Female rats consuming an iron and omega-3 fatty acid deficient diet preconception require combined iron and omega-3 fatty acid supplementation for the prevention of bone impairments in offspring

We previously showed in rats that pre- and postnatal deficiencies in iron and omega-3 (n-3) fatty acids can impair bone development, with additive and potentially irreversible effects when combined. This study aimed to investigate, in female rats consuming a combined iron and n-3 fatty acid deficient (ID + n-3 FAD) diet preconception, whether supplementation with iron and docosahexaenoic/eicosapentaenoic acid (DHA/EPA), alone and in combination, can prevent bone impairments in offspring. Using a 2 × 2 factorial design, female Wistar rats consuming an ID + n-3 FAD diet preconception were randomised to receive an: 1) iron supplemented (Fe + n-3 FAD), 2) DHA/EPA supplemented (ID + DHA/EPA), 3) Fe + DHA/EPA, or 4) ID + n-3 FAD diet from gestational day 10 throughout pregnancy and lactation. Post-weaning, offspring (n = 24/group; male:female = 1:1) remained on the respective experimental diets for three weeks until postnatal day 42-45. Offspring born to female rats consuming a control diet preconception and an Fe+DHA/EPA diet throughout pregnancy and lactation served as non-deficient reference group (Control+Fe+DHA/EPA). Bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry and bone strength using three-point bending tests. Only offspring in the Fe+DHA/EPA group had significantly higher spine and femur BMD, and higher femur stiffness than offspring in the ID + n-3 FAD group, and had similar spine BMD and femur stiffness as the Control + Fe + DHA/EPA group. Offspring in the Fe + DHA/EPA group further had significantly higher femur strength (ultimate load) than the other experimental groups, and a similar femur strength as the Control + Fe + DHA/EPA group. This study shows that only combined iron and DHA/EPA supplementation can prevent bone impairments in offspring of female rats consuming an iron and n-3 FA deficient diet preconception.

Iron status in Swiss adolescents with paediatric major depressive disorder and healthy controls: a matched case-control study

PURPOSE

Depression is associated with low-grade systemic inflammation and impaired intestinal function, both of which may reduce dietary iron absorption. Low iron status has been associated with depression in adults and adolescents. In Swiss adolescents, we determined the associations between paediatric major depressive disorder (pMDD), inflammation, intestinal permeability and iron status.

METHODS

This is a matched case-control study in 95 adolescents with diagnosed pMDD and 95 healthy controls aged 13-17 years. We assessed depression severity using the Children's Depression Rating Scale-Revised. We measured iron status (serum ferritin (SF) and soluble transferrin receptor (sTfR)), inflammation (C-reactive protein (CRP) and alpha-1-acid-glycoprotein (AGP)), and intestinal permeability (intestinal fatty acid binding protein (I-FABP)). We assessed history of ID diagnosis and treatment with a self-reported questionnaire.

RESULTS

SF concentrations did not differ between adolescents with pMDD (median (IQR) SF: 31.2 (20.2, 57.0) μg/L) and controls (32.5 (22.6, 48.3) μg/L, p = 0.4). sTfR was lower among cases than controls (4.50 (4.00, 5.50) mg/L vs 5.20 (4.75, 6.10) mg/L, p < 0.001). CRP, AGP and I-FABP were higher among cases than controls (CRP: 0.16 (0.03, 0.43) mg/L vs 0.04 (0.02, 0.30) mg/L, p = 0.003; AGP: 0.57 (0.44, 0.70) g/L vs 0.52 (0.41, 0.67) g/L, p = 0.024); I-FABP: 307 (17, 515) pg/mL vs 232 (163, 357) pg/mL, p = 0.047). Of cases, 44% reported having a history of ID diagnosis compared to 26% among controls (p = 0.020). Finally, 28% of cases had iron treatment at/close to study inclusion compared to 14% among controls.

CONCLUSION

Cases had significantly higher systemic inflammation and intestinal permeability than controls but did not have lower iron status. Whether this is related to the higher rate of ID diagnosis and iron treatment in adolescents with depression is uncertain.

Comparison of test performance of two commonly used multiplex assays to measure micronutrient and inflammatory markers in serum: results from a survey among pregnant women in South Africa

