Glob Health 2019; 7:e1564-e1574. [PMID: 31607468 PMCID: PMC7109523 DOI: 10.1016/s2214-109x(19)30393-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/31/2019] [Accepted: 09/06/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND WHO recommends daily iron supplementation for pregnant women, but adherence is poor because of side-effects, effectiveness is low, and there are concerns about possible harm. The iron-regulatory hormone hepcidin can signal when an individual is ready-and-safe to receive iron. We tested whether a hepcidin-guided screen-and-treat approach to combat iron-deficiency anaemia could achieve equivalent efficacy to universal administration, but with lower exposure to iron. METHODS We did a three-arm, randomised, double-blind, non-inferiority trial in 19 rural communities in the Jarra West and Kiang East districts of The Gambia. Eligible participants were pregnant women aged 18-45 years at between 14 weeks and 22 weeks of gestation. We randomly allocated women to either WHO's recommended regimen (ie, a daily UN University, UNICEF, and WHO international multiple-micronutrient preparation [UNIMMAP] containing 60 mg iron), a 60 mg screen-and-treat approach (ie, daily UNIMMAP containing 60 mg iron for 7 days if weekly hepcidin was <2·5 μg/L or UNIMMAP without iron if hepcidin was ≥2·5 μg/L), or a 30 mg screen-and-treat approach (ie, daily UNIMMAP containing 30 mg iron for 7 days if weekly hepcidin was <2·5 μg/L or UNIMMAP without iron if hepcidin was ≥2·5 μg/L). We used a block design stratified by amount of haemoglobin at enrolment (above and below the median amount of haemoglobin on every enrolment day) and stage of gestation (14-18 weeks vs 19-22 weeks). Participants and investigators were unaware of the random allocation. The primary outcome was the amount of haemoglobin at day 84 and was measured as the difference in haemoglobin in each screen-and-treat group compared with WHO's recommended regimen; the non-inferiority margin was set at -5·0 g/L. The primary outcome was assessed in the per-protocol population, which comprised all women who completed the study. This trial is registered with the ISRCTN registry, number ISRCTN21955180. FINDINGS Between June 16, 2014, and March 3, 2016, 498 participants were randomised, of whom 167 were allocated to WHO's recommended regimen, 166 were allocated to the 60 mg per day screen-and-treat approach, and 165 were allocated to the 30 mg per day screen-and-treat approach. 78 participants were withdrawn or lost to follow-up during the study; thus, the per-protocol population comprised 140 women assigned to WHO's recommended regimen, 133 allocated to the 60 mg screen-and-treat approach, and 147 allocated to the 30 mg screen-and-treat approach. The screen-and-treat approaches did not exceed the non-inferiority margin. Compared with WHO's recommended regimen, the difference in the amount of haemoglobin at day 84 was -2·2 g/L (95% CI -4·6 to 0·1) with the 60 mg screen-and-treat approach and -2·7 g/L (-5·0 to -0·5) with the 30 mg screen-and-treat approach. Adherence, reported side-effects, and adverse events were similar between the three groups. The most frequent side-effect was stomachache, which was similar in the 60 mg screen-and-treat group (82 cases per 1906 person-weeks) and with WHO's recommended regimen (81 cases per 1974 person-weeks; effect 1·0, 95% CI 0·7 to 1·6); in the 30 mg screen-and-treat group the frequency of stomachache was slightly lower than with WHO's recommended regimen (58 cases per 2009 person-weeks; effect 0·7, 95% CI 0·5 to 1·1). No participants died during the study. INTERPRETATION The hepcidin-guided screen-and-treat approaches had no advantages over WHO's recommended regimen in terms of adherence, side-effects, or safety outcomes. Our results suggest that the current WHO policy for iron administration to pregnant women should remain unchanged while more effective approaches continue to be sought. FUNDING Bill & Melinda Gates Foundation and the UK Medical Research Council.
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Affiliation(s)
- Amat Bah
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; LSHTM, London, UK
| | - Abdul Khalie Muhammad
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Rita Wegmuller
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; GroundWork, Flaesch, Switzerland
| | - Hans Verhoef
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands; LSHTM, London, UK
| | - Morgan M Goheen
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; University of North Carolina at Chapel Hill School of Medicine, Department of Microbiology and Immunology, Chapel Hill, NC, USA
| | - Saikou Sanyang
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Ebrima Danso
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Ebrima A Sise
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, and Department of Medical Biology, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew E Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - James H Cross
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; LSHTM, London, UK
| | - Sophie E Moore
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; Department of Women & Children's Health, King's College London, St Thomas' Hospital, London, UK
| | | | - Andrew M Prentice
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; LSHTM, London, UK.
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11
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Alam I, Almajwal AM, Alam W, Alam I, Ullah N, Abulmeaaty M, Razak S, Khan S, Pawelec G, Paracha PI. The immune-nutrition interplay in aging – facts and controversies. ACTA ACUST UNITED AC 2019. [DOI: 10.3233/nha-170034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Iftikhar Alam
- Department of Community Health Sciences, Clinical Nutrition Program, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
- Department of Human Nutrition & Dietetics, Bacha Khan University Charsadda, Charsadda, Khyber Pakhtunkhwa, Pakistan
- Tübingen Ageing and Tumour Immunology Group, Zentrum für Medizinische Forschung, University of Tübingen, Tübingen, Germany
| | - Ali M. Almajwal
- Department of Community Health Sciences, Clinical Nutrition Program, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Wajid Alam
- Oral and Maxillofacial Surgery, Khyber Colleg of Dentistry, KPK, Peshawar, Pakistan
| | - Ibrar Alam
- Department of Biotechnology, Bacha Khan University Charsadda, Charsadda, Khyber Pakhtunkhwa, Pakistan
| | - Niamat Ullah
- Department of Human Nutrition, The Agriculture University Peshawar, Khyber Pakhtunkhwa, Pakistan
| | - Mahmoud Abulmeaaty
- Department of Community Health Sciences, Clinical Nutrition Program, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Suhail Razak
- Department of Community Health Sciences, Clinical Nutrition Program, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Saleem Khan
- Department of Human Nutrition, The Agriculture University Peshawar, Khyber Pakhtunkhwa, Pakistan
| | - Graham Pawelec
- Tübingen Ageing and Tumour Immunology Group, Zentrum für Medizinische Forschung, University of Tübingen, Tübingen, Germany
- Health Sciences North Research Institute, Sudbury, ON, Canada
- John van Geest Cancer Research Centre, Nottingham Trent University, Nottingham, UK
| | - Parvez Iqbal Paracha
- Department of Human Nutrition, The Agriculture University Peshawar, Khyber Pakhtunkhwa, Pakistan
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12
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Prentice AM, Bah A, Jallow MW, Jallow AT, Sanyang S, Sise EA, Ceesay K, Danso E, Armitage AE, Pasricha SR, Drakesmith H, Wathuo M, Kessler N, Cerami C, Wegmüller R. Respiratory infections drive hepcidin-mediated blockade of iron absorption leading to iron deficiency anemia in African children. SCIENCE ADVANCES 2019; 5:eaav9020. [PMID: 30944864 PMCID: PMC6436921 DOI: 10.1126/sciadv.aav9020] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/05/2019] [Indexed: 06/09/2023]
Abstract
Iron deficiency anemia (IDA) is the most prevalent nutritional condition worldwide. We studied the contribution of hepcidin-mediated iron blockade to IDA in African children. We measured hepcidin and hemoglobin weekly, and hematological, inflammatory, and iron biomarkers at baseline, 7 weeks, and 12 weeks in 407 anemic (hemoglobin < 11 g/dl), otherwise healthy Gambian children (6 to 27 months). Each child maintained remarkably constant hepcidin levels (P < 0.0001 for between-child variance), with half consistently maintaining levels that indicate physiological blockade of iron absorption. Hepcidin was strongly predicted by nurse-ascribed adverse events with dominant signals from respiratory infections and fevers (all P < 0.0001). Diarrhea and fecal calprotectin were not associated with hepcidin. In multivariate analysis, C-reactive protein was the dominant predictor of hepcidin and contributed to iron blockade even at very low levels. We conclude that even low-grade inflammation, especially associated with respiratory infections, contributes to IDA in African children.
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Affiliation(s)
| | - Amat Bah
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, The Gambia
| | | | | | - Saikou Sanyang
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, The Gambia
| | - Ebrima A. Sise
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, The Gambia
| | - Kabiru Ceesay
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, The Gambia
| | - Ebrima Danso
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, The Gambia
| | - Andrew E. Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Sant-Rayn Pasricha
- Walter and Eliza Hall Institute for Medical Research, 1G Royal Parade, Melbourne, Parkville, Victoria 3052, Australia
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Miriam Wathuo
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, The Gambia
| | - Noah Kessler
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, The Gambia
- Department of Genetics, University of Cambridge, Cambridge, UK
| | - Carla Cerami
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, The Gambia
| | - Rita Wegmüller
- MRC Unit The Gambia at LSHTM, Atlantic Road, Fajara, The Gambia
- GroundWork, 7306 Fläsch, Switzerland
- Human Nutrition Laboratory, Institute of Food, Nutrition and Health, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
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13
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Pereira DI, Mohammed NI, Ofordile O, Camara F, Baldeh B, Mendy T, Sanyang C, Jallow AT, Hossain I, Wason J, Prentice AM. A novel nano-iron supplement to safely combat iron deficiency and anaemia in young children: The IHAT-GUT double-blind, randomised, placebo-controlled trial protocol. Gates Open Res 2018; 2:48. [PMID: 30569038 PMCID: PMC6266659 DOI: 10.12688/gatesopenres.12866.2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2018] [Indexed: 12/11/2022] Open
Abstract
Background: Iron deficiency and its associated anaemia (IDA) are the leading forms of micronutrient malnutrition worldwide. Here we describe the rationale and design of the first clinical trial evaluating the efficacy and safety of an innovative nano iron supplement, iron hydroxide adipate tartrate (IHAT), for the treatment of IDA in young children (IHAT-GUT trial). Oral iron is often ineffective due to poor absorption and/or gastrointestinal adverse effects. IHAT is novel since it is effectively absorbed whilst remaining nanoparticulate in the gut, therefore should enable supplementation with fewer symptoms. Methods: IHAT-GUT is a three-arm, double-blind, randomised, placebo-controlled phase II trial conducted in Gambian children 6-35 months of age. The intervention consists of a 12-week supplementation with either IHAT, ferrous sulphate (both at doses bioequivalent to 12.5 mg Fe/day) or placebo. The trial aims to include 705 children with IDA who will be randomly assigned (1:1:1) to each arm. The primary objectives are to test non-inferiority of IHAT in relation to ferrous sulphate at treating IDA, and to test superiority of IHAT in relation to ferrous sulphate and non-inferiority in relation to placebo in terms of diarrhoea incidence and prevalence. Secondary objectives are mechanistic assessments, to test whether IHAT reduces the burden of enteric pathogens, morbidity, and intestinal inflammation, and that it does not cause detrimental changes to the gut microbiome, particularly in relation to Lactobacillaceae, Bifidobacteriaceae and Enterobacteriaceae. Discussion: This trial will test the hypothesis that supplementation with IHAT eliminates iron deficiency and improves haemoglobin levels without inducing gastrointestinal adverse effects. If shown to be the case, this would open the possibility for further testing and use of IHAT as a novel iron source for micronutrient intervention strategies in resource-poor countries, with the ultimate aim to help reduce the IDA global burden. Registration: This trial is registered at clinicaltrials.gov ( NCT02941081).
