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Black MM, Fernandez-Rao S, Nair KM, Balakrishna N, Tilton N, Radhakrishna KV, Ravinder P, Harding KB, Reinhart G, Yimgang DP, Hurley KM. A Randomized Multiple Micronutrient Powder Point-of-Use Fortification Trial Implemented in Indian Preschools Increases Expressive Language and Reduces Anemia and Iron Deficiency. J Nutr 2021; 151:2029-2042. [PMID: 33880548 PMCID: PMC8245888 DOI: 10.1093/jn/nxab066] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/01/2020] [Accepted: 02/22/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Anemia is a global public health problem that undermines childhood development. India provides government-sponsored integrated nutrition/child development preschools. OBJECTIVES This double-masked, cluster-randomized controlled trial examines whether point-of-use multiple micronutrient powder (MNP) compared with placebo fortification of preschool meals impacts child development and whether effects vary by preschool quality (primary outcome) and biomarkers of anemia and micronutrients (secondary outcomes). We also measured growth and morbidity. METHODS We randomly assigned 22 preschools in rural India to receive MNP/placebo fortification. We administered baseline and endline blood sampling and measures of childhood development (Mullen Scales of Early Learning, inhibitory control, social-emotional), anthropometry, and morbidity to preschoolers (aged 29-49 mo). Preschools added MNP/placebo to meals 6 d/wk for 8 mo. We conducted linear mixed-effects regression models accounting for preschool clustering and repeated measures. We evaluated child development, examining effects in high- compared with low-quality preschools using the Early Childhood Environment Rating Scale-Revised and the Home Observation for the Measurement of the Environment Inventory, modified for preschools. RESULTS At baseline, mean age ± SD was 36.6 ± 5.7 mo, with 47.8% anemic, 41.9% stunted, and 20.0% wasted. Baseline expressive/receptive language scores were higher in high-quality compared with low-quality preschools (P = 0.02 and P = 0.03, respectively). At endline (91% retention, n = 293/321), we found MNP compared with placebo effects in expressive language (Cohen's standardized effect d = 0.4), inhibitory control (d = 0.2), and social-emotional (d = 0.3) in low-quality, not high-quality, preschools. MNP had significantly greater reduction of anemia and iron deficiency compared with placebo (37% compared with 13.5% and 41% compared with 1.2%, respectively). There were no effects on growth or morbidity. CONCLUSIONS Providing multiple micronutrient-fortified meals in government-sponsored preschools is feasible; reduced anemia and iron deficiency; and, in low-quality preschools, increased preschoolers' expressive language and inhibitory control and reduced developmental disparities. Improving overall preschool quality by incorporating multiple components of nurturing care (responsive care, learning, and nutrition) may be necessary to enhance preschoolers' development. This trial was registered at clinicaltrials.gov as NCT01660958.
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Affiliation(s)
- Maureen M Black
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
- RTI International, Research Triangle Park, NC, USA
| | - Sylvia Fernandez-Rao
- Department of Behavioral Science, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Krishnapillai Madhavan Nair
- Department of Micronutrient Research, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Nagalla Balakrishna
- Department of Biostatistics, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Nicholas Tilton
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Punjal Ravinder
- Department of Micronutrient Research, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | | | - Gregory Reinhart
- The Mathile Institute for the Advancement of Human Nutrition, Dayton, OH, USA
| | - Doris P Yimgang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristen M Hurley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Holmes JB, Kroeun H, Houghton LA, Gibson RS, Harding KB, De-Regil LM, Kraemer K, Barr SI, Karakochuk CD. Including 60 mg Elemental Iron in a Multiple Micronutrient Supplement Blunts the Increase in Serum Zinc after 12 Weeks of Daily Supplementation in Predominantly Anemic, Nonpregnant Cambodian Women of Reproductive Age. J Nutr 2019; 149:1503-1510. [PMID: 31174215 DOI: 10.1093/jn/nxz097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 03/18/2019] [Accepted: 04/15/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Multiple micronutrient (MMN) supplementation may result in interaction effects due to competing absorptive pathways of trace elements. OBJECTIVES The aim of this study was to investigate the effect of MMN supplementation with or without iron on serum zinc, selenium, and copper concentrations in Cambodian women. METHODS In a 2 × 2 factorial double-blind randomized 12-wk trial, predominantly anemic, nonpregnant women (aged 18-45 y) received daily 60 mg of iron (Fe; n = 201); 14 other micronutrients including zinc (15 mg), selenium (65 μg), and copper (2 mg), but no iron (MMN; n = 202); 60 mg iron plus MMN (Fe + MMN; n = 206); or a placebo (n = 200). Fasting morning blood was collected at baseline and 12 wk from women in 26 villages in Kampong Chhnang province. Serum zinc, selenium, and copper concentrations (secondary outcomes of the randomized controlled trial) were measured using inductively coupled plasma mass spectrometry. Generalized linear regression was used to estimate intervention effects [β coefficient (95% CI)] for Fe (with or without MMN) and MMN (with or without Fe) after testing for the presence of an Fe × MMN interaction. RESULTS A total of 760 women completed the trial. Zinc deficiency prevalence at baseline was 45% (inflammation-adjusted serum zinc <10.7 μmol/L). A significant Fe × MMN interaction (P = 0.02) was detected in the 2 × 2 analysis with serum zinc concentration as the outcome: the MMN group had a higher mean serum zinc concentration at 12 wk (12.3 μmol/L; 95% CI: 12.2, 12.4 μmol/L) compared with all other groups, and the Fe + MMN group had a higher mean serum zinc concentration (11.6 μmol/L; 95% CI: 11.5, 11.7 μmol/L) compared with the Fe group (11.0 μmol/L; 95% CI: 10.9, 11.0 μmol/L) and the placebo group (11.2 μmol/L; 95% CI: 11.1, 11.4 μmol/L). CONCLUSIONS The inclusion of 60 mg iron in the daily MMN formulation may be interfering with the absorption and/or metabolism of supplemental zinc in Cambodian women. This is of particular concern when MMN supplementation is implemented in populations with risk of zinc deficiency. This trial was registered at clinicaltrials.gov as NCT-02481375.