The combined sandwich-ELISA (s-ELISA; VitMin Lab, Germany) and the Quansys Q-Plex™ Human Micronutrient Array (7-Plex) are multiplex serum assays that are used to assess population micronutrient status in low-income countries. We aimed to compare the agreement of five analytes, α-1-acid glycoprotein (AGP), C-reactive protein (CRP), ferritin, retinol-binding protein 4 (RBP4) and soluble transferrin receptor (sTfR) as measured by the 7-Plex and the s-ELISA. Serum samples were collected between March 2016 and December 2017. Pregnant women (n 249) were recruited at primary healthcare clinics in Johannesburg, and serum samples were collected between March 2016 and December 2017. Agreement between continuous measurements was assessed by Bland-Altman plots and concordance measures. Agreement in classifications of deficiency or inflammation was assessed by Cohen's kappa. Strong correlations (r > 0·80) were observed between the 7-Plex and s-ELISA for CRP and ferritin. Except for CRP, the 7-Plex assay gave consistently higher measurements than the s-ELISA. With the exception of CRP (Lin's ρ = 0·92), there was poor agreement between the two assays, with Lin's ρ < 0·90. Discrepancies of test results difference between methods increased as the serum concentrations rose. Cohen's kappa for all the five analytes was < 0·81 and ranged from slight agreement (vitamin A deficiency) to substantial (inflammation and Fe deficiency) agreement. The 7-Plex 1.0 is a research and or surveillance tool with potential for use in low-resource laboratories but cannot be used interchangeably with the s-ELISA. Further optimising and validation is required to establish its interchangeability with other validated methods.

Associations of n-3 polyunsaturated fatty acid status and intake with paediatric major depressive disorder in Swiss adolescents: A case-control study

BACKGROUND

Observational studies suggest a link between n-3 polyunsaturated fatty acid (PUFA) intake, n-3 PUFA status, and depression in adults, but studies in adolescents are scarce. This study aimed to determine associations of n-3 PUFA status and intake with paediatric major depressive disorder (pMDD) in Swiss adolescents.

METHODS

We conducted a matched case-control study in 95 adolescents diagnosed with pMDD and 95 healthy controls aged 13 to <18 years. We analysed red blood cell (RBC) fatty acid (FA) composition (% of total FA). n-3 PUFA intake was assessed using a focused food frequency questionnaire and depression severity was assessed by the Children's Depression Rating Scale-Revised (CDRS-R).

RESULTS

Mean RBC eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were lower in cases than controls (EPA: 0.41 ± 0.11 vs 0.46 ± 0.12, p < 0.001; DHA: 4.07 ± 1.04 vs 4.73 ± 1.04, p < 0.001). Subsequently, the mean RBC n-3 index was lower (4.51 ± 1.10 vs 5.20 ± 1.11, p < 0.001) and the n-6/n-3 PUFA ratio higher (5.51 ± 1.25 vs 4.96 ± 1.08, p < 0.001) in cases than controls. Adolescents with a higher n-3 index had lower odds for depression (OR = 0.49 [95% CI: 0.32-0.71]). In contrast, the n-6/n-3 PUFA ratio was associated with higher odds for depression (OR = 1.58 [95% CI: 1.14-2.25]). Intake of alpha-linolenic acid, EPA and DHA did not differ between cases and controls.

CONCLUSION

Our results suggest that a higher RBC n-3 PUFA status during adolescence is associated with a lower risk for pMDD, whereas a higher n-6/n-3 PUFA ratio is associated with a higher risk for pMDD. Differences in n-3 PUFA intake did not explain the observed differences in n-3 PUFA status.

Iron and n-3 fatty acid depletion, alone and in combination, during early development provoke neurochemical changes, anhedonia, anxiety and social dysfunction in rats

Objectives: Both iron and omega-3 (n-3) fatty acids (FA) play important roles in the development and functioning of the brain. We investigated the effects of n-3 FA and iron deficiencies, alone and in combination, during early development on behaviour and brain monoamines in rats. Methods: Using a 2-factorial design, female Wistar rats were randomly allocated to one of four diet groups: Control, n-3 FA deficient (n-3 FAD), iron deficient (ID), or n-3 FAD + ID. Females received these diets throughout mating, pregnancy and lactation. Offspring (n = 24/group; male:female = 1:1) continued on the same diet until post-natal day 42-45, and underwent a sucrose preference test (SPT), novel object recognition test, elevated plus maze (EPM) and social interaction test (SIT). Results: ID offspring consumed less sucrose in the SPT and spent more time in closed arms and less time in open arms of the EPM than non-ID offspring. In female offspring only, ID and n-3 FAD reduced time approaching and together in the SIT, with an additive effect of ID and n-3 FAD for even less time approaching and spent together in the n-3 FAD + ID group compared to controls. ID offspring had higher striatal dopamine and norepinephrine and lower frontal cortex dopamine concentrations. N-3 FAD and ID affected frontal cortex serotonin concentrations in a sex-specific manner. Conclusions: Our results suggest that ID and n-3 FAD during early development provoke anhedonia, anxiety and social dysfunction in rats, with potential additive and attenuating effects when combined. These effects may in part be attributed to disturbances in brain neurochemistry and may be sex-specific.