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Affiliation(s)
- Dora I.A. Pereira
- Department of Pathology, University of Cambridge, Cambridge, CB2 1QP, UK
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Nuredin I. Mohammed
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Ogochukwu Ofordile
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Famalang Camara
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Bakary Baldeh
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Thomas Mendy
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Chilel Sanyang
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Amadou T. Jallow
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Ilias Hossain
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - James Wason
- MRC Biostatistics Unit, Institute of Public Health, University of Cambridge, Cambridge, CB2 0SR, UK
- Institute of Health and Society, Newcastle University, Newcastle, NE2 4BN, UK
| | - Andrew M. Prentice
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
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14
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Pereira DIA, Mohammed NI, Ofordile O, Camara F, Baldeh B, Mendy T, Sanyang C, Jallow AT, Hossain I, Wason J, Prentice AM. A novel nano-iron supplement to safely combat iron deficiency and anaemia in young children: The IHAT-GUT double-blind, randomised, placebo-controlled trial protocol. Gates Open Res 2018. [PMID: 30569038 DOI: 10.12688/gatesopenres.12866.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Iron deficiency and its associated anaemia (IDA) are the leading forms of micronutrient malnutrition worldwide. Here we describe the rationale and design of the first clinical trial evaluating the efficacy and safety of an innovative nano iron supplement, iron hydroxide adipate tartrate (IHAT), for the treatment of IDA in young children (IHAT-GUT trial). Oral iron is often ineffective due to poor absorption and/or gastrointestinal adverse effects. IHAT is novel since it is effectively absorbed whilst remaining nanoparticulate in the gut, therefore should enable supplementation with fewer symptoms. Methods: IHAT-GUT is a three-arm, double-blind, randomised, placebo-controlled phase II trial conducted in Gambian children 6-35 months of age. The intervention consists of a 12-week supplementation with either IHAT, ferrous sulphate (both at doses bioequivalent to 12.5 mg Fe/day) or placebo. The trial aims to include 705 children with IDA who will be randomly assigned (1:1:1) to each arm. The primary objectives are to test non-inferiority of IHAT in relation to ferrous sulphate at treating IDA, and to test superiority of IHAT in relation to ferrous sulphate and non-inferiority in relation to placebo in terms of diarrhoea incidence and prevalence. Secondary objectives are mechanistic assessments, to test whether IHAT reduces the burden of enteric pathogens, morbidity, and intestinal inflammation, and that it does not cause detrimental changes to the gut microbiome, particularly in relation to Lactobacillaceae, Bifidobacteriaceae and Enterobacteriaceae. Discussion: This trial will test the hypothesis that supplementation with IHAT eliminates iron deficiency and improves haemoglobin levels without inducing gastrointestinal adverse effects. If shown to be the case, this would open the possibility for further testing and use of IHAT as a novel iron source for micronutrient intervention strategies in resource-poor countries, with the ultimate aim to help reduce the IDA global burden. Registration: This trial is registered at clinicaltrials.gov ( NCT02941081).
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Affiliation(s)
- Dora I A Pereira
- Department of Pathology, University of Cambridge, Cambridge, CB2 1QP, UK.,Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Nuredin I Mohammed
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Ogochukwu Ofordile
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Famalang Camara
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Bakary Baldeh
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Thomas Mendy
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Chilel Sanyang
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Amadou T Jallow
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Ilias Hossain
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - James Wason
- MRC Biostatistics Unit, Institute of Public Health, University of Cambridge, Cambridge, CB2 0SR, UK.,Institute of Health and Society, Newcastle University, Newcastle, NE2 4BN, UK
| | - Andrew M Prentice
- Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
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15
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Layden AJ, Täse K, Finkelstein JL. Neglected tropical diseases and vitamin B12: a review of the current evidence. Trans R Soc Trop Med Hyg 2018; 112:423-435. [PMID: 30165408 DOI: 10.1093/trstmh/try078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/30/2018] [Indexed: 12/15/2022] Open
Abstract
Vitamin B12 deficiency is an urgent public health problem that disproportionately affects individuals in low- and middle-income settings, where the burden of neglected tropical diseases (NTDs) is also unacceptably high. Emerging evidence supports a potential role of micronutrients in modulating the risk and severity of NTDs. However, the role of vitamin B12 in NTD pathogenesis is unknown. This systematic review was conducted to evaluate the evidence on the role of vitamin B12 in the etiology of NTDs. Ten studies were included in this review: one study using an in vitro/animal model, eight observational human studies and one ancillary analysis conducted within an intervention trial. Most research to date has focused on vitamin B12 status and helminthic infections. One study examined the effects of vitamin B12 interventions in NTDs in animal and in vitro models. Few prospective studies have been conducted to date to examine the role of vitamin B12 in NTDs. The limited literature in this area constrains our ability to make specific recommendations. Larger prospective human studies are needed to elucidate the role of vitamin B12 in NTD risk and severity in order to inform interventions in at-risk populations.
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Affiliation(s)
| | - Kristos Täse
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Julia L Finkelstein
- Division of Nutritional Sciences, Cornell University, Ithaca, NY.,St. John's Research Institute, Bangalore, India
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16
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Kalidasan V, Joseph N, Kumar S, Hamat RA, Neela VK. The 'Checkmate' for Iron Between Human Host and Invading Bacteria: Chess Game Analogy. Indian J Microbiol 2018; 58:257-267. [PMID: 30013269 PMCID: PMC6023815 DOI: 10.1007/s12088-018-0740-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/05/2018] [Indexed: 12/13/2022] Open
Abstract
Iron is an essential nutrient for all living organisms with critical roles in many biological processes. The mammalian host maintains the iron requirements by dietary intake, while the invading pathogenic bacteria compete with the host to obtain those absorbed irons. In order to limit the iron uptake by the bacteria, the human host employs numerous iron binding proteins and withholding defense mechanisms that capture iron from the microbial invaders. To counteract, the bacteria cope with the iron limitation imposed by the host by expressing various iron acquisition systems, allowing them to achieve effective iron homeostasis. The armamentarium used by the human host and invading bacteria, leads to the dilemma of who wins the ultimate war for iron.
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Affiliation(s)
- V. Kalidasan
- Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia (43400 UPM), Serdang, Selangor Darul Ehsan, Malaysia
| | - Narcisse Joseph
- Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia (43400 UPM), Serdang, Selangor Darul Ehsan, Malaysia
| | - Suresh Kumar
- Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia (43400 UPM), Serdang, Selangor Darul Ehsan, Malaysia
| | - Rukman Awang Hamat
- Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia (43400 UPM), Serdang, Selangor Darul Ehsan, Malaysia
| | - Vasantha Kumari Neela
- Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia (43400 UPM), Serdang, Selangor Darul Ehsan, Malaysia
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17
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Abstract
Iron deficiency remains the largest nutritional deficiency worldwide and the main cause of anaemia. Severe iron deficiency leads to anaemia known as iron deficiency anaemia (IDA), which affects a total of 1·24 billion people, the majority of whom are children and women from resource-poor countries. In sub-Saharan Africa, iron deficiency is frequently exacerbated by concomitant parasitic and bacterial infections and contributes to over 120 000 maternal deaths a year, while it irreparably limits the cognitive development of children and leads to poor outcomes in pregnancy.Currently available iron compounds are cheap and readily available, but constitute a non-physiological approach to providing iron that leads to significant side effects. Consequently, iron deficiency and IDA remain without an effective treatment, particularly in populations with high burden of infectious diseases. So far, despite considerable investment in the past 25 years in nutrition interventions with iron supplementation and fortification, we have been unable to significantly decrease the burden of this disease in resource-poor countries.If we are to eliminate this condition in the future, it is imperative to look beyond the strategies used until now and we should make an effort to combine community engagement and social science approaches to optimise supplementation and fortification programmes.
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18
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Zhang DL, Wu J, Shah BN, Greutélaers KC, Ghosh MC, Ollivierre H, Su XZ, Thuma PE, Bedu-Addo G, Mockenhaupt FP, Gordeuk VR, Rouault TA. Erythrocytic ferroportin reduces intracellular iron accumulation, hemolysis, and malaria risk. Science 2018; 359:1520-1523. [PMID: 29599243 DOI: 10.1126/science.aal2022] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 08/15/2017] [Accepted: 01/25/2018] [Indexed: 12/17/2022]
Abstract
Malaria parasites invade red blood cells (RBCs), consume copious amounts of hemoglobin, and severely disrupt iron regulation in humans. Anemia often accompanies malaria disease; however, iron supplementation therapy inexplicably exacerbates malarial infections. Here we found that the iron exporter ferroportin (FPN) was highly abundant in RBCs, and iron supplementation suppressed its activity. Conditional deletion of the Fpn gene in erythroid cells resulted in accumulation of excess intracellular iron, cellular damage, hemolysis, and increased fatality in malaria-infected mice. In humans, a prevalent FPN mutation, Q248H (glutamine to histidine at position 248), prevented hepcidin-induced degradation of FPN and protected against severe malaria disease. FPN Q248H appears to have been positively selected in African populations in response to the impact of malaria disease. Thus, FPN protects RBCs against oxidative stress and malaria infection.