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Affiliation(s)
- Jeffrey B Holmes
- Food, Nutrition, and Health, University of British Columbia, Vancouver, Canada
| | - Hou Kroeun
- Helen Keller International, Phnom Penh, Cambodia
| | - Lisa A Houghton
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - Rosalind S Gibson
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | | | | | - Klaus Kraemer
- Sight and Life Foundation, Basel, Switzerland, and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Susan I Barr
- Food, Nutrition, and Health, University of British Columbia, Vancouver, Canada
| | - Crystal D Karakochuk
- Food, Nutrition, and Health, University of British Columbia, Vancouver, Canada
- British Columbia Children's Hospital Research Institute, Vancouver, Canada
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Black MM, Yimgang DP, Hurley KM, Harding KB, Fernandez-Rao S, Balakrishna N, Radhakrishna KV, Reinhart GA, Nair KM. Mechanisms linking height to early child development among infants and preschoolers in rural India. Dev Sci 2019; 22:e12806. [PMID: 30715779 PMCID: PMC7428854 DOI: 10.1111/desc.12806] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 10/19/2018] [Accepted: 11/30/2018] [Indexed: 01/16/2023]
Abstract
Stunting has been negatively associated with children's development. We examined the range of height by testing hypotheses: (a) height is positively associated with children's development, with associations moderated by inflammation and (b) home environments characterized by nurturance and early learning opportunities is positively associated with children's development over time and attenuate associations with height. Data included 513 infants (mean age 8.6 months) and 316 preschoolers (mean age 36.6 months) in rural India from a randomized controlled trial of multiple micronutrient powders (MNPs). Measures included height (height-for-age z-scores based on WHO standards), inflammation (C-reactive protein concentration >5 mg/L), nurturance (HOME Inventory), child development (Mullens Scales of Early Learning), and inhibitory control (preschoolers). Linear mixed effects models accounting for repeated measures, clustering, and confounders were used to assess associations between height and child development over time (infants: enrollment, 6 and 12 months; preschoolers: enrollment and 8 months). Moderating effects of inflammation and nurturance were tested with interaction terms. Among infants and preschoolers, height and nurturance were positively associated with all domains of child development over time, with the exception of inhibitory control. Among preschoolers, in the presence of inflammation, height was not associated with child development. Among infants, but not preschoolers, a nurturant home environment attenuated significant associations between height with fine motor and receptive language development. The mechanisms associated with children's development over time are multifactorial and include direct and indirect associations among nutrition, health, and the home environment, as supported by the Nurturing Care Framework.
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Affiliation(s)
- Maureen M Black
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD
- RTI International, Research Triangle Park, NC
| | - Doris P Yimgang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Kristen M Hurley
- Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Wessells KR, Brown KH, Kounnavong S, Barffour MA, Hinnouho GM, Sayasone S, Stephensen CB, Ratsavong K, Larson CP, Arnold CD, Harding KB, Reinhart GA, Lertmemongkolchai G, Fucharoen S, Bernstein RM, Hess SY. Comparison of two forms of daily preventive zinc supplementation versus therapeutic zinc supplementation for diarrhea on young children's physical growth and risk of infection: study design and rationale for a randomized controlled trial. BMC Nutr 2018; 4:39. [PMID: 32153900 PMCID: PMC7050875 DOI: 10.1186/s40795-018-0247-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 08/13/2018] [Indexed: 12/04/2022] Open
Abstract
Background Zinc is an essential nutrient that is required for children’s normal growth and resistance to infections, including diarrhea and pneumonia, two major causes of child mortality. Daily or weekly preventive zinc supplementation has been shown to improve growth and reduce the risk of infection, while therapeutic zinc supplementation for 10–14 days is recommended for the treatment of diarrhea. The overall objective of the present study is to compare several regimens for delivering zinc to young children, both for the prevention of zinc deficiency and the treatment of diarrhea. Methods The present study is a community-based, randomized controlled trial in the Lao People’s Democratic Republic (PDR). Three thousand, four hundred children 6–23 months of age will be randomized to one of four intervention groups (daily preventive zinc dispersible tablet, daily preventive multiple micronutrient powder, therapeutic zinc dispersible tablet for diarrhea, or placebo control); interventions will be delivered for 9 months and outcomes measured at pre-determined intervals. Primary outcomes include physical growth (length and weight), diarrhea incidence, hemoglobin and micronutrient status, and innate and adaptive immune function. Secondary outcomes include mid-upper-arm circumference, neuro-behavioral development, hair cortisol concentrations, markers of intestinal inflammation and parasite burden. Incidence of adverse events and the modifying effects of inherited hemoglobin disorders and iron status on the response to the intervention will also be examined. We will estimate unadjusted effects and effects adjusted for selected baseline covariates using ANCOVA. Discussion Many countries are now rolling out large-scale programs to include therapeutic zinc supplementation in the treatment of childhood diarrhea, but few have established programs demonstrated to be effective in the prevention of zinc deficiency. This study will address how best to deliver supplemental zinc to prevent zinc deficiency and reduce the severity of diarrhea-related health complications. Trial registration Trial registration identifier (NCT02428647) ; Date of registration: April 29, 2015.
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Affiliation(s)
- K Ryan Wessells
- 1Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, 1 Shields Avenue, Davis, CA 95616 USA
| | - Kenneth H Brown
- 1Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, 1 Shields Avenue, Davis, CA 95616 USA.,2Nutrition and Global Development, Bill & Melinda Gates Foundation, Seattle, WA USA
| | - Sengchanh Kounnavong
- 3National Institute of Public Health, Ministry of Health, Vientiane, Lao People's Democratic Republic
| | - Maxwell A Barffour
- 1Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, 1 Shields Avenue, Davis, CA 95616 USA
| | - Guy-Marino Hinnouho
- 1Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, 1 Shields Avenue, Davis, CA 95616 USA
| | - Somphou Sayasone
- 3National Institute of Public Health, Ministry of Health, Vientiane, Lao People's Democratic Republic
| | - Charles B Stephensen
- 4United States Department of Agriculture, Western Human Nutrition Research Center, Davis, CA USA
| | - Kethmany Ratsavong
- 3National Institute of Public Health, Ministry of Health, Vientiane, Lao People's Democratic Republic
| | | | - Charles D Arnold
- 1Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, 1 Shields Avenue, Davis, CA 95616 USA
| | - Kimberly B Harding
- 6Nutrition International, formerly The Micronutrient Initiative, Ottawa, Canada
| | - Gregory A Reinhart
- 7The Mathile Institute for the Advancement of Human Nutrition, Dayton, OH USA
| | - Ganjana Lertmemongkolchai
- 8Centre for Research and Development of Medical Diagnostics Laboratories, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand
| | - Supan Fucharoen
- 8Centre for Research and Development of Medical Diagnostics Laboratories, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand
| | - Robin M Bernstein
- 9Department of Anthropology, University of Colorado, Boulder, CO USA
| | - Sonja Y Hess
- 1Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, 1 Shields Avenue, Davis, CA 95616 USA
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Karakochuk CD, Barker MK, Whitfield KC, Barr SI, Vercauteren SM, Devlin AM, Hutcheon JA, Houghton LA, Prak S, Hou K, Chai TL, Stormer A, Ly S, Devenish R, Oberkanins C, Pühringer H, Harding KB, De-Regil LM, Kraemer K, Green TJ. The effect of oral iron with or without multiple micronutrients on hemoglobin concentration and hemoglobin response among nonpregnant Cambodian women of reproductive age: a 2 x 2 factorial, double-blind, randomized controlled supplementation trial. Am J Clin Nutr 2017; 106:233-244. [PMID: 28490515 DOI: 10.3945/ajcn.116.140996] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 04/10/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Despite a high prevalence of anemia among nonpregnant Cambodian women, current reports suggest that iron deficiency (ID) prevalence is low. If true, iron supplementation will not be an effective anemia reduction strategy.Objective: We measured the effect of daily oral iron with or without multiple micronutrients (MMNs) on hemoglobin concentration in nonpregnant Cambodian women screened as anemic.Design: In this 2 × 2 factorial, double-blind, randomized trial, nonpregnant women (aged 18-45 y) with hemoglobin concentrations ≤117 g/L (capillary blood) were recruited from 26 villages in Kampong Chhnang province and randomly assigned to receive 12 wk of iron (60 mg; Fe group), MMNs (14 other micronutrients; MMN group), iron plus MMNs (Fe+MMN group), or placebo capsules. A 2 × 2 factorial intention-to-treat analysis with the use of a generalized mixed-effects model was used to assess the effects of iron and MMNs and the interaction between these factors. Results: In July 2015, 809 women were recruited and 760 (94%) completed the trial. Baseline anemia prevalence was 58% (venous blood). Mean (95% CI) hemoglobin concentrations at 12 wk in the Fe, MMN, Fe+MMN, and placebo groups were 121 (120, 121), 116 (116, 117), 123 (122, 123), and 116 (116, 117) g/L, with no iron × MMN interaction (P = 0.66). Mean (95% CI) increases in hemoglobin were 5.6 g/L (3.8, 7.4 g/L) (P < 0.001) among women who received iron (n = 407) and 1.2 g/L (-0.6, 3.0 g/L) (P = 0.18) among women who received MMNs (n = 407). The predicted proportions (95% CIs) of women with a hemoglobin response (≥10 g/L at 12 wk) were 19% (14%, 24%), 9% (5%, 12%), 30% (24%, 35%), and 5% (2%, 9%) in the Fe, MMN, Fe+MMN, and placebo groups, respectively.Conclusions: Daily iron supplementation for 12 wk increased hemoglobin in nonpregnant Cambodian women; however, MMNs did not confer additional significant benefit. Overall, ∼24% of women who received iron responded after 12 wk; even fewer would be likely to respond in the wider population. This trial was registered at clinicaltrials.gov as NCT02481375.