Psychotic-like experiences in non-clinical subgroups with and without specific beliefs

BACKGROUND

Assuming a transdiagnostic and extended psychosis phenotype, psychotic-like experiences (PLEs) and psychotic symptoms are on a phenomenological and temporal continuum between clinical and non-clinical populations. Recent research points towards differences in PLE proneness in different subgroups and clinical impact of different PLE subtypes. This study examines the prevalence of PLEs in three groups of individuals with and without specific sets of beliefs aiming to elucidate the question whether proneness to PLEs varies according to traditional versus less traditional supernatural beliefs.

METHODS

The anonymized 16-item version of the Prodromal Questionnaire (PQ-16) was used to assess PLEs in three groups including individuals with religious beliefs (RB), belief in esoterism and paranormal phenomena (EB), and those embedded in scientific evidence approach and scepticism towards para-scientific theories (non-believers, NB). Male and female participants between 18 and 90 years were eligible for participation.

RESULTS

The sample comprised 159 individuals including 41 RB individuals, 43 EB individuals, and 75 NB individuals. The mean PQ-16 score of the EB individuals (6.86 ± 4.13) was significantly higher compared to NB individuals (3.43 ± 2.99) and to RB individuals (3.38 ± 3.23) with almost twice the score (both p-values < 0.001). There was no significant difference between the PQ-16 scores of the NB group and the RB group (p = 0.935). No significant impact of age (p = 0.330) and gender (p = 0.061) was found on the PQ16-Score. Group affiliation to esoterism was associated with a higher PQ-16 score compared to group affiliation to religious beliefs (p < 0.001) and group affiliation to scepticism (p = 0.011), while the latter two did not differ significantly (p = 0.735). No significant difference was found between the three groups in the degree of distress related to the affirmatively answered PQ-16 items (p = 0.74).

CONCLUSION

Under the assumption of a transdiagnostic psychosis phenotype, our findings provide more insight which subgroups within non-clinical samples have a higher likelihood of reporting PLEs.

Associations of HIV and iron status with gut microbiota composition, gut inflammation and gut integrity in South African school-age children: a two-way factorial case-control study

BACKGROUND

Human immunodeficiency virus (HIV) and iron deficiency (ID) affect many African children. Both HIV and iron status interact with gut microbiota composition and related biomarkers. The study's aim was to determine the associations of HIV and iron status with gut microbiota composition, gut inflammation and gut integrity in South African school-age children.

METHODS

In this two-way factorial case-control study, 8- to 13-year-old children were enrolled into four groups based on their HIV and iron status: (1) With HIV (HIV+) and ID (n = 43), (2) HIV+ and iron-sufficient nonanaemic (n = 41), (3) without HIV (HIV-) and ID (n = 44) and (4) HIV- and iron-sufficient nonanaemic (n = 38). HIV+ children were virally suppressed (<50 HIV RNA copies/ml) on antiretroviral therapy (ART). Microbial composition of faecal samples (16S rRNA sequencing) and markers of gut inflammation (faecal calprotectin) and gut integrity (plasma intestinal fatty acid-binding protein [I-FABP]) were assessed.

RESULTS

Faecal calprotectin was higher in ID versus iron-sufficient nonanaemic children (p = 0.007). I-FABP did not significantly differ by HIV or iron status. ART-treated HIV (redundancy analysis [RDA] R2  = 0.009, p = 0.029) and age (RDA R2  = 0.013 p = 0.004) explained the variance in the gut microbiota across the four groups. Probabilistic models showed that the relative abundance of the butyrate-producing genera Anaerostipes and Anaerotruncus was lower in ID versus iron-sufficient children. Fusicatenibacter was lower in HIV+ and in ID children versus their respective counterparts. The prevalence of the inflammation-associated genus Megamonas was 42% higher in children with both HIV and ID versus HIV- and iron-sufficient nonanaemic counterparts.

CONCLUSIONS

In our sample of 8- to 13-year-old virally suppressed HIV+ and HIV- children with or without ID, ID was associated with increased gut inflammation and changes in the relative abundance of specific microbiota. Moreover, in HIV+ children, ID had a cumulative effect that further shifted the gut microbiota to an unfavourable composition.

Higher n-3 polyunsaturated fatty acid status during early pregnancy is associated with lower risk for depression at 12 months postpartum: The NuPED study

Perinatal depression can negatively affect the health of the mother and her offspring. N-3 polyunsaturated fatty acids (PUFA) may play a role in the aetiology of depression. Therefore, we investigated the association of n-3 PUFA status during early pregnancy with perinatal depression among women living in urban Johannesburg, South Africa. For this prospective analysis, we analysed red blood cell (RBC) total phospholipid fatty acid (FA) composition (% of total FA) of 242 pregnant women at <18 weeks' gestation. We used the Edinburgh Postnatal Depression Scale (EPDS) to identify women at risk for depression (EPDS score ≥9) at <18, 22 and 36 weeks' gestation, and at 6 and 12 months postpartum. RBC EPA status was negatively (β=-0.22, p<0.05), and the AA/EPA ratio positively (β=0.24, p<0.05) associated with EPDS scores at 12 months postpartum. Higher RBC DHA and n-3 index were further associated with lower odds (OR=0.56 [95% CI: 0.32-0.91]; OR=0.63 [95% CI: 0.39-0.94]), while higher n-6/n-3 PUFA and AA/EPA ratios early in pregnancy were associated with higher odds for depression at 12 months postpartum ((OR=2.34 [95% CI: 1.12-4.97]; OR=1.02 [95% CI: 1.00-1.05]). Our results suggest that women with a higher RBC n-3 PUFA status during early pregnancy may be at lower risk for depression at 12 months postpartum.