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Affiliation(s)
- De-Liang Zhang
- Section on Human Iron Metabolism, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Jian Wu
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Binal N Shah
- Sickle Cell Center, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Katja C Greutélaers
- Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Tropical Medicine and International Health, Berlin 13353, Germany
| | - Manik C Ghosh
- Section on Human Iron Metabolism, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Hayden Ollivierre
- Section on Human Iron Metabolism, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Xin-Zhuan Su
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | | | - George Bedu-Addo
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Frank P Mockenhaupt
- Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Tropical Medicine and International Health, Berlin 13353, Germany
| | - Victor R Gordeuk
- Sickle Cell Center, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Tracey A Rouault
- Section on Human Iron Metabolism, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
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19
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Reddy VP, Chinta KC, Saini V, Glasgow JN, Hull TD, Traylor A, Rey-Stolle F, Soares MP, Madansein R, Rahman MA, Barbas C, Nargan K, Naidoo T, Ramdial PK, George JF, Agarwal A, Steyn AJC. Ferritin H Deficiency in Myeloid Compartments Dysregulates Host Energy Metabolism and Increases Susceptibility to Mycobacterium tuberculosis Infection. Front Immunol 2018; 9:860. [PMID: 29774023 PMCID: PMC5943674 DOI: 10.3389/fimmu.2018.00860] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 04/06/2018] [Indexed: 12/20/2022] Open
Abstract
Iron is an essential factor for the growth and virulence of Mycobacterium tuberculosis (Mtb). However, little is known about the mechanisms by which the host controls iron availability during infection. Since ferritin heavy chain (FtH) is a major intracellular source of reserve iron in the host, we hypothesized that the lack of FtH would cause dysregulated iron homeostasis to exacerbate TB disease. Therefore, we used knockout mice lacking FtH in myeloid-derived cell populations to study Mtb disease progression. We found that FtH plays a critical role in protecting mice against Mtb, as evidenced by increased organ burden, extrapulmonary dissemination, and decreased survival in Fth-/- mice. Flow cytometry analysis showed that reduced levels of FtH contribute to an excessive inflammatory response to exacerbate disease. Extracellular flux analysis showed that FtH is essential for maintaining bioenergetic homeostasis through oxidative phosphorylation. In support of these findings, RNAseq and mass spectrometry analyses demonstrated an essential role for FtH in mitochondrial function and maintenance of central intermediary metabolism in vivo. Further, we show that FtH deficiency leads to iron dysregulation through the hepcidin-ferroportin axis during infection. To assess the clinical significance of our animal studies, we performed a clinicopathological analysis of iron distribution within human TB lung tissue and showed that Mtb severely disrupts iron homeostasis in distinct microanatomic locations of the human lung. We identified hemorrhage as a major source of metabolically inert iron deposition. Importantly, we observed increased iron levels in human TB lung tissue compared to healthy tissue. Overall, these findings advance our understanding of the link between iron-dependent energy metabolism and immunity and provide new insight into iron distribution within the spectrum of human pulmonary TB. These metabolic mechanisms could serve as the foundation for novel host-directed strategies.
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Affiliation(s)
- Vineel P. Reddy
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Krishna C. Chinta
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Vikram Saini
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Joel N. Glasgow
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Travis D. Hull
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Amie Traylor
- Nephrology Research and Training Center, University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, AL, United States
| | - Fernanda Rey-Stolle
- Centro de Metabolómica y Bioanálisis (CEMBIO), Facultad de Farmacia, Universidad CEU San Pablo, Madrid, Spain
| | | | - Rajhmun Madansein
- Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal, Durban, South Africa
| | | | - Coral Barbas
- Centro de Metabolómica y Bioanálisis (CEMBIO), Facultad de Farmacia, Universidad CEU San Pablo, Madrid, Spain
| | - Kievershen Nargan
- Department of Anatomical Pathology, National Health Laboratory Service, University of KwaZulu-Natal, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Threnesan Naidoo
- Department of Anatomical Pathology, National Health Laboratory Service, University of KwaZulu-Natal, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Pratistadevi K. Ramdial
- Department of Anatomical Pathology, National Health Laboratory Service, University of KwaZulu-Natal, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - James F. George
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Anupam Agarwal
- Nephrology Research and Training Center, University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, AL, United States
| | - Adrie J. C. Steyn
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, United States
- Africa Health Research Institute (AHRI), Durban, South Africa
- UAB Centers for AIDS Research and Free Radical Biology, University of Alabama at Birmingham, Birmingham, AL, United States
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20
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Bahizire E, D'Alessandro U, Dramaix M, Dauby N, Bahizire F, Mubagwa K, Donnen P. Malaria and Iron Load at the First Antenatal Visit in the Rural South Kivu, Democratic Republic of the Congo: Is Iron Supplementation Safe or Could It Be Harmful? Am J Trop Med Hyg 2018; 98:520-523. [PMID: 29313480 DOI: 10.4269/ajtmh.17-0585] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
We investigated the relationship between malaria infection and iron status in 531 pregnant women in South Kivu, Democratic Republic of the Congo. Sociodemographic data, information on morbidity, and clinical data were collected. A blood sample was collected at the first antenatal visit to diagnose malaria and measure serum ferritin (SF), soluble transferrin receptor, C-reactive protein, and α1-acid-glycoprotein. Malaria prevalence was 7.5%. Median (interquartile range) SF (adjusted for inflammation) was significantly higher in malaria-infected (82.9 μg/L [56.3-130.4]) than in non-infected (39.8 μg/L [23.6-60.8]) women (P < 0.001). Similarly, estimated mean body iron store was higher in malaria-infected women (P < 0.001). Malaria was significantly and independently associated with high levels of SF. Efforts to improve malaria prevention while correcting iron deficiency and anemia during pregnancy are warranted.
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Affiliation(s)
- Esto Bahizire
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya.,Center of Research in Epidemiology, Biostatistics and Clinical Research, Université Libre de Bruxelles, Brussels, Belgium.,Centre de Recherche en Sciences Naturelles de Lwiro, Bukavu, DR Congo
| | - Umberto D'Alessandro
- London School of Hygiene and Tropical Medicine, London, United Kingdom.,Medical Research Council Unit The Gambia, Fajara, The Gambia
| | - Michèle Dramaix
- Center of Research in Epidemiology, Biostatistics and Clinical Research, Université Libre de Bruxelles, Brussels, Belgium
| | - Nicolas Dauby
- Department of Infectious Diseases, Centre Hospitalier Universitaire Saint-Pierre, Brussels, Belgium
| | - Fabrice Bahizire
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Kanigula Mubagwa
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Philippe Donnen
- Center of Research in Health Policy and Systems-International Health, Université Libre de Bruxelles, Brussels, Belgium
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21
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Prasetyani MA, de Mast Q, Afeworki R, Kaisar MMM, Stefanie D, Sartono E, Supali T, van der Ven AJ. Effect of a short course of iron polymaltose on acquisition of malarial parasitaemia in anaemic Indonesian schoolchildren: a randomized trial. Malar J 2017; 16:50. [PMID: 28129772 PMCID: PMC5273788 DOI: 10.1186/s12936-017-1691-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 01/11/2017] [Indexed: 01/09/2023] Open
Abstract
Background Concern exists about the safety of iron supplementation given to individuals in malarious areas. The possible unfavourable impact of iron supplementation on malaria might be less when slow-release iron compounds are used instead of ferrous salts, because no toxic non-transferrin bound iron is formed. The aim of this study was to determine the effect of iron supplementation using the slow-release iron compound iron polymaltose (IPM) on the acquisition of malarial parasitaemia. Methods A randomized, placebo-controlled trial was performed in schoolchildren aged 5–18 years with mild or moderate anaemia on the Indonesian island Flores. Microscopic malaria-negative children were randomized to receive 8 weeks of IPM (6 mg elemental iron/kg/day) or placebo . The primary outcomes were the occurrence of microscopically detectable malarial parasitaemia at week 4, 8, 12 and 16 after start of treatment and the proportion of participants with real-time (RT) PCR positive malarial parasitaemia at week 16. Results 294 Children were assigned to the IPM group and 297 to the placebo group. Whereas IPM supplementation failed to increased haemoglobin or ferritin concentrations, the IPM group had a significantly higher rate of occurrence of microscopically detectable parasitaemia [hazard ratio 2.2, 95% C.I. 1.2–4.0; P = 0.01]. This higher rate was confined to iron-replete children. At the end of the study, 89% of the children in the IPM group had remained free from microscopically detectable parasitaemia vs 95% of children in the placebo group. The proportion of plasmodial RT-PCR positive children was similar in both groups at week 16 (IPM group 16.6% vs placebo group 14.3%; P = 0.47). When analysis was restricted to iron-replete children (serum ferritin ≥30 µg/l), there was a trend for a higher proportion being RT-PCR positive at week 16 in the IPM group compared with the placebo group (20 vs 13.3%; P = 0.07). Erythrocyte microcytosis was an independent risk factor for microscopically detectable malarial parasitaemia. Conclusions A short course of IPM should be used cautiously in anaemic children in malaria endemic areas, as it has limited efficacy in treating iron deficiency, while it increases the rate of microscopic malarial parasitaemia in those with replete iron stores. Trial registration ISRCTN 83091970. Registered 16 May 2012 (retrospectively registered) Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1691-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Margaretta A Prasetyani
- Department of Parasitology, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Quirijn de Mast
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Centre, Geert Groote Plein Zuid 8, 6500 HB, Nijmegen, The Netherlands.
| | - Robel Afeworki
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Centre, Geert Groote Plein Zuid 8, 6500 HB, Nijmegen, The Netherlands
| | - Maria M M Kaisar
- Department of Parasitology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Difa Stefanie
- Department of Parasitology, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Erliyani Sartono
- Department of Parasitology, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia.,Department of Parasitology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Taniawati Supali
- Department of Parasitology, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - André J van der Ven
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Centre, Geert Groote Plein Zuid 8, 6500 HB, Nijmegen, The Netherlands
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Prentice AM, Mendoza YA, Pereira D, Cerami C, Wegmuller R, Constable A, Spieldenner J. Dietary strategies for improving iron status: balancing safety and efficacy. Nutr Rev 2017; 75:49-60. [PMID: 27974599 PMCID: PMC5155616 DOI: 10.1093/nutrit/nuw055] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
In light of evidence that high-dose iron supplements lead to a range of adverse events in low-income settings, the safety and efficacy of lower doses of iron provided through biological or industrial fortification of foodstuffs is reviewed. First, strategies for point-of-manufacture chemical fortification are compared with biofortification achieved through plant breeding. Recent insights into the mechanisms of human iron absorption and regulation, the mechanisms by which iron can promote malaria and bacterial infections, and the role of iron in modifying the gut microbiota are summarized. There is strong evidence that supplemental iron given in nonphysiological amounts can increase the risk of bacterial and protozoal infections (especially malaria), but the use of lower quantities of iron provided within a food matrix, ie, fortified food, should be safer in most cases and represents a more logical strategy for a sustained reduction of the risk of deficiency by providing the best balance of risk and benefits. Further research into iron compounds that would minimize the availability of unabsorbed iron to the gut microbiota is warranted.
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Affiliation(s)
- Andrew M Prentice
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
| | - Yery A Mendoza
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Dora Pereira
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Carla Cerami
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Rita Wegmuller
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Anne Constable
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Jörg Spieldenner
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Hanson MA, Bardsley A, De-Regil LM, Moore SE, Oken E, Poston L, Ma RC, McAuliffe FM, Maleta K, Purandare CN, Yajnik CS, Rushwan H, Morris JL. The International Federation of Gynecology and Obstetrics (FIGO) recommendations on adolescent, preconception, and maternal nutrition: "Think Nutrition First". Int J Gynaecol Obstet 2016; 131 Suppl 4:S213-53. [PMID: 26433230 DOI: 10.1016/s0020-7292(15)30034-5] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Mark A Hanson
- Institute of Developmental Sciences, University of Southampton; and NIHR Nutrition Biomedical Research Centre, University Hospital Southampton; Southampton, UK
| | - Anne Bardsley
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | | | | | - Emily Oken
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute; and Department of Nutrition, Harvard TH Chan School of Public Health; Boston, MA, USA
| | | | - Ronald C Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong; and the Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong, China
| | - Fionnuala M McAuliffe
- UCD School of Medicine and Medical Science, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Ken Maleta
- University of Malawi College of Medicine, Blantyre, Malawi
| | | | | | - Hamid Rushwan
- International Federation of Gynecology and Obstetrics, London, UK
| | - Jessica L Morris
- International Federation of Gynecology and Obstetrics, London, UK.
