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Newbolds SF, Wenger MJ. Assessing the pattern electroretinogram as a proxy measure for dopamine in the context of iron deficiency. Nutr Neurosci 2024; 27:1131-1142. [PMID: 38272898 DOI: 10.1080/1028415x.2024.2304943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
OBJECTIVES Animal studies have suggested that dietary iron deficiency (ID) negatively affects dopamine (DA) synthesis and re-uptake, which in turn negatively affects memory and cognition. This study was intended to assess whether the pattern electroretinogram (pattern ERG) could be used as an indirect measure of DA in college-age women with and without ID by determining the extent to which features of the ERG were sensitive to iron status and were related to other indirect measures of DA. METHODS The pattern ERG was measured in 21 iron deficient non-anemic (IDNA) and 21 iron sufficient (IS) women, who also performed a contrast detection and probabilistic selection task, both with concurrent electroencephalography (EEG). Both spontaneous and task-related blink rates were also measured. RESULTS The implicit times of the A- and B-waves were significantly longer for the IDNA than for the IS women. Both the amplitudes and implicit times of the A- and B-waves were significantly correlated with levels of serum ferritin (sFt). Only the amplitude of the A-wave was correlated with spontaneous blink rate. It was possible to accurately identify a woman's iron status solely on the basis of the implicit time of the B-wave. Finally, the implicit times of the ERG features mediated the relationship between iron levels and accuracy in the probabilistic selection task. CONCLUSIONS Results suggest the utility of the pattern ERG in testing the hypothesis that iron deficiency affects DA levels in humans and that this may be one of the mechanisms by which iron deficiency negatively affects cognition.
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Affiliation(s)
- Sarah F Newbolds
- Psychology and Cellular and Behavioral Neurobiology, The University of Oklahoma, Norman, OK, USA
| | - Michael J Wenger
- Psychology and Cellular and Behavioral Neurobiology, The University of Oklahoma, Norman, OK, USA
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Finkelstein JL, Cuthbert A, Weeks J, Venkatramanan S, Larvie DY, De-Regil LM, Garcia-Casal MN. Daily oral iron supplementation during pregnancy. Cochrane Database Syst Rev 2024; 8:CD004736. [PMID: 39145520 PMCID: PMC11325660 DOI: 10.1002/14651858.cd004736.pub6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
BACKGROUND Iron and folic acid supplementation have been recommended in pregnancy for anaemia prevention, and may improve other maternal, pregnancy, and infant outcomes. OBJECTIVES To examine the effects of daily oral iron supplementation during pregnancy, either alone or in combination with folic acid or with other vitamins and minerals, as an intervention in antenatal care. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Trials Registry on 18 January 2024 (including CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO's International Clinical Trials Registry Platform, conference proceedings), and searched reference lists of retrieved studies. SELECTION CRITERIA Randomised or quasi-randomised trials that evaluated the effects of oral supplementation with daily iron, iron + folic acid, or iron + other vitamins and minerals during pregnancy were included. DATA COLLECTION AND ANALYSIS Review authors independently assessed trial eligibility, ascertained trustworthiness based on pre-defined criteria, assessed risk of bias, extracted data, and conducted checks for accuracy. We used the GRADE approach to assess the certainty of the evidence for primary outcomes. We anticipated high heterogeneity amongst trials; we pooled trial results using a random-effects model (average treatment effect). MAIN RESULTS We included 57 trials involving 48,971 women. A total of 40 trials compared the effects of daily oral supplements with iron to placebo or no iron; eight trials evaluated the effects of iron + folic acid compared to placebo or no iron + folic acid. Iron supplementation compared to placebo or no iron Maternal outcomes: Iron supplementation during pregnancy may reduce maternal anaemia (4.0% versus 7.4%; risk ratio (RR) 0.30, 95% confidence interval (CI) 0.20 to 0.47; 14 trials, 13,543 women; low-certainty evidence) and iron deficiency at term (44.0% versus 66.0%; RR 0.51, 95% CI 0.38 to 0.68; 8 trials, 2873 women; low-certainty evidence), and probably reduces maternal iron-deficiency anaemia at term (5.0% versus 18.4%; RR 0.41, 95% CI 0.26 to 0.63; 7 trials, 2704 women; moderate-certainty evidence), compared to placebo or no iron supplementation. There is probably little to no difference in maternal death (2 versus 4 events, RR 0.57, 95% CI 0.12 to 2.69; 3 trials, 14,060 women; moderate-certainty evidence). The evidence is very uncertain for adverse effects (21.6% versus 18.0%; RR 1.29, 95% CI 0.83 to 2.02; 12 trials, 2423 women; very low-certainty evidence) and severe anaemia (Hb < 70 g/L) in the second/third trimester (< 1% versus 3.6%; RR 0.22, 95% CI 0.01 to 3.20; 8 trials, 1398 women; very low-certainty evidence). No trials reported clinical malaria or infection during pregnancy. Infant outcomes: Women taking iron supplements are probably less likely to have infants with low birthweight (5.2% versus 6.1%; RR 0.84, 95% CI 0.72 to 0.99; 12 trials, 18,290 infants; moderate-certainty evidence), compared to placebo or no iron supplementation. However, the evidence is very uncertain for infant birthweight (MD 24.9 g, 95% CI -125.81 to 175.60; 16 trials, 18,554 infants; very low-certainty evidence). There is probably little to no difference in preterm birth (7.6% versus 8.2%; RR 0.93, 95% CI 0.84 to 1.02; 11 trials, 18,827 infants; moderate-certainty evidence) and there may be little to no difference in neonatal death (1.4% versus 1.5%, RR 0.98, 95% CI 0.77 to 1.24; 4 trials, 17,243 infants; low-certainty evidence) or congenital anomalies, including neural tube defects (41 versus 48 events; RR 0.88, 95% CI 0.58 to 1.33; 4 trials, 14,377 infants; low-certainty evidence). Iron + folic supplementation compared to placebo or no iron + folic acid Maternal outcomes: Daily oral supplementation with iron + folic acid probably reduces maternal anaemia at term (12.1% versus 25.5%; RR 0.44, 95% CI 0.30 to 0.64; 4 trials, 1962 women; moderate-certainty evidence), and may reduce maternal iron deficiency at term (3.6% versus 15%; RR 0.24, 95% CI 0.06 to 0.99; 1 trial, 131 women; low-certainty evidence), compared to placebo or no iron + folic acid. The evidence is very uncertain about the effects of iron + folic acid on maternal iron-deficiency anaemia (10.8% versus 25%; RR 0.43, 95% CI 0.17 to 1.09; 1 trial, 131 women; very low-certainty evidence), or maternal deaths (no events; 1 trial; very low-certainty evidence). The evidence is uncertain for adverse effects (21.0% versus 0.0%; RR 44.32, 95% CI 2.77 to 709.09; 1 trial, 456 women; low-certainty evidence), and the evidence is very uncertain for severe anaemia in the second or third trimester (< 1% versus 5.6%; RR 0.12, 95% CI 0.02 to 0.63; 4 trials, 506 women; very low-certainty evidence), compared to placebo or no iron + folic acid. Infant outcomes: There may be little to no difference in infant low birthweight (33.4% versus 40.2%; RR 1.07, 95% CI 0.31 to 3.74; 2 trials, 1311 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. Infants born to women who received iron + folic acid during pregnancy probably had higher birthweight (MD 57.73 g, 95% CI 7.66 to 107.79; 2 trials, 1365 infants; moderate-certainty evidence), compared to placebo or no iron + folic acid. There may be little to no difference in other infant outcomes, including preterm birth (19.4% versus 19.2%; RR 1.55, 95% CI 0.40 to 6.00; 3 trials, 1497 infants; low-certainty evidence), neonatal death (3.4% versus 4.2%; RR 0.81, 95% CI 0.51 to 1.30; 1 trial, 1793 infants; low-certainty evidence), or congenital anomalies (1.7% versus 2.4; RR 0.70, 95% CI 0.35 to 1.40; 1 trial, 1652 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. A total of 19 trials were conducted in malaria-endemic countries, or in settings with some malaria risk. No studies reported maternal clinical malaria; one study reported data on placental malaria. AUTHORS' CONCLUSIONS Daily oral iron supplementation during pregnancy may reduce maternal anaemia and iron deficiency at term. For other maternal and infant outcomes, there was little to no difference between groups or the evidence was uncertain. Future research is needed to examine the effects of iron supplementation on other maternal and infant health outcomes, including infant iron status, growth, and development.