Moving Complementary Feeding Forward: Report on a Workshop of the Federation of International Societies for Pediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN) and the World Health Organization Regional Office for Europe

The WHO Regional Office for Europe and the Federation of International Societies for Pediatric Gastroenterology, Hepatology, and Nutrition held a joint workshop, "Moving Complementary Feeding Forward" at the sixth World Congress Pediatric Gastroenterology, Hepatology, and Nutrition in 2021. Here we summarize workshop presentations and discussions. The workshop covered health implications of complementary feeding (CF) including allergies, challenges to meet dietary needs during the CF period, quality of commercial complementary foods (CFD) and respective marketing practices, national CF guidelines in Europe, a nutrient profiling system for CFD, and global policy perspectives on the standards and regulation of marketing for CFD. Adequate CF practices are of critical importance for short and long-term child health, prevention of nutrient deficiencies, normal growth and development, and reducing the risk of allergies. The workshop identified the need to improve feeding practices, harmonize evidence-based information and develop guidance jointly with various stakeholders, improve the composition and marketing practices of commercial CFD and their transparent labeling based on nutrient profiling. Renewed efforts for collaboration between scientists, public health experts, pediatric associations, national governments, and the WHO are necessary for advancing progress.

The effect of a natural polyphenol supplement on iron absorption in adults with hereditary hemochromatosis

Objectives

We developed a natural polyphenol supplement that strongly chelates iron in vitro and assessed its effect on non-heme iron absorption in patients with hereditary hemochromatosis (HH).

Methods

We performed in vitro iron digestion experiments to determine iron precipitation by 12 polyphenol-rich dietary sources, and formulated a polyphenol supplement (PPS) containing black tea powder, cocoa powder and grape juice extract. In a multi-center, single-blind, placebo-controlled cross-over study, we assessed the effect of the PPS on iron absorption from an extrinsically labelled test meal and test drink in patients (n = 14) with HH homozygous for the p.C282Y variant in the HFE gene. We measured fractional iron absorption (FIA) as stable iron isotope incorporation into erythrocytes.

Results

Black tea powder, cocoa powder and grape juice extract most effectively precipitated iron in vitro. A PPS mixture of these three extracts precipitated ~ 80% of iron when 2 g was added to a 500 g iron solution containing 20 µg Fe/g. In the iron absorption study, the PPS reduced FIA by ~ 40%: FIA from the meal consumed with the PPS was lower (3.01% (1.60, 5.64)) than with placebo (5.21% (3.92, 6.92)) (p = 0.026)), and FIA from the test drink with the PPS was lower (10.3% (7.29 14.6)) than with placebo (16.9% (12.8 22.2)) (p = 0.002).

Conclusion

Our results indicate that when taken with meals, this natural PPS can decrease dietary iron absorption, and might thereby reduce body iron accumulation and the frequency of phlebotomy in patients with HH.

Trial registry: clinicaltrials.gov (registration date: 9.6.2019, NCT03990181).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00394-022-02829-8.

Iron from nanostructured ferric phosphate: absorption and biodistribution in mice and bioavailability in iron deficient anemic women

Food fortification with iron nanoparticles (NPs) could help prevent iron deficiency anemia, but the absorption pathway and biodistribution of iron-NPs and their bioavailability in humans is unclear. Dietary non-heme iron is physiologically absorbed via the divalent metal transporter-1 (DMT1) pathway. Using radio- iron isotope labelling in mice with a partial knockdown of intestine-specific DMT1, we assessed oral absorption and tissue biodistribution of nanostructured ferric phosphate (FePO₄-NP; specific surface area [SSA] 98 m²g^-1) compared to to ferrous sulfate (FeSO₄), the reference compound. We show that absorption of iron from FePO₄-NP appears to be largely DMT1 dependent and that its biodistribution after absorption is similar to that from FeSO₄, without abnormal deposition of iron in the reticuloendothelial system. Furthermore, we demonstrate high bioavailability from iron NPs in iron deficient anemic women in a randomized, cross-over study using stable-isotope labelling: absorption and subsequent erythrocyte iron utilization from two ⁵⁷Fe-labeled FePO₄-NP with SSAs of 98 m²g⁻¹ and 188 m²g⁻¹ was 2.8-fold and 5.4-fold higher than from bulk FePO₄ with an SSA of 25 m²g⁻¹ (P < 0.001) when added to a rice and vegetable meal consumed by iron deficient anemic women. The FePO₄-NP 188 m²g^-1 achieved 72% relative bioavailability compared to FeSO₄. These data suggest FePO₄-NPs may be useful for nutritional applications.