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Hemminki E, Nwaru BI, Salomé G, Parkkali S, Abacassamo F, Augusto O, Cliff J, Regushevskaya E, Dgedge M, Sousa C, Chilundo B. Is selective prenatal iron prophylaxis better than routine prophylaxis: final results of a trial (PROFEG) in Maputo, Mozambique. BMJ Open 2016; 6:e011280. [PMID: 27297013 PMCID: PMC4916582 DOI: 10.1136/bmjopen-2016-011280] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To compare routine versus selective (ie, screening and treatment for anaemia) prenatal iron prophylaxis in a malaria-endemic and HIV-prevalent setting, an extended analysis including previously missing data. DESIGN A pragmatic randomised controlled clinical trial. SETTING 2 health centres in Maputo, Mozambique. PARTICIPANTS Pregnant women (≥18 years old; non-high-risk pregnancy) were randomly allocated to routine iron (n=2184) and selective iron (n=2142) groups. INTERVENTIONS In the routine group, women received 60 mg ferrous sulfate plus 400 μg folic acid daily. In the selective group, women received 1 mg of folic acid daily and haemoglobin (Hb) screening at each visit; with low Hb (cut-off 9 g/dL) treatment (120 mg+800 μg of folic acid daily) for a month. PRIMARY OUTCOMES preterm birth, low birth weight; secondary outcomes: self-reported malaria, labour complications, caesarean section, perinatal death, woman's death. Nurses collected pregnancy data. Birth data were abstracted from hospital records for 52% of women and traced using various methods and linked with probabilistic matching for 24%. Women's deaths were collected from death registers. RESULTS Birth data were available for 3301 (76%) of the women. Outcomes were similar in the two groups: preterm births (27.1% in the selective vs 25.3% in the routine group), low birthweight infants (11.0% vs 11.7%), perinatal deaths (2.4% vs 2.4%) and caesarean sections (4.0% vs 4.5%). Women's deaths during pregnancy or <42 days postpartum were more common in the selective group (0.8% among the two best matched women) than in the routine group (0.4%). Extra deaths could not be explained by the cause of death, Hb level or HIV status at recruitment. CONCLUSIONS Birth outcomes were similar in the two iron groups. There might have been more women's deaths in the selective iron group, but it is unclear whether this was due to the intervention, other factors or chance finding. TRIAL REGISTRATION NUMBER NCT00488579.
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Affiliation(s)
- Elina Hemminki
- Health Services and Policy Research, National Institute for Health and Welfare, Helsinki, Finland
| | - Bright I Nwaru
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, UK
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Graca Salomé
- Medical Faculty, Department of Physiological Sciences, Eduardo Mondlane University, Maputo, Mozambique
| | - Saara Parkkali
- Health Services and Policy Research, National Institute for Health and Welfare, Helsinki, Finland
| | - Fatima Abacassamo
- Medical Faculty, Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
| | - Orvalho Augusto
- Medical Faculty, Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
| | - Julie Cliff
- Medical Faculty, Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
| | - Elena Regushevskaya
- Health Services and Policy Research, National Institute for Health and Welfare, Helsinki, Finland
| | | | - Cesar Sousa
- Medical Faculty, Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
| | - Baltazar Chilundo
- Medical Faculty, Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
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Wirth JP, Rohner F, Woodruff BA, Chiwile F, Yankson H, Koroma AS, Russel F, Sesay F, Dominguez E, Petry N, Shahab-Ferdows S, de Onis M, Hodges MH. Anemia, Micronutrient Deficiencies, and Malaria in Children and Women in Sierra Leone Prior to the Ebola Outbreak - Findings of a Cross-Sectional Study. PLoS One 2016; 11:e0155031. [PMID: 27163254 PMCID: PMC4862671 DOI: 10.1371/journal.pone.0155031] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/25/2016] [Indexed: 12/15/2022] Open
Abstract
To identify the factors associated with anemia and to document the severity of micronutrient deficiencies, malaria and inflammation, a nationally representative cross-sectional survey was conducted. A three-stage sampling procedure was used to randomly select children <5 years of age and adult women from households in two strata (urban and rural). Household and individual data were collected, and blood samples from children and women were used to measure the prevalence of malaria, inflammation, and deficiencies of iron, vitamin A, folate, and vitamin B12. 839 children and 945 non-pregnant women were included in the survey. In children, the prevalence rates of anemia (76.3%; 95% CI: 71.8, 80.4), malaria (52.6%; 95% CI: 46.0, 59.0), and acute and chronic inflammation (72.6%; 95% CI: 67.5, 77.1) were high. However, the prevalence of vitamin A deficiency (17.4%; 95% CI: 13.9, 21.6) was moderate, and the prevalence of iron deficiency (5.2%; 95% CI: 3.3, 8.1) and iron-deficiency anemia (3.8%; 95% CI: 2.5, 5.8) were low. Malaria and inflammation were associated with anemia, yet they explained only 25% of the population-attributable risk. In women, 44.8% (95% CI: 40.1, 49.5), 35.1% (95% CI: 30.1, 40.4), and 23.6% (95% CI: 20.4, 27.3) were affected by anemia, malaria, or inflammation, respectively. The prevalence rates of iron deficiency (8.3%; 95% CI: 6.2, 11.1), iron-deficiency anemia (6.1%; 95% CI: 4.4, 8.6), vitamin A deficiency (2.1%; 95% CI: 1.1, 3.1) and vitamin B12 deficiency (0.5%; 95% CI: 0.2, 1.4) were low, while folate deficiency was high (79.2%; 95% CI: 74.1, 83.5). Iron deficiency, malaria, and inflammation were significantly associated with anemia, but explained only 25% of cases of anemia. Anemia in children and women is a severe public health problem in Sierra Leone. Since malaria and inflammation only contributed to 25% of anemia, other causes of anemia, such as hemoglobinopathies, should also be explored.
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Affiliation(s)
| | | | | | | | | | | | - Feimata Russel
- Ministry of Health and Sanitation, Freetown, Sierra Leone
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van der Kam S, Roll S, Swarthout T, Edyegu-Otelu G, Matsumoto A, Kasujja FX, Casademont C, Shanks L, Salse-Ubach N. Effect of Short-Term Supplementation with Ready-to-Use Therapeutic Food or Micronutrients for Children after Illness for Prevention of Malnutrition: A Randomised Controlled Trial in Uganda. PLoS Med 2016; 13:e1001951. [PMID: 26859481 PMCID: PMC4747529 DOI: 10.1371/journal.pmed.1001951] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 12/21/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Globally, Médecins Sans Frontières (MSF) treats more than 300,000 severely malnourished children annually. Malnutrition is not only caused by lack of food but also by illnesses and by poor infant and child feeding practices. Breaking the vicious cycle of illness and malnutrition by providing ill children with nutritional supplementation is a potentially powerful strategy for preventing malnutrition that has not been adequately investigated. Therefore, MSF investigated whether incidence of malnutrition among ill children <5 y old could be reduced by providing a fortified food product or micronutrients during their 2-wk convalescence period. Two trials, one in Nigeria and one in Uganda, were conducted; here, we report on the trial that took place in Kaabong, a poor agropastoral region of Karamoja, in east Uganda. While the region of Karamoja shows an acute malnutrition rate between 8.4% and 11.5% of which 2% to 3% severe malnutrition, more than half (58%) of the population in the district of Kaabong is considered food insecure. METHODS AND FINDINGS We investigated the effect of two types of nutritional supplementation on the incidence of malnutrition in ill children presenting at outpatient clinics during March 2011 to April 2012 in Kaabong, Karamoja region, Uganda, a resource-poor region where malnutrition is a chronic problem for its seminomadic population. A three-armed, partially-blinded, randomised controlled trial was conducted in children diagnosed with malaria, diarrhoea, or lower respiratory tract infection. Non-malnourished children aged 6 to 59 mo were randomised to one of three arms: one sachet/d of ready-to-use therapeutic food (RUTF), two sachets/d of micronutrient powder (MNP), or no supplement (control) for 14 d for each illness over 6 mo. The primary outcome was the incidence of first negative nutritional outcome (NNO) during the 6 mo follow-up. NNO was a study-specific measure used to indicate progression to moderate or severe acute malnutrition; it was defined as weight-for-height z-score <-2, mid-upper arm circumference (MUAC) <115 mm, or oedema, whichever came first. Of the 2,202 randomised participants, 51.2% were girls, and the mean age was 25.2 (±13.8) mo; 148 (6.7%) participants were lost to follow-up, 9 (0.4%) died, and 14 (0.6%) were admitted to hospital. The incidence rates of NNO (first event/year) for the RUTF, MNP, and control groups were 0.143 (95% confidence interval [CI], 0.107-0.191), 0.185 (0.141-0.239), and 0.213 (0.167-0.272), respectively. The incidence rate ratio was 0.67 (95% CI, 0.46-0.98; p = 0.037) for RUTF versus control; a reduction of 33.3%. The incidence rate ratio was 0.86 (0.61-1.23; p = 0.413) for MNP versus control and 0.77 for RUTF versus MNP (95% CI 0.52-1.15; p = 0.200). The average numbers of study illnesses for the RUTF, MNP, and control groups were 2.3 (95% CI, 2.2-2.4), 2.1 (2.0-2.3), and 2.3 (2.2-2.5). The proportions of children who died in the RUTF, MNP, and control groups were 0%, 0.8%, and 0.4%. The findings apply to ill but not malnourished children and cannot be generalised to a general population including children who are not necessarily ill or who are already malnourished. CONCLUSIONS A 2-wk nutrition supplementation programme with RUTF as part of routine primary medical care to non-malnourished children with malaria, LRTI, or diarrhoea proved effective in preventing malnutrition in eastern Uganda. The low incidence of malnutrition in this population may warrant a more targeted intervention to improve cost effectiveness. TRIAL REGISTRATION clinicaltrials.gov NCT01497236.