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Affiliation(s)
| | - Anna Cuthbert
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Jo Weeks
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | | | - Doreen Y Larvie
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Luz Maria De-Regil
- Multisectoral Action in Food Systems Unit, World Health Organization, Geneva, Switzerland
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Rosell-Díaz M, Santos-González E, Motger-Albertí A, Gallardo-Nuell L, Arnoriaga-Rodríguez M, Coll-Martínez C, Ramió-Torrentà L, Garre-Olmo J, Puig J, Ramos R, Mayneris-Perxachs J, Fernández-Real JM. Lower serum ferritin levels are associated with worse cognitive performance in aging. J Nutr Health Aging 2024; 28:100190. [PMID: 38368845 DOI: 10.1016/j.jnha.2024.100190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVES Iron is important for neurogenesis, synaptic development, and neurotransmitter synthesis. Serum ferritin (SF) is a reliable marker for assessing iron stores. Therefore, we evaluated the cognitive function associated with SF levels. We also assessed brain iron content using R2* Magnetic Resonance Imaging (MRI) and its association with SF levels. DESIGN Data from three cross-sectional observational studies were used. Aging Imageomics (n = 1030) was conducted on aged subjects. Health Imageomics (n = 971) and IR0NMET (n = 175) were conducted in middle-aged subjects. SETTING AND PARTICIPANTS Participants were enrolled at Dr. Josep Trueta University Hospital facilities. The three cohorts included a total of 2176 subjects (mean age, 52 years; 48% men). MEASUREMENTS SF levels were measured by standard laboratory methods. Total Digits Span (TDS), and Phonemic Verbal Fluency (PVF) were used to assess executive function. Language function was assessed by semantic verbal fluency (SVF), attention by the Symbol Digit Modalities Test, and memory by the Memory Binding Tests - Total Free Recall and Total Delayed Free Recall. MRI was used to assess the iron content of the brain by R2*. RESULTS In subjects aged 65 years or older, SF levels were associated with increased TDS (β = 0.003, p = 0.02), PVF (β = 0.004, p = 0.01), and SVF (β = 0.004, p = 0.002) scores. After stratification by sex, these findings were significant only in men, where SF was associated with increased TDS (β = 0.003, p = 0.01), PVF (β = 0.004, p = 0.03), and SVF (β = 0.004, p = 0.009) scores. In middle-aged subjects, SF was also associated with increased SVF scores (β = 0.005, p = 0.011). Lastly, in men, SF levels were negatively associated with R2*, a surrogate marker of brain iron content, in both the left frontal inferior opercular area (r = -0.41, p = 0.005) and the right frontal inferior opercular area (r = -0.44, p = 0.002). CONCLUSIONS SF is significantly and positively associated with cognition. In older people with low SF levels, iron supplementation may be a promising therapy to improve cognition.
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Affiliation(s)
- Marisel Rosell-Díaz
- Department of Diabetes, Endocrinology and Nutrition, Dr. Josep Trueta University Hospital, Girona, Spain; Nutrition, Eumetabolism and Health Group, Girona Biomedical Research Institute (IDIBGI-CERCA), Girona, Spain; CIBER Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, Spain
| | - Elena Santos-González
- Department of Diabetes, Endocrinology and Nutrition, Dr. Josep Trueta University Hospital, Girona, Spain; Nutrition, Eumetabolism and Health Group, Girona Biomedical Research Institute (IDIBGI-CERCA), Girona, Spain; CIBER Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, Spain
| | - Anna Motger-Albertí
- Department of Diabetes, Endocrinology and Nutrition, Dr. Josep Trueta University Hospital, Girona, Spain; Nutrition, Eumetabolism and Health Group, Girona Biomedical Research Institute (IDIBGI-CERCA), Girona, Spain; CIBER Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, Spain
| | - Laura Gallardo-Nuell
- Department of Diabetes, Endocrinology and Nutrition, Dr. Josep Trueta University Hospital, Girona, Spain; Nutrition, Eumetabolism and Health Group, Girona Biomedical Research Institute (IDIBGI-CERCA), Girona, Spain; CIBER Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, Spain
| | - María Arnoriaga-Rodríguez
- Department of Diabetes, Endocrinology and Nutrition, Dr. Josep Trueta University Hospital, Girona, Spain; Nutrition, Eumetabolism and Health Group, Girona Biomedical Research Institute (IDIBGI-CERCA), Girona, Spain; CIBER Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, Spain
| | - Clàudia Coll-Martínez
- Neuroimmunology and Multiple Sclerosis Unit, Department of Neurology, Dr. Josep Trueta Hospital, Neurodegeneration and Neuroinflammation Research Group, (IDIBGI-CERCA), Girona, Spain; Research Group on Health, Gender, and Aging, Girona Biomedical Research Institute (IDIBGI-CERCA) and University of Girona, Girona, Spain
| | - Lluís Ramió-Torrentà
- Neuroimmunology and Multiple Sclerosis Unit, Department of Neurology, Dr. Josep Trueta Hospital, Neurodegeneration and Neuroinflammation Research Group, (IDIBGI-CERCA), Girona, Spain; Department of Medical Sciences, School of Medicine, University of Girona, Girona, Spain
| | - Josep Garre-Olmo
- Research Group on Health, Gender, and Aging, Girona Biomedical Research Institute (IDIBGI-CERCA) and University of Girona, Girona, Spain; Serra-Hunter Professor, Department of Nursing, University of Girona, Spain
| | - Josep Puig
- Department of Medical Sciences, School of Medicine, University of Girona, Girona, Spain; Radiology Department CDI, Hospital Clinic of Barcelona, Barcelona, Spain; Medical Imaging, Girona Biomedical Research Institute (IDIBGI-CERCA), Girona, Spain
| | - Rafael Ramos
- Department of Medical Sciences, School of Medicine, University of Girona, Girona, Spain; Vascular Health Research Group of Girona (ISV-Girona), Jordi Gol Institute for Primary Care Research (Institut Universitari per a la Recerca en Atenció Primària Jordi Gol I Gorina -IDIAPJGol), Red de Investigación en Cronicidad, Atención Primaria y Promoción de la Salud-RICAPPS- ISCIII, Spain; Girona Biomedical Research Institute (IDIBGI-CERCA), Dr. Josep Trueta University Hospital, Catalonia, Spain
| | - Jordi Mayneris-Perxachs
- Department of Diabetes, Endocrinology and Nutrition, Dr. Josep Trueta University Hospital, Girona, Spain; Nutrition, Eumetabolism and Health Group, Girona Biomedical Research Institute (IDIBGI-CERCA), Girona, Spain; CIBER Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, Spain.