Short confinement of sows after farrowing, but not pen type affects live-born piglet mortality

Over the last decades, permanent crating of farrowing and lactating sows has led to serious public concerns with regard to sow welfare. As one alternative, it has been suggested to restrict crating to the period when suckling piglets are at the highest risk to die. Therefore, the aim of this study was to investigate live-born piglet mortality with regard to different confinement periods (CFP) as well as farrowing pen types. On three research farms (A, B and C), four confinement periods were compared: In CFP 0 (control), sows were not confined at all, sows in CFP 3 were crated after the end of farrowing for three days. In CFP 4, sows were confined one day before the due date of farrowing until three days after parturition and sows in CFP 6 were crated one day before expected farrowing until five days after parturition. Furthermore, five different pen types designed for temporary crating (PT; 5.5-7.3 m²) were compared. In total, production data from 638 litters were analysed. For each piglet found dead (n = 1 580), the cause of death was determined by the farm personnel and verified by necropsy (all three farms) and additional video analysis (farms A and B only). Data were analysed using logistic mixed models with CFP 0 and pen type Fluegel as reference categories (CFP 0 was control and this pen type was present on all three farms and the largest number of litters was born in this pen type). Live-born piglet mortality was lower in temporarily crated sows than in sows without confinement (CFP 0; P < 0.015). Pairwise posthoc tests did not reveal differences between CFP 3, CFP 4 and CFP 6 (odds ratios 0.75, 0.59 and 0.69), nor between pen types. Additional factors associated with increasing live-born piglet mortality were larger litter size, higher sow parity as well as the administration of hormones around farrowing. Factors influencing mortality due to crushing were similar to those for total live-born mortality with the exception of CFP 3 not differing significantly from CFP 0. It can be concluded, that confinement of the sow for three days after farrowing is an effective measure to reduce live-born piglet mortality in the pen types tested. An extension of the confinement period to five days after parturition does not result in a further reduction of live-born mortality rate.

Effects and Reversibility of Pre- and Post-natal Iron and Omega-3 Fatty Acid Deficiency, Alone and in Combination, on Bone Development in Rats

Both iron and omega-3 (n-3) polyunsaturated fatty acids may play an important role in bone development. The aim of this study was to investigate the effects of pre- and post-natal iron and n-3 fatty acid deficiency (FAD), alone and in combination, on bone development in rats, and to determine whether effects are reversible when a sufficient diet is provided post-weaning. Using a 2×2-factorial design, 56 female Wistar rats were allocated to one of four diets: (1) control, (2) iron deficient (ID), (3) n-3 FAD or (4) ID and n-3 FAD, and were maintained on the respective diets throughout gestation and lactation. At weaning (post-natal day [PND] 21), offspring (n = 24/group; male:female=1:1) were randomly allocated to either continue with their respective diets or to switch to the control diet until PND 42-45. Bone mineral density (BMD) and bone strength were determined using dual X-ray absorptiometry and three-point bending tests, respectively. Pre- and post-natal ID resulted in significantly lower BMD in the spine and bone strength in the left femur. Both ID and n-3 FAD resulted in lower BMD in the right femur, with an additive reduction in the combined ID and n-3 FAD group vs. controls. While negative effects of pre- and post-natal ID alone were reversed in offspring switched to a control diet post-weaning, lower BMD and bone strength persisted in offspring with combined ID and n-3 FAD during the prenatal and early post-natal period. Effects were not sex-specific. These results indicate that ID during early life may negatively influence bone development, with potential additive effects of n-3 FAD. While the effects of ID alone seem reversible, a combined ID and n-3 FAD may result in irreversible deficits in bone development.

Seasonal effects on urinary iodine concentrations in women of reproductive age: An observational study in Tanzania and South Africa

BACKGROUND

Iodine intake in populations is usually assessed by measuring urinary iodine concentrations (UICs) in spot samples. Hot climate conditions may reduce urine volume, thus leading to overestimations of UIC and thereby masking inadequate iodine intake.

OBJECTIVES

We investigated the effects of season on UICs in 2 populations exposed to high-temperature climates.

METHODS

In this observational study, we examined women (18-49 years) in Tanzania (ncold = 206; nhot = 179) and South Africa (ncold = 157; nhot = 126) during cold and hot seasons. From each woman in both seasons, we obtained two 24-hour urine collections and 2 spot urine samples, as well as salt, water, and cow's milk samples. We measured the urine volume, UIC, and urinary creatinine concentration (UCC). The 24-hour urinary iodine excretion (UIE) was calculated and used to estimate the iodine intake. We used linear mixed-effects models to test for differences between seasons.