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Affiliation(s)
- Saskia van der Kam
- Médecins Sans Frontières, Amsterdam, Netherlands
- Ecole de Santé Publique, Centre de Recherche en Politiques et Systèmes de Santé-Santé Internationale, Université Libre de Bruxelles, Brussels, Belgium
- * E-mail:
| | - Stephanie Roll
- Institute for Social Medicine, Epidemiology and Health Economics, Charité-Universitätsmedizin, Berlin, Germany
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27
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van der Kam S, Salse-Ubach N, Roll S, Swarthout T, Gayton-Toyoshima S, Jiya NM, Matsumoto A, Shanks L. Effect of Short-Term Supplementation with Ready-to-Use Therapeutic Food or Micronutrients for Children after Illness for Prevention of Malnutrition: A Randomised Controlled Trial in Nigeria. PLoS Med 2016; 13:e1001952. [PMID: 26859559 PMCID: PMC4747530 DOI: 10.1371/journal.pmed.1001952] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 12/21/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Globally, Médecins Sans Frontières (MSF) treats more than 300,000 severely malnourished children annually. Malnutrition is not only caused by lack of food and poor infant and child feeding practices but also by illnesses. Breaking the vicious cycle of illness and malnutrition by providing ill children with nutritional supplementation is a potentially powerful strategy for preventing malnutrition that has not been adequately investigated. Therefore, MSF investigated whether incidence of malnutrition among ill children <5 y old could be reduced by providing a fortified food product or micronutrients during their 2-wk convalescence period. Two trials, one in Nigeria and one in Uganda, were conducted; here we report on the trial that took place in Goronyo, a rural region of northwest Nigeria with high morbidity and malnutrition rates. METHODS AND FINDINGS We investigated the effect of supplementation with ready-to-use therapeutic food (RUTF) and a micronutrient powder (MNP) on the incidence of malnutrition in ill children presenting at an outpatient clinic in Goronyo during February to September 2012. A three-armed, partially-blinded, randomised controlled trial was conducted in children diagnosed as having malaria, diarrhoea, or lower respiratory tract infection. Children aged 6 to 59 mo were randomised to one of three arms: one sachet/d of RUTF; two sachets/d of micronutrients or no supplement (control) for 14 d for each illness over 6 mo. The primary outcome was the incidence of first negative nutritional outcome (NNO) during the 6 mo follow-up. NNO was a study-specific measure used to indicate occurrence of malnutrition; it was defined as low weight-for-height z-score (<-2 for non-malnourished and <-3 for moderately malnourished children), mid-upper arm circumference <115 mm, or oedema, whichever came first. Of the 2,213 randomised participants, 50.0% were female and the mean age was 20.2 (standard deviation 11.2) months; 160 (7.2%) were lost to follow-up, 54 (2.4%) were admitted to hospital, and 29 (1.3%) died. The incidence rates of NNO for the RUTF, MNP, and control groups were 0.522 (95% confidence interval (95% CI), 0.442-0.617), 0.495 (0.415-0.589), and 0.566 (0.479-0.668) first events/y, respectively. The incidence rate ratio was 0.92 (95% CI, 0.74-1.15; p = 0.471) for RUTF versus control; 0.87 (0.70-1.10; p = 0.242) for MNP versus control and 1.06 (0.84-1.33, p = 0.642) for RUTF versus MNP. A subgroup analysis showed no interaction nor confounding, nor a different effectiveness of supplementation, among children who were moderately malnourished compared with non-malnourished at enrollment. The average number of study illnesses for the RUTF, MNP, and control groups were 4.2 (95% CI, 4.0-4.3), 3.4 (3.2-3.6), and 3.6 (3.4-3.7). The proportion of children who died in the RUTF, MNP, and control groups were 0.8% (95% CI, 0.3-1.8), 1.8% (1.0-3.3), and 1.4% (0.7-2.8). CONCLUSIONS A 2-wk supplementation with RUTF or MNP to ill children as part of routine primary medical care did not reduce the incidence of malnutrition. The lack of effect in Goronyo may be due to a high frequency of morbidity, which probably further affects a child's nutritional status and children's ability to escape from the illness-malnutrition cycle. The duration of the supplementation may have been too short or the doses of the supplements may have been too low to mitigate the effects of high morbidity and pre-existing malnutrition. An integrated approach combining prevention and treatment of diseases and treatment of moderate malnutrition, rather than prevention of malnutrition by nutritional supplementation alone, might be more effective in reducing the incidence of acute malnutrition in ill children. TRIAL REGISTRATION clinicaltrials.gov NCT01154803.
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Affiliation(s)
- Saskia van der Kam
- Médecins Sans Frontières, Amsterdam, Netherlands
- Ecole de Santé Publique, Centre de Recherche en Politiques et Systèmes de Santé-Santé Internationale, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Stephanie Roll
- Institute for Social Medicine, Epidemiology and Health Economics, Charité- Universitätsmedizin, Berlin, Germany
| | | | | | - Nma Mohammed Jiya
- Department of Paediatrics, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
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8. References. Int J Gynaecol Obstet 2015. [DOI: 10.1016/s0020-7292(15)30032-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Menon MP, Yoon SS. Prevalence and Factors Associated with Anemia Among Children Under 5 Years of Age--Uganda, 2009. Am J Trop Med Hyg 2015; 93:521-6. [PMID: 26055748 PMCID: PMC4559690 DOI: 10.4269/ajtmh.15-0102] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 05/05/2015] [Indexed: 01/08/2023] Open
Abstract
Anemia in children under 5 years of age, defined by the World Health Organization as a hemoglobin concentration < 11 g/dL, is a global public health problem. According to the 2006 Demographic Health Survey, the prevalence of anemia among children under five in Uganda was 72% in 2006. The 2009 Uganda Malaria Indicator Survey was conducted in late 2009 and revealed that over 60% of children less than 5 years of age were anemic and that over half of children tested positive for malaria via a rapid diagnostic test. Children with concomitant malaria infection, and in households without any type of mosquito net were more likely to be anemic, confirming that children under 5 years, are vulnerable to both the threat of malaria and anemia and the beneficial effect of malaria prevention tools. However, prevention and treatment of other factors associated with the etiology of anemia (e.g., iron deficiency) are likely necessary to combat the toll of anemia in Uganda.
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Affiliation(s)
- Manoj P Menon
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia; University of Washington, Seattle, Washington
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Erythrocytic Iron Deficiency Enhances Susceptibility to Plasmodium chabaudi Infection in Mice Carrying a Missense Mutation in Transferrin Receptor 1. Infect Immun 2015; 83:4322-34. [PMID: 26303393 DOI: 10.1128/iai.00926-15] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 08/20/2015] [Indexed: 01/26/2023] Open
Abstract
The treatment of iron deficiency in areas of high malaria transmission is complicated by evidence which suggests that iron deficiency anemia protects against malaria, while iron supplementation increases malaria risk. Iron deficiency anemia results in an array of pathologies, including reduced systemic iron bioavailability and abnormal erythrocyte physiology; however, the mechanisms by which these pathologies influence malaria infection are not well defined. In the present study, the response to malaria infection was examined in a mutant mouse line, Tfrc(MRI24910), identified during an N-ethyl-N-nitrosourea (ENU) screen. This line carries a missense mutation in the gene for transferrin receptor 1 (TFR1). Heterozygous mice exhibited reduced erythrocyte volume and density, a phenotype consistent with dietary iron deficiency anemia. However, unlike the case in dietary deficiency, the erythrocyte half-life, mean corpuscular hemoglobin concentration, and intraerythrocytic ferritin content were unchanged. Systemic iron bioavailability was also unchanged, indicating that this mutation results in erythrocytic iron deficiency without significantly altering overall iron homeostasis. When infected with the rodent malaria parasite Plasmodium chabaudi adami, mice displayed increased parasitemia and succumbed to infection more quickly than their wild-type littermates. Transfusion of fluorescently labeled erythrocytes into malaria parasite-infected mice demonstrated an erythrocyte-autonomous enhanced survival of parasites within mutant erythrocytes. Together, these results indicate that TFR1 deficiency alters erythrocyte physiology in a way that is similar to dietary iron deficiency anemia, albeit to a lesser degree, and that this promotes intraerythrocytic parasite survival and an increased susceptibility to malaria in mice. These findings may have implications for the management of iron deficiency in the context of malaria.
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The HFE genotype and a formulated diet controlling for iron status attenuate experimental cerebral malaria in mice. Int J Parasitol 2015; 45:797-808. [PMID: 26296689 DOI: 10.1016/j.ijpara.2015.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 07/06/2015] [Accepted: 07/07/2015] [Indexed: 12/13/2022]
Abstract
Plasmodium falciparum infects approximately 500million individuals each year. A small but significant number of infections lead to complications such as cerebral malaria. Cerebral malaria is associated with myelin damage and neurological deficits in survivors, and iron status is thought to impact the outcome of infection. We evaluated whether a mouse model of experimental cerebral malaria with Plasmodium berghei ANKA strain was altered by dietary iron deficiency or genetic iron overload (H67D HFE). We found that H67D mice had increased survival over H67H (wild type) mice. Moreover, a specifically designed formulation diet increased survival regardless of whether the diet was iron deficient or iron adequate. To determine potential mechanisms underlying demyelination in experimental cerebral malaria, we measured Semaphorin4A (Sema4A) protein levels in the brain because we found it is cytotoxic to oligodendrocytes. Sema4A was increased in wild type mice that developed experimental cerebral malaria while consuming standard rodent chow, consistent with a decrease in myelin basic protein, an indicator of myelin integrity. The brains of iron deficient and H67D mice had lower levels of Sema4A. Myelin basic protein was decreased in brains of mice fed the iron deficient diet as has been previously reported. We also examined erythropoietin, which is under consideration for treatment of cerebral malaria, and IL-6, which is known to increase during infection. We found that plasma erythropoietin was elevated and IL-6 was low in H67D mice and in the mice fed the formulation diets. These data reveal a paradigm-shifting concept that maintaining iron status may not increase the mortality associated with malaria and provide a dietary strategy for further examination. Moreover, the data provide clues for exploring the mechanism to limit the co-morbidity associated with experimental cerebral malaria that appears to include decreased Sema4A in brain as well as elevated erythropoietin and lower IL-6 in plasma.
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Hadley C, DeCaro JA. Does moderate iron deficiency protect against childhood illness? A test of the optimal iron hypothesis in Tanzania. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 2015; 157:675-9. [PMID: 25913168 DOI: 10.1002/ajpa.22756] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 04/01/2015] [Accepted: 04/08/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To test the hypothesis that moderate iron deficiency among children is associated with lower likelihood of infection. MATERIALS AND METHODS We use data from a population representative cross sectional study of 1164 Tanzanian children aged 6-59 months from the Tanzania Demographic and Health Survey. Respondents' iron levels were assessed through serum transferrin receptor (sTfR) and anemia was assessed using hemoglobin. C-reactive protein (CRP) was used as a marker of infection. RESULTS Nearly 25% of the children were categorized as normal (iron replete, non-anemic); 45% were IDE (low iron, non-anemic), 24% were classified as IDA (low iron, anemic), and 69 children (5.9%) were anemic but had no evidence of iron deficiency. IDE was not associated with a lower likelihood of elevated CRP compared to iron replete, non-anemic children; 45% of normal children had elevated CRP compared to 51% of IDE children (P = 0.10). IDA, by contrast, was associated with a higher likelihood of elevated CRP (68%, P < 0.001). These results were unchanged when child, maternal, and household controls were added to a logistic regression model. DISCUSSION Our results do not support the optimal iron hypothesis as conventionally formulated. The fact that we did not find an effect where some other studies have may be due to differences in study design, sample (e.g., age), or the baseline pathogenic ecology. Alternatively, it may be more fruitful to investigate iron regulation as an allostatic system that responds to infections adaptively, rather than to expect an optimal pre-infection value.