| | - José Manuel Fernández-Real
- Department of Diabetes, Endocrinology and Nutrition, Dr. Josep Trueta University Hospital, Girona, Spain; Nutrition, Eumetabolism and Health Group, Girona Biomedical Research Institute (IDIBGI-CERCA), Girona, Spain; CIBER Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, Spain; Department of Medical Sciences, School of Medicine, University of Girona, Girona, Spain; Girona Biomedical Research Institute (IDIBGI-CERCA), Dr. Josep Trueta University Hospital, Catalonia, Spain.
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Barnett AL, Wenger MJ, Yunus FM, Jalal C, DellaValle DM. The Effect of Iron-Fortified Lentils on Blood and Cognitive Status among Adolescent Girls in Bangladesh. Nutrients 2023; 15:5001. [PMID: 38068859 PMCID: PMC10707902 DOI: 10.3390/nu15235001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Iron deficiency is highly prevalent in South Asia, especially among women and children in Bangladesh. Declines in cognitive performance are among the many functional consequences of iron deficiency. OBJECTIVE We tested the hypothesis that, over the course of a 4-month iron fortification trial, cognitive performance would improve, and that improvement would be related to improvements in iron status. METHODS Participants included 359 adolescent girls attending Bangladesh Rural Advancement Committee (BRAC) clubs as a subsample of a larger double-blind, cluster-randomized community trial in which participants were assigned to one of three conditions: a condition in which no lentils were supplied (NL, n = 118, but which had the usual intake of lentils), a control (non-fortified) lentil condition (CL, n = 124), and an iron-fortified lentil condition (FL, n = 117). In the FL and CL conditions, approximately 200 g of cooked lentils were served five days per week for a total of 85 feeding days. In addition to biomarkers of iron status, five cognitive tasks were measured at baseline (BL) and endline (EL): simple reaction time task (SRT), go/no-go task (GNG), attentional network task (ANT), the Sternberg memory search Task (SMS), and a cued recognition task (CRT). RESULTS Cognitive performance at EL was significantly better for those in the FL relative to the CL and NL conditions, with this being true for at least one variable in each task, except for the GNG. In addition, there were consistent improvements in cognitive performance for those participants whose iron status improved. Although there were overall declines in iron status from BL to EL, the declines were smallest for those in the FL condition, and iron status was significantly better for those in FL condition at EL, relative to those in the CL and NL conditions. CONCLUSIONS the provision of iron-fortified lentils provided a protective effect on iron status in the context of declines in iron status and supported higher levels of cognitive performance for adolescent girls at-risk of developing iron deficiency.
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Affiliation(s)
- Amy L Barnett
- Psychology and Cellular and Behavioral Neurobiology, The University of Oklahoma, Norman, OK 73019, USA
| | - Michael J Wenger
- Psychology and Cellular and Behavioral Neurobiology, The University of Oklahoma, Norman, OK 73019, USA
| | - Fakir M Yunus
- Pharmacy and Nutrition, Saskatoon, The University of Saskatchewan, SK S7N 5B3, Canada
- Psychology and Neuroscience, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | | | - Diane M DellaValle
- Health and Human Performance, King's College, Wilkes-Barre, PA 18711, USA
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Hannes F, Moon K, Moench Pfanner R. Optimizing health and nutrition status of migrant construction workers consuming multiple micronutrient fortified rice in Singapore. PLoS One 2023; 18:e0285708. [PMID: 37262034 DOI: 10.1371/journal.pone.0285708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 03/23/2023] [Indexed: 06/03/2023] Open
Abstract
INTRODUCTION A well-nourished workforce is instrumental in eradicating hunger, alleviating poverty, and spurring economic growth. A fifth of the total workforce in high-income countries are migrant workers. Despite the accessibility of nutritious foods in high-income countries, migrant workers often rely on nutrient-poor diets largely consisting of empty calories, which in turn leads to vitamin and mineral deficiency, also called hidden hunger, and resultant productivity loss. Here, we study the magnitude of hidden hunger in male migrant construction workers in Singapore and investigate the impact of consuming fortified rice for 6 consecutive months on the nutrition and health status of these workers. METHODS 140 male migrant workers aged 20-51 years of either Bangladeshi or Indian ethnicity from a single dormitory in Singapore volunteered to participate in the study. In total, 133 blood samples were taken at the start of the study and were used to assess vitamin B12, hemoglobin, ferritin, folate, and zinc levels; a sub-sample underwent for homocysteine testing. Anthropometric measurements and vital signs, such as blood pressure, were recorded before and after the intervention. RESULTS The results show that vitamin and mineral deficiency was present, especially folate (59% of workers deficient) and vitamin B12 (7% deficient, 31% marginally deficient). The consumption of fortified rice significantly improved the vitamin, iron and zinc level in the workers and significantly reduced the systolic blood pressure amongst the Bangladeshi migrant workers, specifically. CONCLUSION Our study demonstrates that fortified rice may have a positive impact on male migrant construction worker health and nutrition status at the workplace.
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Raz S, Koren A, Levin C. Associations between red blood cell indices and iron status and neurocognitive function in young adults: Evidence from memory and executive function tests and event-related potentials. Ann N Y Acad Sci 2022; 1517:300-313. [PMID: 35976740 PMCID: PMC9804398 DOI: 10.1111/nyas.14877] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Cognitive impairment has been associated with anemia and iron deficiency; however, brain electrophysiological studies correlating red blood cell (RBC) indices and iron status to cognition in adulthood are scarce. We aimed to assess neurocognitive function in young adults of the general population and its correlation with RBC indices and iron status. Neurocognitive function was investigated using scalp-recorded event-related potentials (ERPs) within the context of a task-switching paradigm. ERPs and test performance were also compared across groups of "high"/"low" RBC and iron indices. Working memory was examined using the digit span test, in which mean corpuscular hemoglobin (MCH), mean corpuscular volume (MCV), and ferritin were found to be significant predictors of test performance, with higher MCH/MCV/ferritin being associated with better test scores. In the switching task, MCH, MCV, and ferritin were found to be significant predictors of task performance, with higher MCH/MCV/ferritin levels associated with a lower percentage of errors. Electrophysiological results showed that MCH and MCV were significant predictors of ERPs amplitude, with lower MCH/MCV levels associated with greater amplitude, which may reflect compensatory processes. P1, N1, P2, and P3 were greater for the low MCH/MCV groups. This is the first evidence of association between levels of MCH/MCV and brain function while engaged in an executive function task; possibly reflecting brain iron availability.