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Affiliation(s)
- Crystal D Karakochuk
- Food, Nutrition, and Health and Departments of.,British Columbia Children's Hospital Research Institute, Vancouver, Canada
| | - Mikaela K Barker
- Food, Nutrition, and Health and Departments of.,British Columbia Children's Hospital Research Institute, Vancouver, Canada
| | | | | | - Suzanne M Vercauteren
- British Columbia Children's Hospital Research Institute, Vancouver, Canada.,Division of Hematopathology, Children's and Women's Health Centre of British Columbia, Vancouver, Canada
| | - Angela M Devlin
- Pediatrics and.,British Columbia Children's Hospital Research Institute, Vancouver, Canada
| | - Jennifer A Hutcheon
- Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada.,British Columbia Children's Hospital Research Institute, Vancouver, Canada
| | - Lisa A Houghton
- Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - Sophonneary Prak
- National Maternal and Child Health Center, Cambodian Ministry of Health, Phnom Penh, Cambodia
| | - Kroeun Hou
- Helen Keller International, Phnom Penh, Cambodia
| | - Tze Lin Chai
- Helen Keller International, Phnom Penh, Cambodia
| | - Ame Stormer
- Helen Keller International, Phnom Penh, Cambodia
| | - Sokhoing Ly
- Helen Keller International, Phnom Penh, Cambodia
| | - Robyn Devenish
- Laboratory Department, National Pediatric Hospital, Phnom Penh, Cambodia
| | | | | | | | | | - Klaus Kraemer
- Sight and Life Foundation, Basel, Switzerland.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Tim J Green
- Discipline of Paediatrics, University of Adelaide, Adelaide, Australia; and .,Healthy Mothers, Babies, and Children's Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
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Nguyen PH, DiGirolamo AM, Gonzalez-Casanova I, Pham H, Hao W, Nguyen H, Truong TV, Nguyen S, Harding KB, Reinhart GA, Martorell R, Ramakrishnan U. Impact of preconceptional micronutrient supplementation on maternal mental health during pregnancy and postpartum: results from a randomized controlled trial in Vietnam. BMC Womens Health 2017; 17:44. [PMID: 28623904 PMCID: PMC5473979 DOI: 10.1186/s12905-017-0401-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 06/08/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Micronutrient malnutrition has been associated with maternal depressive symptoms (MDS), but little is known about the effects of preconceptional micronutrient supplementation. This paper examined the effects of preconceptional micronutrient supplementation on MDS during pregnancy and postpartum. METHODS We used data from a double-blind controlled trial (PRECONCEPT) in which 5011 Vietnamese women were randomized to receive weekly supplements containing either a) multiple micronutrients (MM) b) iron and folic acid (IFA) or c) folic acid (FA) until conception (n = 1813). Maternal mental health was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D) at baseline (preconception), and the Edinburgh Postnatal Depression Scale (EPDS) during pregnancy and 3 months postpartum. Elevated MDS was defined as EPDS score ≥ 4. All group comparisons were done using ANOVA or chi-square tests of proportions intention to treat and per protocol analyses (women consumed supplements ≥26 weeks before conception). We also conducted stratified analyses by preconception CES-D scores, underweight, or anemia status using generalized linear models. RESULTS Baseline CES-D scores were similar across treatment groups. The proportion of women experiencing elevated MDS was 11.3, 8.1 and 4.9% at first, second and third trimesters of pregnancy, respectively, and 3.6% at 3 mo postpartum. Mean EPDS scores at first (1.5 ± 2.7), second (1.1 ± 2.4), and third trimester of pregnancy (0.7 ± 2.0) and early postpartum (0.6 ± 1.8) were low and did not differ by treatment group. However, among women in the highest tertile of CES-D scores at preconception, mean EPDS scores in the first and second trimesters of pregnancy were lower in the MM and IFA groups compared to FA only (P < 0.05). CONCLUSIONS Weekly preconceptional micronutrient supplements containing iron did not improve depression measures relative to folic acid alone among all women, but may have benefitted women who were at risk for depression. TRIAL REGISTRATION The trial was registered retrospectively at ClinicalTrials.Gov as NCT01665378 on August 13, 2012.