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Affiliation(s)
- Craig Hadley
- Department of Anthropology, Emory University, Atlanta, GA, 30322
| | - Jason A DeCaro
- Department of Anthropology, University of Alabama, Tuscaloosa, AL
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Nwaru BI, Parkkali S, Abacassamo F, Salomé G, Chilundo B, Augusto O, Cliff J, Dgedge M, Regushevskaya E, Nikula M, Hemminki E. A pragmatic randomised controlled trial on routine iron prophylaxis during pregnancy in Maputo, Mozambique (PROFEG): rationale, design, and success. MATERNAL & CHILD NUTRITION 2015; 11:146-63. [PMID: 23020829 PMCID: PMC6860233 DOI: 10.1111/mcn.12006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The effects of prophylactic iron during pregnancy on maternal and child health in developing settings with endemic malaria and high prevalence of HIV remain unclear. This paper describes the rationale, implementation and success of a pragmatic randomised controlled trial comparing routine iron supplementation vs. screening and treatment for anaemia during pregnancy. The setting was two health centres in Maputo, Mozambique. Pregnant women (≥ 12-week gestation; ≥ 18 years old; and not with a high-risk pregnancy, n=4326) were recruited. The main outcomes are preterm delivery and low birthweight. The women were randomly assigned to one of two iron administration policies: a routine iron group (n=2184) received 60 mg of ferrous sulphate plus 400 μg of folic acid daily while a selective iron group (n=2142) had screening and treatment for anaemia and a daily intake of 1 mg of folic acid. The recruitment, follow-up, and collection of follow-up data were successful; both groups were similar to each other in all the trial stages. Collection of delivery data was challenging and data on about 40% of births is missing. These are currently being traced through different hospitals and health centres. The compliance of the study personnel and the women with regard to regular measurement of haemoglobin and intake of the iron and folic acid tablets was high and similar in both trial arms. Taking into account the various constraints encountered, the stages of the present trial prior to delivery were carried out well.
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Affiliation(s)
- Bright I. Nwaru
- School of Health SciencesUniversity of TampereTampereFinland
| | - Saara Parkkali
- Health Services and Policy ResearchNational Institute for Health and WelfareHelsinkiFinland
| | - Fatima Abacassamo
- Department of Community HealthEduardo Mondlane UniversityMaputoMozambique
| | - Graca Salomé
- Department of Biochemistry, Biology, Genetics and Molecular BiologyEduardo Mondlane UniversityMaputoMozambique
| | - Baltazar Chilundo
- Department of Community HealthEduardo Mondlane UniversityMaputoMozambique
| | - Orvalho Augusto
- Department of Community HealthEduardo Mondlane UniversityMaputoMozambique
| | - Julie Cliff
- Department of Community HealthEduardo Mondlane UniversityMaputoMozambique
| | | | - Elena Regushevskaya
- Health Services and Policy ResearchNational Institute for Health and WelfareHelsinkiFinland
| | - Minna Nikula
- Health Services and Policy ResearchNational Institute for Health and WelfareHelsinkiFinland
| | - Elina Hemminki
- Health Services and Policy ResearchNational Institute for Health and WelfareHelsinkiFinland
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Filteau S, PrayGod G, Kasonka L, Woodd S, Rehman AM, Chisenga M, Siame J, Koethe JR, Changalucha J, Michael D, Kidola J, Manno D, Larke N, Yilma D, Heimburger DC, Friis H, Kelly P. Effects on mortality of a nutritional intervention for malnourished HIV-infected adults referred for antiretroviral therapy: a randomised controlled trial. BMC Med 2015; 13:17. [PMID: 25630368 PMCID: PMC4308881 DOI: 10.1186/s12916-014-0253-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 12/10/2014] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Malnourished HIV-infected African adults are at high risk of early mortality after starting antiretroviral therapy (ART). We hypothesized that short-course, high-dose vitamin and mineral supplementation in lipid nutritional supplements would decrease mortality. METHODS The study was an individually-randomised phase III trial conducted in ART clinics in Mwanza, Tanzania, and Lusaka, Zambia. Participants were 1,815 ART-naïve non-pregnant adults with body mass index (BMI) <18.5 kg/m² who were referred for ART based on CD4 count <350 cells/μL or WHO stage 3 or 4 disease. The intervention was a lipid-based nutritional supplement either without (LNS) or with additional vitamins and minerals (LNS-VM), beginning prior to ART initiation; supplement amounts were 30 g/day (150 kcal) from recruitment until 2 weeks after starting ART and 250 g/day (1,400 kcal) from weeks 2 to 6 after starting ART. The primary outcome was mortality between recruitment and 12 weeks of ART. Secondary outcomes were serious adverse events (SAEs) and abnormal electrolytes throughout, and BMI and CD4 count at 12 weeks ART. RESULTS Follow-up for the primary outcome was 91%. Median adherence was 66%. There were 181 deaths in the LNS group (83.7/100 person-years) and 184 (82.6/100 person-years) in the LNS-VM group (rate ratio (RR), 0.99; 95% CI, 0.80-1.21; P = 0.89). The intervention did not affect SAEs or BMI, but decreased the incidence of low serum phosphate (RR, 0.73; 95% CI, 0.55-0.97; P = 0.03) and increased the incidence of high serum potassium (RR, 1.60; 95% CI, 1.19-2.15; P = 0.002) and phosphate (RR, 1.23; 95% CI, 1.10-1.37; P <0.001). Mean CD4 count at 12 weeks post-ART was 25 cells/μL (95% CI, 4-46) higher in the LNS-VM compared to the LNS arm (P = 0.02). CONCLUSIONS High-dose vitamin and mineral supplementation in LNS, compared to LNS alone, did not decrease mortality or clinical SAEs in malnourished African adults initiating ART, but improved CD4 count. The higher frequency of elevated serum potassium and phosphate levels suggests high-level electrolyte supplementation for all patients is inadvisable but the addition of micronutrient supplements to ART may provide clinical benefits in these patients. TRIAL REGISTRATION PACTR201106000300631, registered on 1st June 2011.
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Affiliation(s)
| | - Suzanne Filteau
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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Frosch AEP, Ondigo BN, Ayodo GA, Vulule JM, John CC, Cusick SE. Decline in childhood iron deficiency after interruption of malaria transmission in highland Kenya. Am J Clin Nutr 2014; 100:968-73. [PMID: 25080460 PMCID: PMC4135504 DOI: 10.3945/ajcn.114.087114] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Achieving optimal iron status in children in malaria-endemic areas may increase the risk of malaria. Malaria itself may contribute to iron deficiency, but the impact of an interruption in malaria transmission on the prevalence of iron deficiency is unknown. OBJECTIVES We aimed to determine whether 1) iron status improved in children living in 2 Kenyan villages with a documented cessation in malaria transmission and 2) changes in iron status correlated with changes in hemoglobin. DESIGN We measured iron [hemoglobin, ferritin, soluble transferrin receptor (sTfR)] and inflammatory [C-reactive protein (CRP)] markers in paired plasma samples from 190 children aged 4-59 mo at the beginning (May 2007) and end (July 2008) of a documented 12-mo period of interruption in malaria transmission in 2 highland areas in Kenya with unstable malaria transmission and ongoing malaria surveillance. RESULTS Between May 2007 and July 2008, mean (±SD) hemoglobin increased from 10.8 ± 1.6 to 11.6 ± 1.6 g/dL. Median (25th, 75th percentile) ferritin increased from 17.0 (9.7, 25.6) to 22.6 (13.4, 34.7) μg/L (P < 0.001), whereas median sTfR decreased from 32.4 (26.3, 43.2) to 27.7 (22.1, 36.0) nmol/L (P < 0.001). Median CRP was low (<1 mg/L in both years) and did not change significantly. Iron deficiency prevalence (ferritin <12 μg/L, or <30 μg/L if CRP ≥10 mg/L) decreased from 35.9% (95% CI: 28.9%, 43.0%) to 24.9% (18.5%, 31.2%) (P = 0.005). The prevalence of iron deficiency with anemia (hemoglobin <11.0 g/dL) declined from 27.2% (20.7%, 33.8%) to 12.2% (7.4%, 17.1%) (P < 0.001). Improvement in iron status correlated with an increase in hemoglobin and was greater than explained by physiologic changes expected with age. CONCLUSIONS In this area of unstable malaria transmission, the prevalence of iron deficiency in children decreased significantly after the interruption of malaria transmission and was correlated with an increase in hemoglobin. These findings suggest that malaria elimination strategies themselves may be an effective way to address iron deficiency in malaria-endemic areas.
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Affiliation(s)
- Anne E P Frosch
- From the Division of Global Pediatrics, University of Minnesota, Minneapolis, MN (AEPF, CCJ, and SEC); the Department of Biomedical Science and Technology, Maseno University, Maseno, Kenya (BNO); and the Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya (BNO, GAA, JMV, and CCJ)
| | - Bartholomew N Ondigo
- From the Division of Global Pediatrics, University of Minnesota, Minneapolis, MN (AEPF, CCJ, and SEC); the Department of Biomedical Science and Technology, Maseno University, Maseno, Kenya (BNO); and the Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya (BNO, GAA, JMV, and CCJ)
| | - George A Ayodo
- From the Division of Global Pediatrics, University of Minnesota, Minneapolis, MN (AEPF, CCJ, and SEC); the Department of Biomedical Science and Technology, Maseno University, Maseno, Kenya (BNO); and the Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya (BNO, GAA, JMV, and CCJ)
| | - John M Vulule
- From the Division of Global Pediatrics, University of Minnesota, Minneapolis, MN (AEPF, CCJ, and SEC); the Department of Biomedical Science and Technology, Maseno University, Maseno, Kenya (BNO); and the Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya (BNO, GAA, JMV, and CCJ)
| | - Chandy C John
- From the Division of Global Pediatrics, University of Minnesota, Minneapolis, MN (AEPF, CCJ, and SEC); the Department of Biomedical Science and Technology, Maseno University, Maseno, Kenya (BNO); and the Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya (BNO, GAA, JMV, and CCJ)
| | - Sarah E Cusick
- From the Division of Global Pediatrics, University of Minnesota, Minneapolis, MN (AEPF, CCJ, and SEC); the Department of Biomedical Science and Technology, Maseno University, Maseno, Kenya (BNO); and the Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya (BNO, GAA, JMV, and CCJ)
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Adherence in a pragmatic randomized controlled trial on prophylactic iron supplementation during pregnancy in Maputo, Mozambique. Public Health Nutr 2014; 18:1127-34. [PMID: 24999785 DOI: 10.1017/s1368980014001359] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Assessing the level of adherence and its determinants is important in appraising the overall effectiveness of trials. The present study aimed to evaluate the extent of adherence and its determinants in a pragmatic randomized controlled trial of Fe prophylaxis during pregnancy in Maputo, Mozambique. DESIGN A pragmatic randomized controlled trial. SETTING Two health centres (1° de Maio and Machava) in Maputo, Mozambique. SUBJECTS Pregnant women (≥12 weeks' gestation, ≥18 years old, non-high-risk pregnancy; n 4326) attending prenatal care consultations at two health centres were randomized to receive routine Fe (n 2184; 60 mg ferrous sulfate plus 400 μg folic acid daily throughout pregnancy) or selective Fe (n 2142; screening and treatment for anaemia and daily intake of 1 mg folic acid). RESULTS The level of adherence was 79% for having two or more visits, 53% for adequate prenatal care and 67% for complete intake of Fe/folic acid tablets during the trial. The correlation between the adherence measures ranged between 0·151 and 0·739. Adherence did not differ by trial arm, but there were centre differences in adequate prenatal visits and intake of tablets. Older women (>20 years) and those with a history of abortion were more likely to achieve greater adherence, whereas an increased number of previous births decreased the likelihood of adherence. HIV positivity decreased the likelihood of adherence in one trial centre and increased it in the other. CONCLUSIONS The variation in adherence by trial centre, women's characteristics and outcome measures suggests that adherence in trials fully depends on participants' behaviour and can be increased by paying attention to contextual factors.