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Affiliation(s)
- Sivan Raz
- Department of Behavioral Sciences, The Center for Psychobiological ResearchThe Max Stern Yezreel Valley CollegeJezreel ValleyIsrael,Department of PsychologyTel Hai CollegeTel HaiIsrael
| | - Ariel Koren
- Pediatric Hematology UnitEmek Medical CenterAfulaIsrael,The Ruth and Bruce Rappaport Faculty of Medicine, TechnionIsrael Institute of TechnologyHaifaIsrael
| | - Carina Levin
- Pediatric Hematology UnitEmek Medical CenterAfulaIsrael,The Ruth and Bruce Rappaport Faculty of Medicine, TechnionIsrael Institute of TechnologyHaifaIsrael
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7
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Kaur N, Agarwal A, Sabharwal M. Food fortification strategies to deliver nutrients for the management of iron deficiency anaemia. Curr Res Food Sci 2022; 5:2094-2107. [PMID: 36387591 PMCID: PMC9641006 DOI: 10.1016/j.crfs.2022.10.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 09/16/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
A rising trend in the global prevalence of anaemia is still prevailing. To combat micronutrient deficiencies, World Health Organisation/Food Agriculture Organisation (2006) guidelines recommended four chief strategies - supplementation, fortification, nutrition education and dietary diversity. Of the four strategies, food fortification has been considered as the most efficacious and economical approach. However, it is the directives themselves that highlight two major bottlenecks associated with conventional fortification - uniform dissemination of the fortifier in food vehicle that mostly include staple foods, and internal and external compliance evaluation of fortification regulations and standards by the producers. As a result, researchers envisaged a new strategy - Food-to-food fortification that complements conventional fortification. This strategy involves fortification of food vehicles with nutrient-rich food-based fortifiers. The major advantage of utilising food-based fortifiers is that they hold the potential of enhancing the bioavailability of the fortified food and providing additional nutrients and thus, resulting in dietary diversification. It also facilitates the utilisation of underutilised crops as food-based fortifiers. Underutilised crops have been recognised as potential beneficial food source accounting to their nutritional, ecological, and fiscal benefits. This review paper delves into the strengths and shortcomings of conventional iron fortification. It delineates the concept of food-to-food fortification, while precisely discussing about the best practices to be followed to address the possible challenges associated with this strategy. It also promotes the utilisation of underutilised iron rich foods to develop fortified foods and avert global food insecurity. Furthermore, it provides a summary of the studies conducted around the world to develop fortified foods using iron compounds and iron-rich foods, and to investigate their efficacy in managing iron deficiency anaemia.
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Affiliation(s)
- Naman Kaur
- Department of Food and Nutrition, Lady Irwin College, University of Delhi, Sikandra Road, New Delhi, 110001, India
| | - Aparna Agarwal
- Food Technology, Department of Food and Nutrition, Lady Irwin College, University of Delhi, Sikandra Road, New Delhi, 110001, India
| | - Manisha Sabharwal
- Department of Food and Nutrition, Lady Irwin College, University of Delhi, Sikandra Road, New Delhi, 110001, India
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Wenger MJ, Murray Kolb LE, Scott SP, Boy E, Haas JD. Modeling relationships between iron status, behavior, and brain electrophysiology: evidence from a randomized study involving a biofortified grain in Indian adolescents. BMC Public Health 2022; 22:1299. [PMID: 35794587 PMCID: PMC9260997 DOI: 10.1186/s12889-022-13612-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 06/08/2022] [Indexed: 11/10/2022] Open
Abstract
Background Iron deficiency (ID) and iron deficiency anemia (IDA) are highly-prevalent nutrient deficiencies and have been shown to have a range of negative effects on cognition and brain function. Human intervention studies including measures at three levels—blood, brain, and behavior—are rare and our objective was to model the relationships among measures at these three levels in school-going Indian adolescents. Methods Male and female adolescents in rural India were screened for ID/IDA. Subjects consumed 2 meals/day for 6 months; half were randomly assigned to consume meals made from a standard grain (pearl millet) and half consumed meals made from an iron biofortified pearl millet (BPM). Prior to and then at the conclusion of the feeding trial, they completed a set of cognitive tests with concurrent electroencephalography (EEG). Results Overall, serum ferritin (sFt) levels improved over the course of the study. Ten of 21 possible measures of cognition showed improvements from baseline (BL) to endline (EL) that were larger for those consuming BPM than for those consuming the comparison pearl millet (CPM). Critically, the best model for the relationship between change in iron status and change in cognition had change in brain measures as a mediating factor, with both change in serum ferritin as a primary predictor and change in hemoglobin as a moderator. Conclusions A dietary intervention involving a biofortified staple grain was shown to be efficacious in improving blood iron biomarkers, behavioral measures of cognition, and EEG measures of brain function. Modeling the relationships among these variables strongly suggests multiple mechanisms by which blood iron level affects brain function and cognition. Trial registration Registered at ClinicalTrials.gov, NCT02152150, 02 June 2014. Supplementary Information The online version contains supplementary material available at (10.1186/s12889-022-13612-z).
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Affiliation(s)
- Michael J Wenger
- Department of Psychology, Cellular and Behavioral Neurobiology, The University of Oklahoma, Norman, OK, USA. .,Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA.