RESULTS

In Tanzanian women, we observed no seasonal effect on the urine volume, 24-hour UIE, 24-hour UIC, spot UIC, spot UIC:UCC ratio, or salt iodine concentration. In South African women, the median 24-hour urine volume was 1.40 L (IQR, 0.96-2.05 L) in the winter and 15% lower in the summer (P < 0.001). The median 24-hour UIE was 184 µg/day (IQR, 109-267 µg/day) in the winter and 34% lower in the summer (P < 0.001), indicating a lower iodine intake. As a result, UICs did not significantly differ between seasons in 24-hour collections and spot samples, whereas the spot UIC:UCC ratio differed by 21% (P < 0.001) and reflected the lower iodine intake. In both study populations, the within- and between-person variabilities in urine volume, 24-hour UICs, and spot UICs were higher than the variability between seasons.

CONCLUSIONS

Spot UIC may slightly overestimate the iodine intake in hot temperatures due to concentrated urine, and methods to correct for urine volume may be considered. Local seasonal differences in iodine intakes may also occur in some populations. This trial was registered at http://www.clinicaltrials.gov as NCT03215680.

The effect of oral iron supplementation on the gut microbiota, gut inflammation, and iron status in iron-depleted South African school-age children with virally suppressed HIV and without HIV

PURPOSE

Both HIV and oral iron interventions may alter gut microbiota composition and increase gut inflammation. We determined the effect of oral iron supplementation on gut microbiota composition, gut inflammation, and iron status in iron-depleted South Africa school-aged children living with HIV (HIV+) but virally suppressed on antiretroviral therapy and children without HIV (HIV-ve).

METHODS

In this before-after intervention study with case-control comparisons, we provided 55 mg elemental iron from ferrous sulphate, once daily for 3 months, to 33 virally suppressed (< 50 HIV RNA copies/mL) HIV+ and 31 HIV-ve children. At baseline and endpoint, we assessed microbial composition of faecal samples (16S rRNA sequencing), and markers of gut inflammation (faecal calprotectin), anaemia (haemoglobin) and iron status (plasma ferritin, soluble transferrin receptor). This study was nested within a larger trial registered at clinicaltrials.gov as NCT03572010.

RESULTS

HIV+ (11.3y SD ± 1.8, 46% male) and HIV-ve (11.1y SD ± 1.7, 52% male) groups did not significantly differ in age or sex ratio. Following iron supplementation, improvements were observed in haemoglobin (HIV+ : 118 to 124 g/L, P = 0.003; HIV-ve: 120 to 124 g/L, P = 0.003), plasma ferritin (HIV+ : 15 to 34 µg/L, P < 0.001; HIV-ve: 18 to 37 µg/L, P < 0.001), and soluble transferrin receptor (HIV+ : 7.1 to 5.9 mg/L, P < 0.001; HIV-ve: 6.6 to 5.7 mg/L, P < 0.001), with no significant change in the relative abundance of any genera, alpha diversity of the gut microbiota (HIV+ : P = 0.37; HIV-ve: P = 0.77), or faecal calprotectin (HIV+ : P = 0.42; HIV-ve: P = 0.80).

CONCLUSION

Our findings suggest that oral iron supplementation can significantly improve haemoglobin and iron status without increasing pathogenic gut microbial taxa or gut inflammation in iron-depleted virally suppressed HIV+ and HIV-ve school-age children.

Barriers and facilitators of micronutrient supplementation among non-pregnant women of reproductive age in Johannesburg, South Africa

The prevalence of anaemia among South African women of reproductive age (WRA) remains high at 39%. Multiple micronutrient supplementation (MMS) may be an effective strategy in the prevention and management of anaemia. Our aim was to understand facilitators and barriers to preconception MMS adherence and to explore perceptions and beliefs of MMS in the prevention and treatment of anaemia among non-pregnant WRA. This qualitative study was embedded in a preconception MMS intervention trial of WRA and was conducted in two phases. Phase one assessed the barriers and facilitators of MMS adherence. Individual interviews were conducted with the community health workers (n = 7) administering MMS, and with non-pregnant WRA (n = 25) participating in the trial. Phase two included four focus groups with participating WRA (n = 26), which further explored participants' perceptions and beliefs of MMS provision and adherence, and strategies to improve adherence. The reported facilitators to supplementation were family support, interaction with the community health workers, easy access to MMS, and experienced benefits of MMS. Barriers to preconception supplementation included the lack of family support, the link of supplements to antenatal care, and the perceived lack of benefits of MMS. Participants reported negative associations of supplements with medication, individual and societal stigma around medication and challenges around the supplementation schedule. For successful preconception MMS interventions, young women, their families, and communities need to be convinced of the value of supplementation. Public health interventions utilising preconception supplementation will require specialised training for health care providers, targeted counselling materials and community household support.