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Dawson DR, Branch-Mays G, Gonzalez OA, Ebersole JL. Dietary modulation of the inflammatory cascade. Periodontol 2000 2013; 64:161-97. [DOI: 10.1111/j.1600-0757.2012.00458.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Schümann K, Solomons NW. Can iron supplementation be reconciled with benefits and risks in areas hyperendemic for malaria? Food Nutr Bull 2013; 34:349-56. [PMID: 24167915 DOI: 10.1177/156482651303400307] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Malaria is associated with about a million fatalities annually, largely among young children in zones of intense malarial transmission. The last thing needed would be measures that might increase the severity of clinical malaria. Thus, the finding in a field trial on Pemba Island, Tanzania, that routine oral iron supplementation produced adverse effects in iron-sufficient subjects had a ripple effect throughout the international public health community; it has effectively paralyzed efforts to redress iron-deficiency anemia in malaria-endemic regions. From a Hippocratic perspective, we consider the de facto moratorium on oral supplementation in such circumstance as a prudent interim measure. Public health programs to combat iron-deficiency anemia cannot be denied indefinitely to malaria-endemic populations, but the universal campaigns of iron provision cannot simply resume in the manner of the past. Contemporary biological and epidemiological understanding of the coevolution of humans and their pathogens should be able to provide guidance within the context of the essential and harmful aspects of iron. From these evolutionary standpoints, we identify a series of unresolved dilemmas. Toward a way forward, we highlight the pros and cons, as well as possible directions toward short-term strengthening, within three domains: tailored oral iron compounds, iron administration targeted only to iron-deficient individuals through screening, and prudent use of antimalarial prophylaxis. Although the tension between the essentiality of iron for humans and its role in pathogen virulence looms through every consideration, this recognition is a starting point toward the weighing of appropriate options balancing benefits and safety.
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Affiliation(s)
- Klaus Schümann
- Research Center for Nutrition and Food Science (ZIEL), Technische Universität München, Am Forum 5, D-85350 Freising-Weihenstephan, Germany.
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Schümann K, Solomons NW, Orozco M, Romero-Abal ME, Weiss G. Differences in Circulating Non-Transferrin-Bound Iron after Oral Administration of Ferrous Sulfate, Sodium Iron EDTA, or Iron Polymaltose in Women with Marginal Iron Stores. Food Nutr Bull 2013; 34:185-93. [DOI: 10.1177/156482651303400207] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The adverse interactions between iron supplements and malaria have driven the assessment of new therapeutic options for anemia prophylaxis in areas holoendemic for falciparum malaria. Objective To determine the responses of circulating non-transferrin-bound iron (NTBI) and plasma iron to three different oral iron compounds—ferrous sulfate, sodium iron ethylenediaminetetraacetate (NaFeEDTA), and iron polymaltose (IPM)—in women with marginal iron stores. Methods Serum samples from 10 Guatemalan women with marginal iron stores were collected every 90 minutes over a period of 270 minutes, after the individually randomized administration of 100 mg of iron from each of the three studied iron compounds or water alone. Serum iron concentration was quantified by the ferrozine method, and circulating NTBI concentration was determined with a fluorometric competitive binding assay. Kinetic responses and maximal cumulative changes in serum concentrations of iron and NTBI were compared between the four treatments. Comparison was made with data from the same protocol in iron-adequate men. Results The serum iron and NTBI responses to ferrous sulfate were significantly greater than those to water and the other two iron compounds. Serum iron responses to IPM did not differ from those to water alone. Conclusions The administration of the two “slow-release” iron compounds, NaFeEDTA and IPM, resulted in a highly significant suppression of the appearance of NTBI in the circulation in the postsupplement period. These two bioavailable forms of iron supplement could represent a safe option for supplementation in malarial areas. The slope of the iron—NTBI relationship is steeper in men than in women.
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Parkkali S, Abacassamo F, Nwaru BI, Salomé G, Augusto O, Regushevskaya E, Dgedge M, Sousa C, Cliff J, Chilundo B, Hemminki E. Comparison of routine prenatal iron prophylaxis and screening and treatment for anaemia: pregnancy results and preliminary birth results from a pragmatic randomised controlled trial (PROFEG) in Maputo, Mozambique. BMJ Open 2013; 3:bmjopen-2012-001948. [PMID: 23396557 PMCID: PMC3585968 DOI: 10.1136/bmjopen-2012-001948] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To present the pregnancy results and interim birth results of a pragmatic randomised controlled trial comparing routine iron prophylaxis with screening and treatment for anaemia during pregnancy in a setting of endemic malaria and HIV. DESIGN A pragmatic randomised controlled trial. SETTING Two health centres (1° de Maio and Machava) in Maputo, Mozambique, a setting of endemic malaria and high prevalence of HIV. PARTICIPANTS Pregnant women (≥18-year-olds; non-high-risk pregnancy, n=4326) attending prenatal care consultation at the two health centres were recruited to the trial. INTERVENTIONS The women were randomly allocated to either Routine iron (n=2184; 60 mg ferrous sulfate plus 400 μg of folic acid daily throughout pregnancy) or Selective iron (n=2142; screening and treatment for anaemia and daily intake of 1 mg of folic acid). OUTCOME MEASURES The primary outcomes were preterm delivery (delivery <37 weeks of gestation) and low birth weight (<2500 g). The secondary outcomes were symptoms suggestive of malaria and self-reported malaria during pregnancy; birth length; caesarean section; maternal and child health status after delivery. RESULTS The number of follow-up visits was similar in the two groups. Between the first and fifth visits, the two groups were similar regarding the occurrence of fever, headache, cold/chills, nausea/vomiting and body aches. There was a suggestion of increased incidence of self-reported malaria during pregnancy (OR 1.37, 95% CI 0.98 to1.92) in the Routine iron group. Birth data were available for 1109 (51%) in the Routine iron group and for 1149 (54%) in the Selective iron group. The birth outcomes were relatively similar in the two groups. However, there was a suggestion (statistically non-significant) of poorer outcomes in the Routine iron group with regard to long hospital stay after birth (relative risk (RR) 1.43, 95% CI 0.97 to 1.26; risk difference (RD) 0.02, 95% CI -0.00 to 0.03) and unavailability of delivery data (RR 1.06, 95% CI 1.00 to 1.13; RD 0.03, 95% CI -0.01 to 0.07). CONCLUSIONS These interim results suggest that routine iron prophylaxis during pregnancy did not confer advantage over screening and treatment for anaemia regarding maternal and child health. Complete data on birth outcomes are being collected for firmer conclusions. TRIAL REGISTRATION The trial is registered at ClinicalTrials.gov, number NCT00488579 (June 2007). The first women were randomised to the trial proper April 2007-March 2008. The pilot was November 2006-March 2008. The 3-month lag was due to technical difficulties in completing trial registration.
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Affiliation(s)
- Saara Parkkali
- Health Services and Policy Research, National Institute for Health and Welfare, Helsinki, Finland
| | - Fatima Abacassamo
- Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
| | | | - Graca Salomé
- Department of Physiological Sciences, Eduardo Mondlane University, Maputo, Mozambique
| | - Orvalho Augusto
- Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
| | - Elena Regushevskaya
- Health Services and Policy Research, National Institute for Health and Welfare, Helsinki, Finland
| | | | - Cesar Sousa
- Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
| | - Julie Cliff
- Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
| | - Baltazar Chilundo
- Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
| | - Elina Hemminki
- Health Services and Policy Research, National Institute for Health and Welfare, Helsinki, Finland
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Zhao H, Konishi A, Fujita Y, Yagi M, Ohata K, Aoshi T, Itagaki S, Sato S, Narita H, Abdelgelil N, Inoue M, Culleton R, Kaneko O, Nakagawa A, Horii T, Akira S, Ishii K, Coban C. Lipocalin 2 Bolsters Innate and Adaptive Immune Responses to Blood-Stage Malaria Infection by Reinforcing Host Iron Metabolism. Cell Host Microbe 2012; 12:705-16. [DOI: 10.1016/j.chom.2012.10.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 09/03/2012] [Accepted: 10/09/2012] [Indexed: 10/27/2022]
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Abstract
The resurgence in interest and concern regarding the potentially malign interactions between iron administration and malaria infections, especially in young children and pregnant women, has generated a research agenda that is both broad and deep. This paper highlights some of the key questions under 5 headings: basic science; clinical science and epidemiology; technological developments; country level planning; and global policy. At a time of unparalleled progress in basic science, which is illuminating the mechanisms by which iron interacts with infectious organisms, it is concluded that there are good medium-term prospects for achieving policy breakthroughs based on a secure foundation of disease-nutrient interactions. However, it is also stressed that there is much that can be done in the interim, especially in relation to health systems and implementation research that can empower systems to integrate iron interventions with programs for malaria prevention, surveillance, and treatment.
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Affiliation(s)
- Andrew M Prentice
- MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, London, UK.
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Schümann K, Solomons NW, Romero-Abal ME, Orozco M, Weiss G, Marx J. Oral Administration of Ferrous Sulfate, but not of Iron Polymaltose or Sodium Iron Ethylenediaminetetraacetic Acid (NaFeEDTA), Results in a Substantial Increase of Non-Transferrin-Bound Iron in Healthy Iron-Adequate Men. Food Nutr Bull 2012; 33:128-36. [DOI: 10.1177/156482651203300206] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Oral iron supplementation with ferrous sulfate (FeSO4) at dosage levels suggested by the international guidelines poses a safety hazard to young children with malaria. Exposure to loosely bound iron in the circulation has been advanced as a potential factor. Objective To evaluate the kinetics of circulating concentrations of plasma iron and non-transferrin-bound iron (NTBI) in response to oral iron administration in healthy adults. Methods Plasma samples were collected at 90-minute intervals over a period of 270 minutes from 10 healthy Guatemalan men after oral administration of water or 100 mg of iron from each of three iron compounds: FeSO4, sodium iron ethylenediaminetetraacetic acid (NaFeEDTA), and iron polymaltose. The four tests were administered in an individually randomized sequence. Serum iron concentration was measured spectrophotometrically by the ferrozine method, and NTBI concentration was measured by a fluorometric competitive binding assay. The kinetic response and the maximal and cumulative changes in circulating concentrations of the biomarkers of interest were compared. Results Serum iron and NTBI responses to oral administration of FeSO4 were significantly greater than responses to plain water or the other two iron compounds. NTBI concentrations after NaFeEDTA or iron polymaltose ingestion were not different from those determined after water intake. Conclusions Administration of two iron compounds of proven bioavailability, but with complex absorption characteristics, is associated with a negligible NTBI response, potentially mitigating the safety concerns associated with iron supplementation in malarial areas.