| | | | - Samuel P Scott
- Poverty Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - Erick Boy
- HarvestPlus, International Food Policy Research Institute, Washington, DC, USA
| | - Jere D Haas
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
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Baxter JAB, Carducci B, Kamali M, Zlotkin SH, Bhutta ZA. Fortification of salt with iron and iodine versus fortification of salt with iodine alone for improving iron and iodine status. Cochrane Database Syst Rev 2022; 4:CD013463. [PMID: 35446435 PMCID: PMC9022669 DOI: 10.1002/14651858.cd013463.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Iron deficiency is an important micronutrient deficiency contributing to the global burden of disease, and particularly affects children, premenopausal women, and people in low-resource settings. Anaemia is a possible consequence of iron deficiency, although clinical and functional manifestations of anemia can occur without iron deficiency (e.g. from other nutritional deficiencies, inflammation, and parasitic infections). Direct nutritional interventions, such as large-scale food fortification, can improve micronutrient status, especially in vulnerable populations. Given the highly successful delivery of iodine through salt iodisation, fortifying salt with iodine and iron has been proposed as a method for preventing iron deficiency anaemia. Further investigation of the effect of double-fortified salt (i.e. with iron and iodine) on iron deficiency and related outcomes is warranted. OBJECTIVES: To assess the effect of double-fortified salt (DFS) compared to iodised salt (IS) on measures of iron and iodine status in all age groups. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, five other databases, and two trial registries up to April 2021. We also searched relevant websites, reference lists, and contacted the authors of included studies. SELECTION CRITERIA All prospective randomised controlled trials (RCTs), including cluster-randomised controlled trials (cRCTs), and controlled before-after (CBA) studies, comparing DFS with IS on measures of iron and iodine status were eligible, irrespective of language or publication status. Study reports published as abstracts were also eligible. DATA COLLECTION AND ANALYSIS Three review authors applied the study selection criteria, extracted data, and assessed risk of bias. Two review authors rated the certainty of the evidence using GRADE. When necessary, we contacted study authors for additional information. We assessed RCTs, cRCTs and CBA studies using the Cochrane RoB 1 tool and Cochrane Effective Practice and Organisation of Care (EPOC) tool across the following domains: random sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective reporting; and other potential sources of bias due to similar baseline characteristics, similar baseline outcome assessments, and declarations of conflicts of interest and funding sources. We also assessed cRCTs for recruitment bias, baseline imbalance, loss of clusters, incorrect analysis, and comparability with individually randomised studies. We assigned studies an overall risk of bias judgement (low risk, high risk, or unclear). MAIN RESULTS: We included 18 studies (7 RCTs, 7 cRCTs, 4 CBA studies), involving over 8800 individuals from five countries. One study did not contribute to analyses. All studies used IS as the comparator and measured and reported outcomes at study endpoint. With regards to risk of bias, five RCTs had unclear risk of bias, with some concerns in random sequence generation and allocation concealment, while we assessed two RCTs to have a high risk of bias overall, whereby high risk was noted in at least one or more domain(s). Of the seven cRCTs, we assessed six at high risk of bias overall, with one or more domain(s) judged as high risk and one cRCT had an unclear risk of bias with concerns around allocation and blinding. The four CBA studies had high or unclear risk of bias for most domains. The RCT evidence suggested that, compared to IS, DFS may slightly improve haemoglobin concentration (mean difference (MD) 0.43 g/dL, 95% confidence interval (CI) 0.23 to 0.63; 13 studies, 4564 participants; low-certainty evidence), but DFS may reduce urinary iodine concentration compared to IS (MD -96.86 μg/L, 95% CI -164.99 to -28.73; 7 studies, 1594 participants; low-certainty evidence), although both salts increased mean urinary iodine concentration above the cut-off deficiency. For CBA studies, we found DFS made no difference in haemoglobin concentration (MD 0.26 g/dL, 95% CI -0.10 to 0.63; 4 studies, 1397 participants) or urinary iodine concentration (MD -17.27 µg/L, 95% CI -49.27 to 14.73; 3 studies, 1127 participants). No studies measured blood pressure. For secondary outcomes reported in RCTs, DFS may result in little to no difference in ferritin concentration (MD -3.94 µg/L, 95% CI -20.65 to 12.77; 5 studies, 1419 participants; low-certainty evidence) or transferrin receptor concentration (MD -4.68 mg/L, 95% CI -11.67 to 2.31; 5 studies, 1256 participants; low-certainty evidence) compared to IS. However, DFS may reduce zinc protoporphyrin concentration (MD -27.26 µmol/mol, 95% CI -47.49 to -7.03; 3 studies, 921 participants; low-certainty evidence) and result in a slight increase in body iron stores (MD 1.77 mg/kg, 95% CI 0.79 to 2.74; 4 studies, 847 participants; low-certainty evidence). In terms of prevalence of anaemia, DFS may reduce the risk of anaemia by 21% (risk ratio (RR) 0.79, 95% CI 0.66 to 0.94; P = 0.007; 8 studies, 2593 participants; moderate-certainty evidence). Likewise, DFS may reduce the risk of iron deficiency anaemia by 65% (RR 0.35, 95% CI 0.24 to 0.52; 5 studies, 1209 participants; low-certainty evidence). Four studies measured salt intake at endline, although only one study reported this for both groups. Two studies reported prevalence of goitre, while one CBA study measured and reported serum iron concentration. One study reported adverse effects. No studies measured hepcidin concentration. AUTHORS' CONCLUSIONS Our findings suggest DFS may have a small positive impact on haemoglobin concentration and the prevalence of anaemia compared to IS, particularly when considering efficacy studies. Future research should prioritise studies that incorporate robust study designs and outcome measures (e.g. anaemia, iron status measures) to better understand the effect of DFS provision to a free-living population (non-research population), where there could be an added cost to purchase double-fortified salt. Adequately measuring salt intake, both at baseline and endline, and adjusting for inflammation will be important to understanding the true effect on measures of iron status.
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Affiliation(s)
- Jo-Anna B Baxter
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada
| | - Bianca Carducci
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Mahdis Kamali
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Offord Centre for Child Studies, Hamilton, Canada
| | - Stanley H Zlotkin
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
- Munk School of Global Affairs and Public Policy, University of Toronto, Toronto, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
- Centre of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
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Jadhav MH, Mannar MGV. Uptake of Encapsulated Ferrous Fumarate Double Fortified Salt in the Public Distribution System in India: A Value Chain Analysis. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:832-845. [PMID: 34933979 PMCID: PMC8691893 DOI: 10.9745/ghsp-d-20-00448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 09/07/2021] [Indexed: 06/14/2023]
Abstract
Food fortification is a powerful strategy to reach large populations with multiple micronutrients added to a single food vehicle. The impact depends on the sustained provision and utilization of adequately fortified food by a large population (mainly in low-income and food-insecure settings). We apply a value chain (VC) analysis framework to diagnose and address the barriers to the uptake of encapsulated ferrous fumarate double fortified salt (DFS) distributed through public-sector-led DFS interventions in India.We adapt the VC requirements framework proposed by Henson and Humphrey to identify and categorize barriers along the DFS VC as technological, market-related, and policy-related. We conducted a desk review of published and unpublished literature on DFS and information available in the public domain, semi-structured interviews with VC stakeholders from the private sector, program data from implementing organizations, and participation in multistakeholder consultations on DFS.Major supply-side barriers were under-developed private markets, inconsistent demand from public markets, unpredictable returns-on-investments, and inadequate business incentives to invest in DFS. The product's weak consumer orientation, uncreated consumer demand, low awareness of fortified foods, inadequate nutrition signaling were significant demand-side barriers. Technological barriers related to the requirement of high-grade salt for DFS production and residual organoleptic property of mild discoloration of food. Policy barriers related to inadequate and irregular financing for distributing subsidized DFS through the public distribution system; insufficient policy support for risk-sharing and managing costs associated with fortification; and a weak institutional environment for sustaining DFS interventions.Building an enabling institutional environment, demand creation through consumer awareness, strengthening institutional markets through public financing, managing cost and risks through public-private partnerships, and assuring quality during commercial scale-up are critical interventions necessary to ensure impact at scale.
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11
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Wenger MJ, DellaValle DM, Todd LE, Barnett AL, Haas JD. Limited Shared Variance among Measures of Cognitive Performance Used in Nutrition Research: The Need to Prioritize Construct Validity and Biological Mechanisms in Choice of Measures. Curr Dev Nutr 2021; 5:nzab070. [PMID: 34056512 PMCID: PMC8141094 DOI: 10.1093/cdn/nzab070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/13/2021] [Accepted: 04/20/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The literature on correlates of nutrition has seen an increase in studies focused on functional consequences at the levels of neural, perceptual, and cognitive functioning. A range of measurement methodologies have been used in these studies, and investigators and funding agencies have raised the questions of how and if these various methodologies are at all comparable. OBJECTIVE The aim was to determine the extent to which 3 different sets of cognitive measures provide comparable information across 2 subsamples that shared culture and language but differed in terms of socioeconomic status (SES) and academic preparation. METHODS A total of 216 participants were recruited at 2 US universities. Each participant completed 3 sets of cognitive measures: 1 custom-designed set based on well-understood laboratory measures of cognition [cognitive task battery (COGTASKS)] and 2 normed batteries [Cambridge Neuropsychological Test Automated Battery (CANTAB), Weschler Adult Intelligence Scale, fourth edition (WAIS-IV)] designed for assessing general cognitive function. RESULTS The 3 sets differed with respect to the extent to which SES and educational preparation affected the results, with COGTASKS showing no differences due to testing location and WAIS-IV showing substantial differences. There were, at best, weak correlations among tasks sharing the same name or claiming to measure the same construct. CONCLUSIONS Comparability of measures of cognition cannot be assumed, even if measures have the same name or claim to assess the same construct. In selecting and evaluating different measures, construct validity and underlying biological mechanisms need to be at least as important as population norms and the ability to connect with existing literatures.