Effects of media stories featuring coping with suicidal crises on psychiatric patients: Randomized controlled trial

BACKGROUND

Accumulating evidence suggests beneficial effects of media stories featuring individuals mastering their suicidal crises, but effects have not been assessed for psychiatric patients.

METHODS

We randomized n = 172 adult psychiatric patients (n = 172, 97.1% inpatients) to read an educative article featuring a person mastering a suicidal crisis (n = 92) or an unrelated article (n = 80) in a single-blind randomized controlled trial. Questionnaire data were collected before (T1) and after exposure (T2) as well as 1 week later (study end-point, T3). The primary outcome was suicidal ideation as assessed with the Reasons for Living Inventory; secondary outcomes were help-seeking intentions, mood, hopelessness, and stigmatization. Differences between patients with affective versus other diagnoses were explored based on interaction tests.

RESULTS

We found that patients with affective disorders (n = 99) experienced a small-sized reduction of suicidal ideation at 1-week follow up (mean difference to control group [MD] at T3 = -0.17 [95% CI -0.33, -0.03], d = -0.15), whereas patients with nonaffective diagnoses (n = 73) experienced a small-sized increase (T2: MD = 0.24 [95% CI 0.06, 0.42], d = 0.19). Intervention group participants further experienced a nonsustained increase of help-seeking intentions (T2: MD = 0.53 [95% CI 0.11, 0.95], d = 0.19) and a nonsustained deterioration of mood (T2: MD = -0.14 [95% CI -0.27, -0.02], d = -0.17).

CONCLUSIONS

This study suggests that patients with affective disorders appear to benefit from media materials featuring mastery of suicidal crises. More research is needed to better understand which patient groups are at possible risk of unintended effects.

Characterization of Genetic Variants in the SLC5A5 Gene and Associations With Breast Milk Iodine Concentration in Lactating Women of African Descent: The NUPED Study

Background: The sodium iodide symporter is responsible for the transfer of iodine into breast milk and is encoded for by the SLC5A5 gene. The role of genetic variants in the SLC5A5 gene locus in relation to the transfer of iodine from plasma into breast milk in healthy lactating individuals has, to our knowledge, not been explored. Objective: To identify and characterize possible genetic variants of the SLC5A5 gene in women of African descent living in urban South Africa, and to study associations with breast milk iodine concentrations (BMIC) in lactating women. Methods: This study is affiliated to the Nutrition during Pregnancy and Early Development (NuPED) cohort study (n = 250 enrolled pregnant women). In a randomly selected sub-sample of 32 women, the SLC5A5 gene was sequenced to identify known and novel variants. Of the identified variants, genotyping of selected variants was performed in all pregnant women who gave consent for genetic analyses (n = 246), to determine the frequency of the variants in the study sample. Urinary iodine concentration (UIC) in spot urine samples and BMIC were measured to determine iodine status. Associations of SLC5A5 genetic variants with BMIC were studied in lactating women (n = 55). Results: We identified 27 variants from sequencing of gene exomes and 10 variants were selected for further study. There was a significant difference in BMIC between the genotypes of the rs775249401 variant (P = 0.042), with the homozygous GG group having lower BMIC [86.8 (54.9-167.9) μg/L] compared to the (A) allele carriers rs775249401(AG+AA) [143.9 (122.4-169.3) μg/L] (P = 0.042). Of the rs775249401(GG), 49% had UIC <100 μg/L and 61% had BMIC <100 μg/L. On the other hand, 60% of the rs775249401(AG+AA) carriers had UIC <100 μg/L, and none had a BMIC <100 μg/L. Conclusion: Our results suggest that A-allele carriers of rs775249401(AG+AA) are likely to have higher iodine transfer into breast milk compared to the homozygous GG counterparts. Thus, genetic variations in the SLC5A5 gene may play an important role in the transfer of iodine from plasma into breast milk and may partially explain inter-individual variability in BMIC.

Iodine status of pregnant women living in urban Johannesburg, South Africa

Adequate intake of iodine is important during pregnancy because of its essential role in foetal growth and neurodevelopment. Data on iodine status of South African pregnant women are scarce, and the salt reduction policy implemented in 2016 may decrease iodine intake of South Africans. This cross-sectional study assessed the iodine status of pregnant women residing in urban Johannesburg, South Africa. A total of 250 pregnant women were enrolled into the 'Nutrition during Pregnancy and Early Development' (NuPED) study and 312 pregnant women into the 'Assessment of dried blood spot thyroglobulin in pregnant women to redefine the range of median urinary iodine concentration that indicates adequate iodine intake, South Africa' (STRIPE-SA) study and were included in this analysis. Urinary iodine concentration (UIC) was analysed in a spot urine sample. Thyroglobulin (Tg) was measured in serum, and thyroid-stimulating hormone (TSH) and total thyroxine (tT4) were measured in dried blood spots. The median [interquartile range (IQR)] UIC of pregnant women was 144 (84-234) μg/L. Women in the first (n = 99), second (n = 262) and third (n = 174) trimester had a median UIC of 133 (81-316), 145 (84-236) and 156 (89-245) μg/L, respectively (p = 0.419). Median TSH, tT4 and Tg were 2.7 (2.3-3.2) mU/L, 202 (163-236) nmol/L and 9.2 (5.4-17.9) μg/L, respectively. Based on the median UIC, pregnant women residing in urban Johannesburg may be borderline iodine deficient. These findings highlight the need for ongoing monitoring of iodine status among vulnerable pregnant women, especially considering the recently introduced salt reduction policy in South Africa.