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Scientific Opinion on the welfare of cattle kept for beef production and the welfare in intensive calf farming systems. EFSA J 2012; 10:2669. [PMID: 32313568 PMCID: PMC7163673 DOI: 10.2903/j.efsa.2012.2669] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Information given in previous Opinions "Welfare of cattle kept for beef production" (SCAHAW, 2001) and "The risks of poor welfare in intensive calf farming systems" (EFSA, 2006) is updated and recent scientific evidence on the topics reviewed. Risks of poor welfare are identified using a structured analysis, and issues not identified in the SCAHAW (2001) beef Opinion, especially effects of housing and management on enteric and respiratory diseases are reviewed. The Opinion covers all systems of beef production, although the welfare of suckler cows or breeding bulls is not considered. The Chapter on beef cattle presents new evidence and recommendations in relation to heat and cold stress, mutilations and pain management, digestive disorders linked to high concentrate feeds and respiratory disorders linked to overstocking, inadequate ventilation, mixing of animals and failure of early diagnosis and treatment. Major welfare problems in cattle kept for beef production, as identified by risk assessment, were respiratory diseases linked to overstocking, inadequate ventilation, mixing of animals and failure of early diagnosis and treatment, digestive disorders linked to intensive concentrate feeding, lack of physically effective fibre in the diet, and behavioural disorders linked to inadequate floor space, and co-mingling in the feedlot. Major hazards for white veal calves were considered to be iron-deficiency anaemia, a direct consequence of dietary iron restriction, enteric diseases linked to high intakes of liquid feed and inadequate intake of physically effective fibre, discomfort and behavioural disorders linked to inadequate floors and floor space.
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Abstract
Anaemia affects a quarter of the global population, including 293 million (47%) children younger than 5 years and 468 million (30%) non-pregnant women. In addition to anaemia's adverse health consequences, the economic effect of anaemia on human capital results in the loss of billions of dollars annually. In this paper, we review the epidemiology, clinical assessment, pathophysiology, and consequences of anaemia in low-income and middle-income countries. Our analysis shows that anaemia is disproportionately concentrated in low socioeconomic groups, and that maternal anaemia is strongly associated with child anaemia. Anaemia has multifactorial causes involving complex interaction between nutrition, infectious diseases, and other factors, and this complexity presents a challenge to effectively address the population determinants of anaemia. Reduction of knowledge gaps in research and policy and improvement of the implementation of effective population-level strategies will help to alleviate the anaemia burden in low-resource settings.
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Affiliation(s)
- Yarlini Balarajan
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA 02115-6096, USA
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Veenemans J, Milligan P, Prentice AM, Schouten LRA, Inja N, van der Heijden AC, de Boer LCC, Jansen EJS, Koopmans AE, Enthoven WTM, Kraaijenhagen RJ, Demir AY, Uges DRA, Mbugi EV, Savelkoul HFJ, Verhoef H. Effect of supplementation with zinc and other micronutrients on malaria in Tanzanian children: a randomised trial. PLoS Med 2011; 8:e1001125. [PMID: 22131908 PMCID: PMC3222646 DOI: 10.1371/journal.pmed.1001125] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 10/14/2011] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND It is uncertain to what extent oral supplementation with zinc can reduce episodes of malaria in endemic areas. Protection may depend on other nutrients. We measured the effect of supplementation with zinc and other nutrients on malaria rates. METHODS AND FINDINGS In a 2×2 factorial trial, 612 rural Tanzanian children aged 6-60 months in an area with intense malaria transmission and with height-for-age z-score≤-1.5 SD were randomized to receive daily oral supplementation with either zinc alone (10 mg), multi-nutrients without zinc, multi-nutrients with zinc, or placebo. Intervention group was indicated by colour code, but neither participants, researchers, nor field staff knew who received what intervention. Those with Plasmodium infection at baseline were treated with artemether-lumefantrine. The primary outcome, an episode of malaria, was assessed among children reported sick at a primary care clinic, and pre-defined as current Plasmodium infection with an inflammatory response, shown by axillary temperature ≥37.5°C or whole blood C-reactive protein concentration ≥ 8 mg/L. Nutritional indicators were assessed at baseline and at 251 days (median; 95% reference range: 191-296 days). In the primary intention-to-treat analysis, we adjusted for pre-specified baseline factors, using Cox regression models that accounted for multiple episodes per child. 592 children completed the study. The primary analysis included 1,572 malaria episodes during 526 child-years of observation (median follow-up: 331 days). Malaria incidence in groups receiving zinc, multi-nutrients without zinc, multi-nutrients with zinc and placebo was 2.89/child-year, 2.95/child-year, 3.26/child-year, and 2.87/child-year, respectively. There was no evidence that multi-nutrients influenced the effect of zinc (or vice versa). Neither zinc nor multi-nutrients influenced malaria rates (marginal analysis; adjusted HR, 95% CI: 1.04, 0.93-1.18 and 1.10, 0.97-1.24 respectively). The prevalence of zinc deficiency (plasma zinc concentration <9.9 µmol/L) was high at baseline (67% overall; 60% in those without inflammation) and strongly reduced by zinc supplementation. CONCLUSIONS We found no evidence from this trial that zinc supplementation protected against malaria. TRIAL REGISTRATION ClinicalTrials.gov NCT00623857
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Affiliation(s)
- Jacobien Veenemans
- Wageningen University, Cell Biology and Immunology Group, Wageningen, The Netherlands
- Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda, The Netherlands
| | - Paul Milligan
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Andrew M. Prentice
- MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC Keneba, The Gambia
| | - Laura R. A. Schouten
- Wageningen University, Cell Biology and Immunology Group, Wageningen, The Netherlands
| | - Nienke Inja
- Wageningen University, Cell Biology and Immunology Group, Wageningen, The Netherlands
| | | | - Linsey C. C. de Boer
- Wageningen University, Cell Biology and Immunology Group, Wageningen, The Netherlands
| | - Esther J. S. Jansen
- Wageningen University, Cell Biology and Immunology Group, Wageningen, The Netherlands
| | - Anna E. Koopmans
- Wageningen University, Cell Biology and Immunology Group, Wageningen, The Netherlands
| | - Wendy T. M. Enthoven
- Wageningen University, Cell Biology and Immunology Group, Wageningen, The Netherlands
| | - Rob J. Kraaijenhagen
- Meander Medical Centre, Laboratory for Clinical Chemistry and Haematology, Amersfoort, The Netherlands
| | - Ayse Y. Demir
- Meander Medical Centre, Laboratory for Clinical Chemistry and Haematology, Amersfoort, The Netherlands
| | - Donald R. A. Uges
- University of Groningen, University Medical Center, Department of Pharmacy, Laboratory for Clinical and Forensic Toxicology and Drug Analysis, Groningen, The Netherlands
| | - Erasto V. Mbugi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Huub F. J. Savelkoul
- Wageningen University, Cell Biology and Immunology Group, Wageningen, The Netherlands
| | - Hans Verhoef
- Wageningen University, Cell Biology and Immunology Group, Wageningen, The Netherlands
- MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
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Moráis López A, Dalmau Serra J. Importancia de la ferropenia en el niño pequeño: repercusiones y prevención. An Pediatr (Barc) 2011; 74:415.e1-415.e10. [DOI: 10.1016/j.anpedi.2011.01.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 01/31/2011] [Indexed: 11/30/2022] Open
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Abstract
Adequate prenatal nutrition is essential for optimal brain development. There is a growing body of evidence from epidemiology linking exposure to nutritional deprivation and increased risk of schizophrenia. Based on studies from the Netherlands and China, those exposed to macronutrient deficiencies during famine have an increased risk of schizophrenia. With respect to micronutrients, we focus on 3 candidates where there is biological plausibility for a role in this disorder and at least 1 study of an association with schizophrenia. These nutrients include vitamin D, folic acid, and iron. While the current evidence is incomplete, we discuss the potential implications of these findings for the prevention of schizophrenia. We argue that schizophrenia can draw inspiration from public health interventions related to prenatal nutrition and other outcomes and speculate on relevant factors that bear on the nature, risks, impact, and logistics of various nutritional strategies that may be employed to prevent this disorder.
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Affiliation(s)
- John McGrath
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health,Wacol, Australia.
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Gara SN, Madaki AJK, Thacher TD. A comparison of iron and folate with folate alone in hematologic recovery of children treated for acute malaria. Am J Trop Med Hyg 2010; 83:843-7. [PMID: 20889877 DOI: 10.4269/ajtmh.2010.10-0170] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Concern has been raised that iron supplementation for treatment of acute malaria may worsen the severity of malaria. We compared the effect of iron and folate with folate alone on hematologic recovery in children treated for acute malaria. We randomized 82 children 6-60 months of age from Nigeria with smear-positive malaria and anemia (hematocrit < 33%) to receive iron (2 mg/kg/day) plus folate (5 mg/day) or folate alone in addition to antimalarial drugs. The mean ± SD hematocrit at baseline was 28.5% ± 2.9%. At four weeks, the mean hematocrit increased by 2.5% ± 1.6% in the iron plus folate group and by 1.4% ± 1.0% in the folate alone group (P = 0.001). Baseline hematocrit, iron supplementation, weight for height, and weekly meat intake were significant predictors of final hematocrit. The effect of iron was not significantly modified by baseline hematocrit, weekly meat intake, nutritional status, mother's education, sex, or age of the child. Iron supplementation improved hematologic recovery in children with malarial anemia.
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Affiliation(s)
- Samuel N Gara
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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50
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Abstract
Iron and its homeostasis are intimately tied to the inflammatory response. The adaptation to iron deficiency, which confers resistance to infection and improves the inflammatory condition, underlies what is probably the most obvious link: the anemia of inflammation or chronic disease. A large number of stimulatory inputs must be integrated to tightly control iron homeostasis during the inflammatory response. In order to understand the pathways of iron trafficking and how they are regulated, this article presents a brief overview of iron homeostasis. A major focus is on the regulation of the peptide hormone hepcidin during the inflammatory response and how its function contributes to the process of iron withdrawal. The review also summarizes new and emerging information about other iron metabolic regulators and effectors that contribute to the inflammatory response. Potential benefits of treatment to ameliorate the hypoferremic condition promoted by inflammation are also considered.
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Affiliation(s)
- Marianne Wessling-Resnick
- Department of Genetics and Complex Diseases, Harvard School of Public Health, Boston, Massachusetts 02115, USA.
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