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Affiliation(s)
- Michael J Wenger
- Department of Psychology, Cellular, and Behavioral Neurobiology, The University of Oklahoma, Norman, OK, USA
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Diane M DellaValle
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
- Nutrition Science, King's College, Wilkes-Barre, PA, USA
| | - Lauren E Todd
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Amy L Barnett
- Department of Psychology, Cellular, and Behavioral Neurobiology, The University of Oklahoma, Norman, OK, USA
| | - Jere D Haas
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
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12
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Hurrell RF. The Potential of Iodine and Iron Double-Fortified Salt Compared with Iron-Fortified Staple Foods to Increase Population Iron Status. J Nutr 2021; 151:47S-63S. [PMID: 33582784 PMCID: PMC7882360 DOI: 10.1093/jn/nxaa204] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/10/2020] [Accepted: 06/22/2020] [Indexed: 11/28/2022] Open
Abstract
The potential of double-fortified salt (DFS) to improve population iron status is compared with the potential of iron-fortified wheat flour, maize flour, rice grains, and milk products. The potential for a positive impact on iron status is based on reported efficacy studies, consumption patterns, the extent of industrialization, and whether there are remaining technical issues with the fortification technologies. Efficacy studies with DFS, and with iron-fortified wheat flour, maize flour, and rice, have all reported good potential to improve population iron status. Iron-fortified milk powder has shown good impact in young children. When these foods are industrially fortified in modern, automated facilities, with high-level quality control and assurance practices, high-quality raw materials, and a wide population coverage, all vehicles have good potential to improve iron status. Relative to other fortification vehicles, fortification practices with wheat flour are the most advanced and iron-fortified wheat flour has the highest potential for impact in the short- to medium-term in countries where wheat flour is consumed as a staple. Liquid milk has the least potential, mainly because an acceptable iron fortification technology has not yet been developed. Maize is still predominantly milled in small-scale local mills and, although the extruded rice premix technology holds great promise, it is still under development. Salt has a proven record as an excellent vehicle for iodine fortification and has demonstrated good potential for iron fortification. However, technical issues remain with DFS and further studies are needed to better understand and avoid color formation and iron-catalyzed iodine losses in both high- and low-quality salts under different storage conditions. There is currently a risk that the introduction of DFS may jeopardize the success of existing salt iodization programs because the addition of iron may increase iodine losses and cause unacceptable color formation.
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Affiliation(s)
- Richard F Hurrell
- Institute of Food, Nutrition and Health, ETH Zurich, Zurich, Switzerland
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13
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Larson LM, Cyriac S, Djimeu EW, Mbuya MNN, Neufeld LM. Can Double Fortification of Salt with Iron and Iodine Reduce Anemia, Iron Deficiency Anemia, Iron Deficiency, Iodine Deficiency, and Functional Outcomes? Evidence of Efficacy, Effectiveness, and Safety. J Nutr 2021; 151:15S-28S. [PMID: 33582785 PMCID: PMC7882357 DOI: 10.1093/jn/nxaa192] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/24/2020] [Accepted: 06/12/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Anemia, iron deficiency, and iodine deficiency are problems of important public health concern in many parts of the world, with consequences for the health, development, and work capacity of populations. Several countries are beginning to implement double fortified salt (DFS) programs to simultaneously address iodine and iron deficiencies. OBJECTIVE Our objective was to summarize the evidence for efficacy and effectiveness of DFS on the full range of status and functional outcomes and across different implementation and evaluation designs essential to successful interventions. METHODS We conducted a systematic review and meta-analysis of published and gray literature examining the effects of DFS on nutritional status, cognition, work productivity, development, and morbidity of all population groups. We searched for articles in Medline, Embase, CINAHL, Cochrane Central Register, and ProQuest for randomized trials, quasi-randomized trials, and program effectiveness evaluations. RESULTS A total of 22 studies (N individuals = 52,758) were included. Efficacy studies indicated a significant overall positive effect on hemoglobin concentration [standardized mean difference (95% CI): 0.33 (0.18, 0.48)], ferritin [0.42 (0.08, 0.76)], anemia [risk ratio (95% CI): 0.80 (0.70, 0.92)], and iron deficiency anemia [0.36 (0.24, 0.55)]. Effects on urinary iodine concentration were not significantly different between DFS and iodized salt. The impact on functional outcomes was mixed. Only 2 effectiveness studies were identified. They reported programmatic challenges including low coverage, suboptimal DFS quality, and storage constraints. CONCLUSIONS Given the biological benefits of DFS across several populations in efficacy research, additional evaluations of robust DFS programs delivered at scale, which consider effective implementation and measure appropriate biomarkers, are needed.
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Affiliation(s)
- Leila M Larson
- University of South Carolina, Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, Columbia, SC, USA
| | - Shruthi Cyriac
- Emory University, Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Atlanta, GA, USA
| | - Eric W Djimeu
- Global Alliance for Improved Nutrition, Geneva, Switzerland
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14
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Cyriac S, Haardörfer R, Neufeld LM, Girard AW, Ramakrishnan U, Martorell R, Mbuya MNN. High Coverage and Low Utilization of the Double Fortified Salt Program in Uttar Pradesh, India: Implications for Program Implementation and Evaluation. Curr Dev Nutr 2020; 4:nzaa133. [PMID: 32885134 PMCID: PMC7455457 DOI: 10.1093/cdn/nzaa133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Double fortified salt (DFS) is efficacious in addressing iron deficiency, but evidence of its effectiveness is limited. The few published evaluations do not include details on program implementation, limiting their utility for programmatic decisions. OBJECTIVES We sought to characterize the coverage of a DFS program implemented through the Public Distribution System (PDS) in Uttar Pradesh, India, and understand the drivers of DFS adherence. METHODS After 8 mo of implementation, we surveyed 1202 households in 5 districts and collected data on sociodemographic characteristics, asset ownership, food security, and regular PDS utilization. We defined DFS program coverage as the proportion of PDS beneficiaries who had heard of and purchased DFS, and we defined DFS adherence as DFS use reported by households. We used principal component analysis to create an asset-based index of relative wealth, and we categorized households into higher/lower relative wealth quintiles. We conducted path analyses to examine the drivers of DFS adherence, particularly the mediated influence of household wealth on DFS adherence. The evaluation is registered with 3ie's Registry for International Development Impact Evaluations (RIDIE-STUDY-ID-58f6eeb45c050). RESULTS The DFS program had good coverage: 83% of respondents had heard of DFS and 74% had purchased it at least once. However, only 23% exclusively used DFS. Respondents had low awareness about DFS benefits and considered DFS quality as poor. Being in a lower household wealth quintile and being food insecure were significant drivers of DFS adherence, and regular PDS utilization acted as a mediator. Adherence was lower in urban areas. CONCLUSIONS We observed significant heterogeneity in DFS implementation as reflected by high coverage and low adherence. Findings from this process evaluation informed the design of an adaptive impact evaluation and provided generalizable insights for ensuring that the potential for impact is realized. Efforts are needed to increase awareness, improve product quality, as well as mitigate against the sensory challenges identified.