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Affiliation(s)
- Phuong H. Nguyen
- International Food Policy Research Institute, Washington, DC USA
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | | | | | - Hoa Pham
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | - Wei Hao
- Emory University, Atlanta, GA USA
| | - Hieu Nguyen
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | - Truong V. Truong
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | - Son Nguyen
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | | | - Gregory A. Reinhart
- The Mathile Institute for the Advancement of Human Nutrition, Dayton, OH USA
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Gonzalez-Casanova I, Nguyen PH, Young MF, Harding KB, Reinhart G, Nguyen H, Nechitillo M, Truong TV, Pham H, Nguyen S, Neufeld LM, Martorell R, Ramakrishnan U. Predictors of adherence to micronutrient supplementation before and during pregnancy in Vietnam. BMC Public Health 2017; 17:452. [PMID: 28511688 PMCID: PMC5434576 DOI: 10.1186/s12889-017-4379-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 05/07/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Poor adherence to micronutrient supplementation often limits the effectiveness of public health programs. While predictors of adherence to micronutrient supplementation during pregnancy are well documented, information on adherence to preconception supplements is scarce. The objective of this study was to describe the predictors of adherence to preconception and prenatal micronutrient supplementation among women participating in a randomized control trial in Vietnam. METHODS Adherence data were collected prospectively from a double blind randomized controlled trial in rural Vietnam. Five thousand eleven women of reproductive age were randomized to receive preconception supplements for weekly consumption containing either: Folic Acid, Iron and Folic Acid (IFA), or Multiple Micronutrients. Women who became pregnant received prenatal IFA supplements for daily consumption through delivery. Village health workers visited participants' homes every two weeks to deliver supplements and record consumption and side effects. Multivariate logistic regression was used to assess individual, household, and programmatic predictors of supplement adherence. RESULTS Adherence was high with 78 and 82% of the women consuming more than 80% of the preconception and prenatal supplements, respectively. Women of minority ethnicity (OR = 0.78 95% CI = 0.67, 0.91) and farmers (OR = 0.71 95% CI = 0.58, 0.88) were less likely to consume >80% of the preconception supplements while socioeconomic status (SES) (OR = 2.71 highest vs. lowest quintile; 95% CI = 2.10, 3.52) was positively associated with >80% adherence in the entire preconception sample with available information (n = 4417). Women in their first pregnancy had lower prenatal adherence compared to multiparous women. At the programmatic level, each village health worker visit was associated with higher odds of >80% adherence by 3-5% before pregnancy and 18% during pregnancy. CONCLUSIONS Key determinants of adherence included SES, ethnicity, occupation (farmer) and parity which may be helpful for targeting women for counseling on supplement adherence. Increased contact with village health workers was positively associated with adherence to micronutrient supplementation both before conception and during pregnancy indicating the need for resources to support community outreach to women of reproductive age. TRIAL REGISTRATION NCT01665378 . Registered on August 12, 2012.
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Affiliation(s)
- Ines Gonzalez-Casanova
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA.
| | - Phuong Hong Nguyen
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, 2033 K St, NW, Washington, DC, 20006-1002, USA.,Thai Nguyen University of Medicine and Pharmacy, 284 Luong Ngoc Quyen St, Thai Nguyen City, Vietnam
| | - Melissa Fox Young
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Kimberly B Harding
- The Micronutrient Initiative, 180 Elgin Street, Suite 1000, Ottawa, ON, K2P 2K3, Canada
| | - Greg Reinhart
- The Mathile Institute, 241 Taylor St, Ste 300, Dayton, OH, 45402, USA
| | - Hieu Nguyen
- Thai Nguyen University of Medicine and Pharmacy, 284 Luong Ngoc Quyen St, Thai Nguyen City, Vietnam
| | - Meredith Nechitillo
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Truong V Truong
- Thai Nguyen University of Medicine and Pharmacy, 284 Luong Ngoc Quyen St, Thai Nguyen City, Vietnam
| | - Hoa Pham
- Thai Nguyen University of Medicine and Pharmacy, 284 Luong Ngoc Quyen St, Thai Nguyen City, Vietnam
| | - Son Nguyen
- Thai Nguyen University of Medicine and Pharmacy, 284 Luong Ngoc Quyen St, Thai Nguyen City, Vietnam
| | - Lynnette M Neufeld
- The Global Alliance for Improved Nutrition (GAIN), Rue de Vermont 37-39, CH-1202, Geneva, Switzerland
| | - Reynaldo Martorell
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Usha Ramakrishnan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA
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Harding KB, Peña‐Rosas JP, Webster AC, Yap CMY, Payne BA, Ota E, De‐Regil LM. Iodine supplementation for women during the preconception, pregnancy and postpartum period. Cochrane Database Syst Rev 2017; 3:CD011761. [PMID: 28260263 PMCID: PMC6464647 DOI: 10.1002/14651858.cd011761.pub2] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Iodine is an essential nutrient required for the biosynthesis of thyroid hormones, which are responsible for regulating growth, development and metabolism. Iodine requirements increase substantially during pregnancy and breastfeeding. If requirements are not met during these periods, the production of thyroid hormones may decrease and be inadequate for maternal, fetal and infant needs. The provision of iodine supplements may help meet the increased iodine needs during pregnancy and the postpartum period and prevent or correct iodine deficiency and its consequences. OBJECTIVES To assess the benefits and harms of supplementation with iodine, alone or in combination with other vitamins and minerals, for women in the preconceptional, pregnancy or postpartum period on their and their children's outcomes. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (14 November 2016), and the WHO International Clinical Trials Registry Platform (ICTRP) (17 November 2016), contacted experts in the field and searched the reference lists of retrieved studies and other relevant papers. SELECTION CRITERIA Randomized and quasi-randomized controlled trials with randomisation at either the individual or cluster level comparing injected or oral iodine supplementation (such as tablets, capsules, drops) during preconception, pregnancy or the postpartum period irrespective of iodine compound, dose, frequency or duration. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility, risk of bias, extracted data and conducted checks for accuracy. We used the GRADE approach to assess the quality of the evidence for primary outcomes.We anticipated high heterogeneity among trials, and we pooled trial results using random-effects models and were cautious in our interpretation of the pooled results. MAIN RESULTS We included 14 studies and excluded 48 studies. We identified five ongoing or unpublished studies and two studies are awaiting classification. Eleven trials involving over 2700 women contributed data for the comparisons in this review (in three trials, the primary or secondary outcomes were not reported). Maternal primary outcomesIodine supplementation decreased the likelihood of the adverse effect of postpartum hyperthyroidism by 68% (average risk ratio (RR) 0.32; 95% confidence interval (CI) 0.11 to 0.91, three trials in mild to moderate iodine deficiency settings, 543 women, no statistical heterogeneity, low-quality evidence) and increased the likelihood of the adverse effect of digestive intolerance in pregnancy by 15 times (average RR 15.33; 95% CI 2.07 to 113.70, one trial in a mild-deficiency setting, 76 women, very low-quality evidence).There were no clear differences between groups for hypothyroidism in pregnancy or postpartum (pregnancy: average RR 1.90; 95% CI 0.57 to 6.38, one trial, 365 women, low-quality evidence, and postpartum: average RR 0.44; 95% CI 0.06 to 3.42, three trials, 540 women, no statistical heterogeneity, low-quality evidence), preterm birth (average RR 0.71; 95% CI 0.30 to 1.66, two trials, 376 women, statistical heterogeneity, low-quality evidence) or the maternal adverse effects of elevated thyroid peroxidase antibodies (TPO-ab) in pregnancy or postpartum (average RR 0.95; 95% CI 0.44 to 2.07, one trial, 359 women, low-quality evidence, average RR 1.01; 95% CI 0.78 to 1.30, three trials, 397 women, no statistical heterogeneity, low-quality evidence), or hyperthyroidism in pregnancy (average RR 1.90; 95% CI 0.57 to 6.38, one trial, 365 women, low-quality