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Affiliation(s)
- Shruthi Cyriac
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA, USA
- Global Alliance for Improved Nutrition, Washington, DC, USA
| | - Regine Haardörfer
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Amy Webb Girard
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Usha Ramakrishnan
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Reynaldo Martorell
- Doctoral Program in Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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15
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Fernandez-Jimenez MC, Moreno G, Wright I, Shih PC, Vaquero MP, Remacha AF. Iron Deficiency in Menstruating Adult Women: Much More than Anemia. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2020; 1:26-35. [PMID: 33786470 PMCID: PMC7784796 DOI: 10.1089/whr.2019.0011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Background: Iron deficiency anemia (IDA) is highly prevalent in women of child-bearing age. However, their nonhematological symptoms have been overlooked. This study aims to analyze the nonhematological features and symptoms of IDA in a group of women of reproductive age and the changes occurred during iron therapy. Materials and Methods: IDA women underwent dietary, physical activity, menstrual blood loss, and cognitive function assessment at baseline. Hematological and biochemical parameters were analyzed. Executive attention was tested by the flanker task and working memory by the 2-back task. Oral iron therapy (ferrous sulfate) was given to 35 women for 8 weeks and the changes in iron status, biochemical markers, cognitive function, and nonhematological symptoms were evaluated. Results: Patients presented nonhematological symptoms: pica, 32.4%; cheilitis, 20.6%; restless legs syndrome (RLS), 20.6%; diffuse hair loss, 55.9%; and ungual alterations, 38.2%. Two or more symptoms were present in 58.8% of women. Serum iron and working memory were correlated at baseline. Multivariate analyses show associations (odds ratio [OR], 95% confidence interval [CI]) between pica and reaction time in the working memory test (OR 2.14, 95% CI 1.19-3.87, p = 0.012); RLS with total serum protein (OR 0.08, 95% CI 0.06-0.92, p = 0.043); and cheilitis with mean corpuscular hemoglobin (OR 0.388, 95% CI 0.189-0.799, p = 0.01). Pica, cheilitis, and RLS completely resolved with iron therapy, and ungual alterations and hair loss improved in 92.3% and 84.2% of women, respectively. Better performance in executive attention and working memory was observed after iron therapy. Conclusions: More attention should be given to the nonhematological manifestations of IDA to improve the quality of life of menstruating women.
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Affiliation(s)
| | - Gemma Moreno
- Hematology Department, Hospital Ramón y Cajal, Madrid, Spain
| | - Ione Wright
- Department of Metabolism and Nutrition, Institute of Food Science, Technology and Nutrition (ICTAN), Consejo Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| | - Pei-Chun Shih
- Faculty of Psychology, Universidad Autónoma de Madrid, Madrid, Spain
| | - M. Pilar Vaquero
- Department of Metabolism and Nutrition, Institute of Food Science, Technology and Nutrition (ICTAN), Consejo Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| | - Angel F. Remacha
- Hematology Laboratory Department, Hospital Sant Pau, Barcelona, Spain
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16
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Waller AW, Andrade JE, Mejia LA. Performance Factors Influencing Efficacy and Effectiveness of Iron Fortification Programs of Condiments for Improving Anemia Prevalence and Iron Status in Populations: A Systematic Review. Nutrients 2020; 12:nu12020275. [PMID: 31973015 PMCID: PMC7070935 DOI: 10.3390/nu12020275] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 11/16/2022] Open
Abstract
Iron fortification of staple foods is a common practice around the world to reduce the prevalence of iron-deficiency anemia. More recently, fortified condiments, including salts, sauces, and powders, have been tested in various efficacy trials. However, there is limited information on how nutritional, environmental, and experimental factors affect their efficacy and effectiveness. The purpose of the present work was to systematically review performance factors affecting the efficacy of condiment fortification trials. Three databases were searched using a standardized keyword search and included based on four-point inclusion criteria. Studies were evaluated against a quality assessment tool and effect sizes were calculated. Studies were ranked as low or high performing, based on whether or not they significantly improved iron-deficiency outcomes (hemoglobin, anemia prevalence, and ferritin levels). Of the 955 retrieved studies, 23 were included-of which, nine performed poorly, eight performed highly, and six were classified as neither because they did not meet the criteria of assessing the three iron outcomes. Results showed that unsuccessful trials did not consider environmental factors such as parasitic infections, nutritional factors such as micronutrient deficiencies other than iron, consumer acceptability of the product or experimental factors such as monitoring and adherence to the trials. Two common performing factors identified among those studies performing highly vs. those that did not were the control of sensory changes and monitoring of consumption compliance (i.e., dose delivery). The present work can be used as decision-making support for nutrition policy makers when determining the appropriate implementation of condiment fortification programs.
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Affiliation(s)
- Anna W. Waller
- Department of Food Science and Human Nutrition, University of Illinois, Urbana-Champaign. 260 Bevier Hall-MC 182. 905 Goodwin Ave, Urbana, IL 61801, USA; (A.W.W.); (J.E.A.)
| | - Juan E. Andrade
- Department of Food Science and Human Nutrition, University of Illinois, Urbana-Champaign. 260 Bevier Hall-MC 182. 905 Goodwin Ave, Urbana, IL 61801, USA; (A.W.W.); (J.E.A.)
- Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | - Luis A. Mejia
- Department of Food Science and Human Nutrition, University of Illinois, Urbana-Champaign. 260 Bevier Hall-MC 182. 905 Goodwin Ave, Urbana, IL 61801, USA; (A.W.W.); (J.E.A.)
- Correspondence: ; Tel.: +1-217-493-0242
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17
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Diosady LL, Mannar MGV, Krishnaswamy K. Improving the lives of millions through new double fortification of salt technology. MATERNAL AND CHILD NUTRITION 2019; 15 Suppl 3:e12773. [PMID: 31148400 PMCID: PMC6594086 DOI: 10.1111/mcn.12773] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 11/17/2018] [Accepted: 12/12/2018] [Indexed: 12/02/2022]
Abstract
Micronutrient deficiencies (including iodine and iron deficiency) is a global health problem affecting one third of the world's population. Salt is an ideal carrier for food fortification as it is universally consumed at equal rates, independently of economic status, and it is industrially processed. Addressing iron and iodine deficiencies together is a challenge, due to interaction between iodine and iron, negating the effect of added iodine. This paper explains the development of an improved microencapsulation‐based technology to produce iron premix, which, when added to iodized salt, is stable and organoleptically indistinguishable. Ferrous fumarate was extruded, followed by cutting, sieving to achieve a size of 300–710 μm (salt grain size). Agglomerated extrudates were microencapsulated (5% hydroxypropyl methylcellulose and 5% soy stearin) to form iron premix. Microencapsulation ensures that the added micronutrients are stable without interaction or degradation. Double Fortified Salt is formed by blending iron premix with iodized salt (1:200 ratio). This technology was transferred to India for industrial scale‐up. The public distribution system was utilized to establish and monitor an efficient distribution network for DFS in a transparent manner. The scale‐up process was initially demonstrated in the state of Uttar Pradesh, following its success two more Indian states have started distribution of DFS. At present, the DFS with iron and iodine is reaching 60 million people in India. This important health intervention technology through food fortification has the potential to be scaled globally to ensure a world free from iron deficiency anemia.