evidence). All of the trials contributing data to these outcomes took place in settings with mild to moderate iodine deficiency. Infant/child primary outcomesCompared with those who did not receive iodine, those who received iodine supplements had a 34% lower likelihood of perinatal mortality, however this difference was not statistically significant (average RR 0.66; 95% CI 0.42 to 1.03, two trials, 457 assessments, low-quality evidence). All of the perinatal deaths occurred in one trial conducted in a severely iodine-deficient setting. There were no clear differences between groups for low birthweight (average RR 0.56; 95% CI 0.26 to 1.23, two trials, 377 infants, no statistical heterogeneity, low-quality evidence), neonatal hypothyroidism/elevated thyroid-stimulating hormone (TSH) (average RR 0.58; 95% CI 0.11 to 3.12, two trials, 260 infants, very low-quality evidence) or the adverse effect of elevated neonatal thyroid peroxidase antibodies (TPO-ab) (average RR 0.61; 95% CI 0.07 to 5.70, one trial, 108 infants, very low-quality evidence). All of the trials contributing data to these outcomes took place in areas with mild to moderate iodine deficiency. No trials reported on hypothyroidism/elevated TSH or any adverse effect beyond the neonatal period. AUTHORS' CONCLUSIONS There were insufficient data to reach any meaningful conclusions on the benefits and harms of routine iodine supplementation in women before, during or after pregnancy. The available evidence suggested that iodine supplementation decreases the likelihood of postpartum hyperthyroidism and increases the likelihood of the adverse effect of digestive intolerance in pregnancy - both considered potential adverse effects. We considered evidence for these outcomes low or very low quality, however, because of study design limitations and wide confidence intervals. In addition, due to the small number of trials and included women in our meta-analyses, these findings must be interpreted with caution. There were no clear effects on other important maternal or child outcomes though these findings must also be interpreted cautiously due to limited data and low-quality trials. Additionally, almost all of the evidence came from settings with mild or moderate iodine deficiency and therefore may not be applicable to settings with severe deficiency.More high-quality randomised controlled trials are needed on iodine supplementation before, during and after pregnancy on maternal and infant/child outcomes. However, it may be unethical to compare iodine to placebo or no treatment in severe deficiency settings. Trials may also be unfeasible in settings where pregnant and lactating women commonly take prenatal supplements with iodine. Information is needed on optimal timing of initiation as well as supplementation regimen and dose. Future trials should consider the outcomes in this review and follow children beyond the neonatal period. Future trials should employ adequate sample sizes, assess potential adverse effects (including the nature and extent of digestive intolerance), and be reported in a way that allows assessment of risk of bias, full data extraction and analysis by the subgroups specified in this review.
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Affiliation(s)
- Kimberly B Harding
- Micronutrient InitiativeResearch and Evaluation180 Elgin Street, Suite 1000OttawaONCanadaK2P 2K3
| | - Juan Pablo Peña‐Rosas
- World Health OrganizationEvidence and Programme Guidance, Department of Nutrition for Health and Development20 Avenue AppiaGenevaGESwitzerland1211
| | - Angela C Webster
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
| | - Constance MY Yap
- Westmead HospitalDepartment of Diabetes and EndocrinologyCorner Hawkesbury and Darcy RoadsWestmeadNSWAustralia2145
| | - Brian A Payne
- Ministry of Health BarbadosNational Nutrition CenterSt MichaelBarbados
| | - Erika Ota
- St. Luke's International University, Graduate School of Nursing SciencesGlobal Health Nursing10‐1 Akashi‐choChuo‐KuTokyoJapan104‐0044
| | - Luz Maria De‐Regil
- Micronutrient InitiativeResearch and Evaluation180 Elgin Street, Suite 1000OttawaONCanadaK2P 2K3
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Galicia L, de Romaña DL, Harding KB, De-Regil LM, Grajeda R. Tackling malnutrition in Latin America and the Caribbean: challenges and opportunities. Rev Panam Salud Publica 2016; 40:138-146. [PMID: 27982371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 06/15/2016] [Indexed: 06/06/2023] Open
Abstract
Undernutrition and micronutrient deficiencies are still a public health problem in Latin America and the Caribbean (LAC), and overweight and obesity have reached epidemic proportions. To assess the nutrition landscape in LAC countries and guide future nutrition efforts and investments, the Pan American Health Organization and the Micronutrient Initiative joined efforts to 1) identify information gaps and describe the current nutritional situation in the region; 2) map existing policies to address malnutrition in Latin America; 3) describe the impact of conditional cash transfer programs (CCTs) on nutrition and health outcomes; and 4) identify the challenges and opportunities to address malnutrition in the region. This article summarizes the methods and key findings from that research and describes the current challenges and opportunities in addressing malnutrition in the LAC region. LAC countries have advanced in reducing undernutrition and micronutrient deficiencies, but important gaps in information are a major concern. These countries have policies to address undernutrition and micronutrient deficiencies, but comprehensive and intersectoral policies to tackle obesity are lacking. CCTs in Brazil, Colombia, and Mexico have been reported to have a positive impact on child nutrition and health outcomes, providing an opportunity to integrate nutrition actions in intersectoral platforms. The current epidemiological situation and policy options offer an opportunity for countries, technical agencies, donors, and other stakeholders to jointly scale up nutrition actions. This can support the development of comprehensive and intersectoral policies to tackle the double burden of malnutrition, strengthen national nutrition surveillance systems, incorporate monitoring and evaluation as systematic components of policies and programs, document and increase investments in nutrition, and assess the effectiveness of such policies to support political commitment and guarantee sustainability.
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Affiliation(s)
- Luis Galicia
- Pan American Health Organization, Washington, D.C., United States of America
| | | | - Kimberly B Harding
- Research and Evaluation Unit, Micronutrient Initiative, Ottawa, Ontario, Canada
| | - Luz María De-Regil
- Research and Evaluation Unit, Micronutrient Initiative, Ottawa, Ontario, Canada
| | - Rubén Grajeda
- Pan American Health Organization, Washington, D.C., United States of America
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Black MM, Fernandez-Rao S, Hurley KM, Tilton N, Balakrishna N, Harding KB, Reinhart G, Radhakrishna KV, Nair KM. Growth and development among infants and preschoolers in rural India. International Journal of Behavioral Development 2016. [DOI: 10.1177/0165025416644690] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Economic inequities are common in low and middle-income countries (LMIC), and are associated with poor growth and development among young children. The objectives are to examine whether maternal education and home environment quality: 1) protect children by attenuating the association between economic inequities and children’s growth and development, or 2) promote children’s growth and development, regardless of economic inequities. The sample includes 512 infants and 321 preschoolers in 26 villages in rural India (Project Grow Smart). Data for children: physical growth (weight and length/height measured) and development (Mullen Scales of Early Learning); for mothers/households: economic inequities measured by household assets, education, depressive symptoms, and home environment (HOME Inventory). Data are analyzed with linear mixed models (LMM) for infants and preschoolers separately, adjusted for village/preschool clustering, including asset-by-education/home interactions. Among infants, but not preschoolers, the education/home factor attenuates relations between assets and growth, eliminating differential relations in infant growth between high/low-asset families, suggesting protection. Among infants and preschoolers, the education/home factor is significantly or marginally associated with most child development scales, regardless of economic inequities, suggesting promotion. Strategies to enhance maternal education and home environment quality may protect infants in low-asset families from poor growth, promote development among infants and preschoolers, and prevent early disparities.