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Affiliation(s)
- Levente L Diosady
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, Canada
| | - M G Venkatesh Mannar
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, Canada
| | - Kiruba Krishnaswamy
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, Canada.,Department of Biomedical, Biological and Chemical Engineering & Food Science Program, University of Missouri, Columbia, USA
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18
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Wenger MJ, Rhoten SE, Murray-Kolb LE, Scott SP, Boy E, Gahutu JB, Haas JD. Changes in Iron Status Are Related to Changes in Brain Activity and Behavior in Rwandan Female University Students: Results from a Randomized Controlled Efficacy Trial Involving Iron-Biofortified Beans. J Nutr 2019; 149:687-697. [PMID: 30926992 PMCID: PMC6461719 DOI: 10.1093/jn/nxy265] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/20/2018] [Accepted: 09/24/2018] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Evidence suggests that iron deficiency (ID) affects cognitive performance, as measured in behavior. Although such effects must be mediated by changes in the brain, very few studies have included measures of brain activity to assess this relation. OBJECTIVE We tested the hypothesis that provision of iron-biofortified beans would result in improvements in measures of iron status, brain dynamics, and behavior. METHODS A double-blind, randomized, intervention study was conducted in 55 women aged 18-27 y with low iron status (serum ferritin <20 µg/L). Women were randomly assigned to consume iron-biofortified (86.1 ppm iron) or comparison beans (50.1 ppm iron) daily for 18 wk. Iron status was assessed by hemoglobin, ferritin, transferrin receptor, and body iron; cognitive performance with 5 computerized tasks; and brain dynamics by concurrent electroencephalography (EEG). All measures were taken at baseline and endline. RESULTS The groups did not differ on any measures at baseline. Intention-to-treat analyses revealed significant (all P < 0.05) improvements in hemoglobin (partial effect size attributable to the independent variable, η2 = 0.16), ferritin (η2 = 0.17), and body iron (η2 = 0.10), speed of responding in attentional and mnemonic tasks (η2 = 0.04-0.29), sensitivity and efficiency of memory retrieval (η2 = 0.12-0.55), and measures of EEG amplitude and spectral power (η2 = 0.08 to 0.49). Mediation models provided evidence in support of the hypothesis that changes in iron status produce changes in behavior by way of changes in brain activity. CONCLUSIONS Behavioral performance and brain activity, as measured by EEG, are sensitive to iron status, and the consumption of iron-biofortified beans for 18 wk resulted in improvements in measures of both, relative to what was obtained with a comparison bean, in a sample of female university students. Furthermore, the results support the conclusion that changes in brain activity resulting from consumption of biofortified beans mediate the relations between changes in iron biomarkers and changes in cognition. Clinical trial registry: ClinicalTrials.gov Reg No. NCT01594359.
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Affiliation(s)
- Michael J Wenger
- Department of Psychology and Cellular and Behavioral Neurobiology, The University of Oklahoma, Norman, OK,Division of Nutritional Sciences, Cornell University, Ithaca, NY,Address correspondence to MJW (e-mail: )
| | - Stephanie E Rhoten
- Department of Psychology and Cellular and Behavioral Neurobiology, The University of Oklahoma, Norman, OK
| | - Laura E Murray-Kolb
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA
| | - Samuel P Scott
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA
| | - Erick Boy
- HarvestPlus, International Food Policy Research Institute, Washington, DC
| | - Jean-Bosco Gahutu
- University of Rwanda, College of Medicine and Health Sciences, Huye, Rwanda
| | - Jere D Haas
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
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Scott SP, Murray-Kolb LE, Wenger MJ, Udipi SA, Ghugre PS, Boy E, Haas JD. Cognitive Performance in Indian School-Going Adolescents Is Positively Affected by Consumption of Iron-Biofortified Pearl Millet: A 6-Month Randomized Controlled Efficacy Trial. J Nutr 2018; 148:1462-1471. [PMID: 30016516 DOI: 10.1093/jn/nxy113] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/01/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Iron deficiency remains the most prevalent micronutrient deficiency globally, but few studies have examined how iron status relates to cognition in adolescents. Iron biofortification of staple food crops is being scaled up, yet it is unknown whether consuming biofortified crops can benefit cognition. Objective Our objective was to determine the efficacy of iron-biofortified pearl millet in improving attention and memory in Indian school-going adolescents. Methods A double-blind, randomized, intervention study was conducted in 140 Indian boys and girls, aged 12-16 y, who were assigned to consume iron-biofortified [Fe = 86 parts per million (ppm)] or conventional (Fe = 21-52 ppm) pearl millet. Hemoglobin, ferritin, and transferrin receptor (TfR) were measured and body iron (BI) was calculated at baseline and after 4 and 6 mo. Five measures of cognitive function were obtained at baseline and 6 mo: simple reaction time (SRT), Go/No-Go (GNG) task, Attentional Network Task (ANT), Composite Face Effect (CFE) task, and Cued Recognition Task (CRT). Intention-to-treat analysis was used. Results Daily iron intake from pearl millet was higher in those consuming biofortified compared with conventional pearl millet (19.6 compared with 4.8 mg/d). Effects on ferritin, TfR, and BI at 4 mo, and on TfR at 6 mo (all P < 0.05), indicated efficacy of biofortified pearl millet over conventional pearl millet in improving iron status. Compared with conventional pearl millet, the consumption of biofortified pearl millet resulted in greater improvement in attention (SRT, GNG, and ANT) and memory (CFE and CRT). Reaction time decreased twice as much from 0 to 6 mo in those consuming biofortified compared with conventional pearl millet on attention tasks (SRT: -123 compared with -63 ms; GNG: -67 compared with -30 ms; ANT double cue: -74 compared with -32 ms; all P < 0.01). Conclusion Consuming iron-biofortified pearl millet improves iron status and some measures of cognitive performance in Indian adolescents. This trial was registered at http://www.clinicaltrials.gov as NCT02152150.
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Affiliation(s)
- Samuel P Scott
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA
| | - Laura E Murray-Kolb
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA
| | - Michael J Wenger
- Department of Psychology and Cellular and Behavioral Neurobiology, The University of Oklahoma, Norman, OK
| | - Shobha A Udipi
- Department of Food Science and Nutrition, Shreemati Nathibai Damodar Thackersey Women's University Women's University, Mumbai, India
| | - Padmini S Ghugre
- Department of Food Science and Nutrition, Shreemati Nathibai Damodar Thackersey Women's University Women's University, Mumbai, India
| | - Erick Boy
- Harvest Plus, International Food Policy Research Institute, Washington, DC
| | - Jere D Haas
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
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