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Affiliation(s)
- Maureen M. Black
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sylvia Fernandez-Rao
- National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, Telangana, India
| | - Kristen M. Hurley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nicholas Tilton
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nagalla Balakrishna
- National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, Telangana, India
| | | | - Greg Reinhart
- The Mathile Institute for the Advancement of Human Nutrition, Dayton, OH, USA
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Ramakrishnan U, Nguyen PH, Gonzalez-Casanova I, Pham H, Hao W, Nguyen H, Truong TV, Nguyen S, Harding KB, Reinhart GA, Neufeld LM, Martorell R. Neither Preconceptional Weekly Multiple Micronutrient nor Iron-Folic Acid Supplements Affect Birth Size and Gestational Age Compared with a Folic Acid Supplement Alone in Rural Vietnamese Women: A Randomized Controlled Trial. J Nutr 2016; 146:1445S-52S. [PMID: 27281806 DOI: 10.3945/jn.115.223420] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 01/26/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Maternal nutritional status before and during early pregnancy plays a critical role in fetal growth and development. The benefits of periconception folic acid (FA) supplementation in the prevention of neural tube defects is well recognized, but the evidence for preconception micronutrient interventions for improving pregnancy outcomes is limited. OBJECTIVE This study aimed to evaluate whether preconception supplementation with weekly iron and folic acid (IFA) or multiple micronutrients (MMs) improves birth outcomes compared with FA alone. METHODS We recruited 5011 women of reproductive age in a double-blind, randomized controlled trial in Vietnam and provided weekly supplements containing either 2800 μg FA, 60 mg Fe and 2800 μg FA (IFA), or the same amount of FA and iron plus other MMs until they conceived (n = 1813). All pregnant women received daily IFA through delivery, and were followed up for birth outcomes, including birth weight, gestational age, preterm delivery and small for gestational age (SGA). Group comparisons were done with the use of ANOVA or chi-square tests for both intention-to-treat (n = 1599) and per-protocol analyses (women consumed supplements ≥26 wk before conception; n = 824). Effect modification by baseline underweight or anemia status was tested with the use of generalized linear models. RESULTS The mean age of the women was 26 y, 30% were underweight, and <10% were nulliparous. The groups were similar for most baseline characteristics. The mean ± SD duration of the preconception intervention was 33 ± 25 wk and compliance was high (>90%). Infants born to the 3 groups of women did not differ (P ≥ 0.05) on mean ± SD birth weight (3076.8 ± 444.5 g) or gestational age (39.2 ± 2.0 wk), or prevalence of SGA (12%), low birth weight (5%) and preterm delivery (10%). There were no significant differences in women who consumed supplements ≥26 wk before conception or by baseline underweight or anemia. CONCLUSION Weekly supplementation with MMs or IFA before conception did not affect birth outcomes compared with FA in rural Vietnamese women. The trial was registered at clinicaltrials.gov as NCT01665378.
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Affiliation(s)
- Usha Ramakrishnan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA;
| | - Phuong H Nguyen
- International Food Policy Research Institute, Hanoi, Vietnam; Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | - Ines Gonzalez-Casanova
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Hoa Pham
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | - Wei Hao
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Hieu Nguyen
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | - Truong V Truong
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | - Son Nguyen
- Thai Nguyen University of Pharmacy and Medicine, Thai Nguyen, Vietnam
| | | | - Gregory A Reinhart
- The Mathile Institute for the Advancement of Human Nutrition, Dayton, OH; and
| | | | - Reynaldo Martorell
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
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De-Regil LM, Harding KB, Roche ML. Preconceptional Nutrition Interventions for Adolescent Girls and Adult Women: Global Guidelines and Gaps in Evidence and Policy with Emphasis on Micronutrients. J Nutr 2016; 146:1461S-70S. [PMID: 27281812 DOI: 10.3945/jn.115.223487] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 04/19/2016] [Indexed: 12/15/2022] Open
Abstract
Much of the global nutrition efforts in recent years have been focused on improving the nutritional status of children during the window of the first 1000 d of life, from conception to 2 y of age. However, as the world transitions from the Millennium Development Goals to the Sustainable Development Goals, women's and adolescent girls' overall health and well-being are being placed at the center of the global agenda. It is also increasingly recognized that a woman's nutritional status before pregnancy affects maternal and child outcomes and thus needs to be improved to ensure optimal outcomes. This article reviews the global picture of preconception nutrition in women and girls, including some of the key factors that influence women's outcomes, as well as their children's outcomes, if they do become pregnant. This article describes the current global guidelines on preconceptional nutrition interventions for girls and women; highlights related gaps in evidence, guidelines, and policy; and discusses research to forward the agenda of improving women's and girls' preconceptional nutrition.
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Affiliation(s)
- Luz M De-Regil
- Research and Evaluation, Micronutrient Initiative, Ottawa, Canada
| | | | - Marion L Roche
- Research and Evaluation, Micronutrient Initiative, Ottawa, Canada
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De-Regil LM, Harding KB, Peña-Rosas JP, Webster AC. Iodine supplementation for women during the preconception, pregnancy and postpartum period. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011761] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Fernandez-Rao S, Hurley KM, Nair KM, Balakrishna N, Radhakrishna KV, Ravinder P, Tilton N, Harding KB, Reinhart GA, Black MM. Integrating nutrition and early child-development interventions among infants and preschoolers in rural India. Ann N Y Acad Sci 2014; 1308:218-231. [PMID: 24673168 DOI: 10.1111/nyas.12278] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This article describes the development, design, and implementation of an integrated randomized double-masked placebo-controlled trial (Project Grow Smart) that examines how home/preschool fortification with multiple micronutrient powder (MNP) combined with an early child-development intervention affects child development, growth, and micronutrient status among infants and preschoolers in rural India. The 1-year trial has an infant phase (enrollment age: 6-12 months) and a preschool phase (enrollment age: 36-48 months). Infants are individually randomized into one of four groups: placebo, placebo plus early learning, MNP alone, and MNP plus early learning (integrated intervention), conducted through home visits. The preschool phase is a cluster-randomized trial conducted in Anganwadi centers (AWCs), government-run preschools sponsored by the Integrated Child Development System of India. AWCs are randomized into MNP or placebo, with the MNP or placebo mixed into the children's food. The evaluation examines whether the effects of the MNP intervention vary by the quality of the early learning opportunities and communication within the AWCs. Study outcomes include child development, growth, and micronutrient status. Lessons learned during the development, design, and implementation of the integrated trial can be used to guide large-scale policy and programs designed to promote the developmental, educational, and economic potential of children in developing countries.
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Affiliation(s)
- Sylvia Fernandez-Rao
- Department of Behavioural Sciences, National Institute of Nutrition, Hyderabad, India
| | - Kristen M Hurley
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland.,Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Nagalla Balakrishna
- Department of Biostatistics, National Institute of Nutrition, Hyderabad, India
| | | | - Punjal Ravinder
- Department of Micronutrient Research, National Institute of Nutrition, Hyderabad, India
| | - Nicholas Tilton
- Department of Micronutrient Research, National Institute of Nutrition, Hyderabad, India
| | | | - Greg A Reinhart
- The Mathile Institute for the Advancement of Human Nutrition, Dayton, Ohio
| | - Maureen M Black
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
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Bougma K, Marquis GS, Aboud FE, Frongillo EA, Singla D, Harding KB, Lemma T, Samuel A, Serfu D. Iodine Deficiency and Child Development in Ethiopia. FASEB J 2013. [DOI: 10.1096/fasebj.27.1_supplement.845.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Karim Bougma
- School of Dietetics and Human NutritionMcGill UniversitySainte‐Anne‐de‐BellevueQCCanada
| | - Grace S Marquis
- School of Dietetics and Human NutritionMcGill UniversitySainte‐Anne‐de‐BellevueQCCanada
| | | | - Edward A Frongillo
- Department of Health Promotion, Education, and BehaviorUniversity of South CarolinaColombiaSC
| | - Daisy Singla
- Department of PsychologyMcGill UniversityMontrealQCCanada
| | | | - Tizita Lemma
- School of PsychologyBahir Dar UniversityBahir DarEthiopia
| | - Aregash Samuel
- Ethiopian Health and Nutrition Research InstitutionAddis AbabaEthiopia
| | - Dilnesaw Serfu
- Ethiopian Health and Nutrition Research InstitutionAddis AbabaEthiopia
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Nguyen PH, Strizich G, Lowe AL, Nguyen H, Pham H, Truong T, Nguyen S, Reinhart GA, Harding KB, Neufeld LM, Martorell R, Ramakrishnan U. Food consumption pattern and associated factors in Vietnam. FASEB J 2013. [DOI: 10.1096/fasebj.27.1_supplement.844.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- P H Nguyen
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
- International Food Policy Research Inst.HanoiVietnam
| | | | | | - H Nguyen
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
| | - H Pham
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
| | - T Truong
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
| | - S Nguyen
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
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Nguyen PH, Katz B, Lowe AE, Nguyen H, Truong T, Pham H, Nguyen S, Reinhart GA, Harding KB, Neufeld LM, Martorell R, Ramakrishnan U. Anthropometric differences and body composition among ethnic minorities in northern Vietnam. FASEB J 2013. [DOI: 10.1096/fasebj.27.1_supplement.1055.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- P H Nguyen
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
- International Food Policy Research Inst.HanoiVietnam
| | | | | | - H Nguyen
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
| | - T Truong
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
| | - H Pham
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
| | - S Nguyen
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
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Mohammed H, Marquis GS, Aboud F, Bougma K, Singla D, Harding KB, Samuel A. Nutritional Status and Mental Development of Children Under 5 Years of Age in Amhara Region of Ethiopia. FASEB J 2013. [DOI: 10.1096/fasebj.27.1_supplement.845.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Husein Mohammed
- School of Dietetics and Human NutritionMcGill UniversityMontrealQCCanada
| | - Grace S Marquis
- School of Dietetics and Human NutritionMcGill UniversityMontrealQCCanada
| | - Frances Aboud
- Department of PsychologyMcGill UniversityMontrealQCCanada
| | - Karim Bougma
- School of Dietetics and Human NutritionMcGill UniversityMontrealQCCanada
| | - Daisy Singla
- Department of PsychologyMcGill UniversityMontrealQCCanada
| | | | - Aregash Samuel
- Food Sciences and Nutrition Lab.Ethiopian Health and Nutrition Research Institute (EHNRI)Addis AbabaEthiopia
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Ramakrishnan U, Nguyen PH, Copeland E, Lowe AE, Strizich G, Nguyen H, Pham H, Truong T, Nguyen S, Reinhart GA, Harding KB, Neufeld LM, Martorell R. Vitamin and Micronutrient Intakes among Women of Reproductive Age in Vietnam. FASEB J 2013. [DOI: 10.1096/fasebj.27.1_supplement.844.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - P H Nguyen
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
- International Food Policy Research Inst.HanoiVietnam
| | | | | | | | - H Nguyen
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
| | - H Pham
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
| | - T Truong
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
| | - S Nguyen
- Thai Nguyen Univ. of Pharmacy and MedicineThai NguyenVietnam
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Nguyen PH, Lowe AE, Martorell R, Nguyen H, Pham H, Nguyen S, Harding KB, Neufeld LM, Reinhart GA, Ramakrishnan U. Rationale, design, methodology and sample characteristics for the Vietnam pre-conceptual micronutrient supplementation trial (PRECONCEPT): a randomized controlled study. BMC Public Health 2012; 12:898. [PMID: 23092451 PMCID: PMC3533960 DOI: 10.1186/1471-2458-12-898] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2012] [Accepted: 10/11/2012] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Low birth weight and maternal anemia remain intractable problems in many developing countries. The adequacy of the current strategy of providing iron-folic acid (IFA) supplements only during pregnancy has been questioned given many women enter pregnancy with poor iron stores, the substantial micronutrient demand by maternal and fetal tissues, and programmatic issues related to timing and coverage of prenatal care. Weekly IFA supplementation for women of reproductive age (WRA) improves iron status and reduces the burden of anemia in the short term, but few studies have evaluated subsequent pregnancy and birth outcomes.The Preconcept trial aims to determine whether pre-pregnancy weekly IFA or multiple micronutrient (MM) supplementation will improve birth outcomes and maternal and infant iron status compared to the current practice of prenatal IFA supplementation only. This paper provides an overview of study design, methodology and sample characteristics from baseline survey data and key lessons learned. METHODS/DESIGN We have recruited 5011 WRA in a double-blind stratified randomized controlled trial in rural Vietnam and randomly assigned them to receive weekly supplements containing either: 1) 2800 μg folic acid 2) 60 mg iron and 2800 μg folic acid or 3) MM. Women who become pregnant receive daily IFA, and are being followed through pregnancy, delivery, and up to three months post-partum. Study outcomes include birth outcomes and maternal and infant iron status. Data are being collected on household characteristics, maternal diet and mental health, anthropometry, infant feeding practices, morbidity and compliance. DISCUSSION The study is timely and responds to the WHO Global Expert Consultation which identified the need to evaluate the long term benefits of weekly IFA and MM supplementation in WRA. Findings will generate new information to help guide policy and programs designed to reduce the burden of anemia in women and children and improve maternal and child health outcomes in resource poor settings. TRIAL REGISTRATION NCT01665378.
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Affiliation(s)
- Phuong H Nguyen
- Thai Nguyen University of Medicine and Pharmacy, Thai Nguyen, Vietnam
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Hanoi, Vietnam
| | - Alyssa E Lowe
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Reynaldo Martorell
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Hieu Nguyen
- Thai Nguyen University of Medicine and Pharmacy, Thai Nguyen, Vietnam
| | - Hoa Pham
- Thai Nguyen University of Medicine and Pharmacy, Thai Nguyen, Vietnam
| | - Son Nguyen
- Thai Nguyen University of Medicine and Pharmacy, Thai Nguyen, Vietnam
| | | | | | - Gregory A Reinhart
- The Mathile Institute for the Advancement of Human Nutrition, Dayton, OH, USA
| | - Usha Ramakrishnan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Harding KB, Neufeld LM. Iron deficiency and anemia control for infants and young children in malaria-endemic areas: a call to action and consensus among the research community. Adv Nutr 2012; 3:551-4. [PMID: 22797991 PMCID: PMC3649725 DOI: 10.3945/an.111.000760] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
WHO recommendations on iron supplementation for infants and young children in malaria-endemic areas changed dramatically from universal to targeted supplementation for iron-deficient children only, after a trial in a high malaria transmission area showed an increased risk of hospital admission and mortality among iron-replete children following iron and folic acid supplementation. Since this time, there has been much debate and little agreement among the nutrition research community on how to move forward, and country policy and program decision makers have been left with incomplete guidance on how to address young child iron deficiency and anemia in their countries. The focus of a recent symposium during the American Society for Nutrition annual meeting, held in Washington, DC, in April 2011, was on exploring options for addressing iron deficiency and anemia among infants and young children in malaria-endemic areas, now, with safe, effective, and feasible interventions that provide iron. Papers based on the invited presentations are included in this supplement. The first paper is a review of the relationship between iron and malaria. The second is an analysis of theoretical and practical considerations regarding the targeted approach of providing iron and includes results from field testing noninvasive screening devices. This is followed by a review of the safety of universal provision of iron through home-fortification products in malaria-endemic areas. The final papers provide a call to action by highlighting pending research issues (fourth paper) and feasible strategies to move programs forward (fifth paper).
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Campbell N, Dary O, Cappuccio FP, Neufeld LM, Harding KB, Zimmermann MB. Collaboration to optimize dietary intakes of salt and iodine: a critical but overlooked public health issue. Bull World Health Organ 2012; 90:73-4. [PMID: 22271970 DOI: 10.2471/blt.11.092080] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 08/30/2011] [Accepted: 09/06/2011] [Indexed: 11/27/2022] Open
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Addo AA, Marquis GS, Lartey AA, Pérez-Escamilla R, Mazur RE, Harding KB. Food insecurity and perceived stress but not HIV infection are independently associated with lower energy intakes among lactating Ghanaian women. Matern Child Nutr 2011; 7:80-91. [PMID: 21143587 DOI: 10.1111/j.1740-8709.2009.00229.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Human immunodeficiency virus (HIV) seropositive women living in low-income communities may have difficulty meeting the increased energy requirements that are associated with both lactation and HIV infection. Data on household food security and maternal socio-demographic characteristics, perceived stress, anthropometry, reported illness, dietary intakes and preferences, and exposure to nutrition education were collected from 70 lactating women [16 seropositive (HP), 27 seronegative (HN), and 27 who refused to be tested and had unknown HIV status (HU)]. Diet was assessed with three 24-h recalls (one market day, one weekend day, and one non-market weekday). Data were collected at 8.4 (SD = 4.7) months postpartum. Most women (74.3%) reported being in good health at the time of study. Three-day mean energy intakes did not differ by HIV status [HP: 12,000 kJ (SD = 3600), HN: 12,600 kJ (SD = 5100), and HU: 12,300 kJ (SD = 4800); P = 0.94]. Protein, fat, vitamin A, thiamin, riboflavin, niacin, vitamin C, calcium, iron, and zinc intakes also did not differ by group (P > 0.10). There was a higher proportion of women with high stress levels in food insecure households compared with food secure households (55.6% vs. 26.5%; P = 0.01). Energy intake was independently negatively associated with food insecurity [high: 11,300 kJ (SD = 3500) vs. low: 13,400 kJ (SD = 5400), respectively; P = 0.050] and stress [high: 10,800 kJ (SD = 2800) vs. low: 13,400 kJ (SD = 5300), P = 0.021]. These results suggest the need to integrate multi-dimensional interventions that address economic and mental health constraints which may limit some women's ability to meet their dietary needs.
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Affiliation(s)
- Adolphina A Addo
- Department of Nutrition, School of Public Health & Health Sciences, University of Massachusetts, Amherst, Massachusetts 01003, USA
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Harding KB, Ramakrishnan U, Mejia F, Guerra AG, Martorell R, Neufeld LM. Early childhood multiple micronutrient supplementation is associated with lower obesity prevalence in later childhood, compared with iron and vitamin A supplementation only. FASEB J 2010. [DOI: 10.1096/fasebj.24.1_supplement.lb291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | | | | | - Lynnette M Neufeld
- Micronutrient InitiativeOttawaONCanada
- National Institute of Public HealthCuernavacaMexico
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Marquis GS, Harding KB, Colecraft EK, Lartey A, Sakyi‐Dawson O, Ahunu BK, Reddy MB, Jensen HH, Butler LM, Lonergan E. Integrating economic and educational intervention activities in the ENAM project leads to improved child nutritional status in rural Ghana. FASEB J 2009. [DOI: 10.1096/fasebj.23.1_supplement.352.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Grace S Marquis
- School of Dietetics and Human NutritionMcGill UniversitySte‐Anne‐de‐BellevueQCCanada
- Food Science & Human NutritionIowa State UniversityAmesIA
| | - Kimberly B Harding
- School of Dietetics and Human NutritionMcGill UniversitySte‐Anne‐de‐BellevueQCCanada
| | | | | | | | - B K Ahunu
- Animal ScienceUniversity of GhanaLegonGhana
| | - Manju B Reddy
- Food Science & Human NutritionIowa State UniversityAmesIA
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Harding KB, Marquis GS, Colecraft EK, Lartey A, Sakyi‐Dawson O, Ahunu BK, Reddy MB, Jensen HH, Butler LM, Lonergan E. An integrated economic and education intervention (the ENAM project) decreased household food insecurity in rural Ghana. FASEB J 2009. [DOI: 10.1096/fasebj.23.1_supplement.336.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Kimberly B Harding
- School of Dietetics & Human NutritionMcGill UniversitySte‐Anne‐de‐BellevueQCCanada
| | - Grace S Marquis
- School of Dietetics & Human NutritionMcGill UniversitySte‐Anne‐de‐BellevueQCCanada
- Food Science & Human NutritionIowa State UniversityAmesIA
| | | | | | | | - B K Ahunu
- Animal ScienceUniversity of GhanaLegonGhana
| | - Manju B Reddy
- Food Science & Human NutritionIowa State UniversityAmesIA
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