Examining Associations of HIV and Iron Status with Nutritional and Inflammatory Status, Anemia, and Dietary Intake in South African Schoolchildren

The etiology of multifactorial morbidities such as undernutrition and anemia in children living with the human immunodeficiency virus (HIV) (HIV+) on antiretroviral therapy (ART) is poorly understood. Our objective was to examine associations of HIV and iron status with nutritional and inflammatory status, anemia, and dietary intake in school-aged South African children. Using a two-way factorial case-control design, we compared four groups of 8 to 13-year-old South African schoolchildren: (1) HIV+ and low iron stores (inflammation-unadjusted serum ferritin ≤ 40 µg/L), n = 43; (2) HIV+ and iron sufficient non-anemic (inflammation-unadjusted serum ferritin > 40 µg/L, hemoglobin ≥ 115 g/L), n = 41; (3) children without HIV (HIV-ve) and low iron stores, n = 45; and (4) HIV-ve and iron sufficient non-anemic, n = 45. We assessed height, weight, plasma ferritin (PF), soluble transferrin receptor (sTfR), plasma retinol-binding protein, plasma zinc, C-reactive protein (CRP), α-1-acid glycoprotein (AGP), hemoglobin, mean corpuscular volume, and selected nutrient intakes. Both HIV and low iron stores were associated with lower height-for-age Z-scores (HAZ, p < 0.001 and p = 0.02, respectively), while both HIV and sufficient iron stores were associated with significantly higher CRP and AGP concentrations. HIV+ children with low iron stores had significantly lower HAZ, significantly higher sTfR concentrations, and significantly higher prevalence of subclinical inflammation (CRP 0.05 to 4.99 mg/L) (54%) than both HIV-ve groups. HIV was associated with 2.5-fold higher odds of iron deficient erythropoiesis (sTfR > 8.3 mg/L) (95% CI: 1.03–5.8, p = 0.04), 2.7-fold higher odds of subclinical inflammation (95% CI: 1.4–5.3, p = 0.004), and 12-fold higher odds of macrocytosis (95% CI: 6–27, p < 0.001). Compared to HIV-ve counterparts, HIV+ children reported significantly lower daily intake of animal protein, muscle protein, heme iron, calcium, riboflavin, and vitamin B₁₂, and significantly higher proportions of HIV+ children did not meet vitamin A and fiber requirements. Compared to iron sufficient non-anemic counterparts, children with low iron stores reported significantly higher daily intake of plant protein, lower daily intake of vitamin A, and lower proportions of inadequate fiber intake. Along with best treatment practices for HIV, optimizing dietary intake in HIV+ children could improve nutritional status and anemia in this vulnerable population. This study was registered at clinicaltrials.gov as NCT03572010.

Salt-reduction strategies may compromise salt iodization programs: Learnings from South Africa and Ghana

OBJECTIVES

Universal salt iodization has been adopted by many countries to address iodine deficiency. More recently, salt-reduction strategies have been widely implemented to meet global salt intake targets of <5 g/d. Compatibility of the two policies has yet to be demonstrated. This study compares urinary iodine excretion (UIE) according to 24-h urinary sodium excretion, between South Africa (SA) and Ghana; both countries have implemented universal salt iodization, but in Ghana no salt-reduction legislation has been implemented.

METHODS

Participants from the World Health Organization's Study on Global Ageing and Adult Health Wave 3, with survey and valid 24-h urinary data (Ghana, n = 495; SA, n = 707), comprised the sample. Median 24-h UIE was compared across salt intake categories of <5, 5-9 and >9 g/d.

RESULTS

In Ghana, median sodium excretion indicated a salt intake of 10.7 g/d (interquartile range [IQR] = 7.6), and median UIE was 182.4 µg/L (IQR = 162.5). In SA, both values were lower: median salt = 5.6 g/d (IQR = 5.0), median UIE = 100.2 µg/L (IQR = 129.6). UIE differed significantly across salt intake categories (P < 0.001) in both countries, with positive correlations observed in both-Ghana: r = 0.1501, P < 0.0011; South Africa: r = 0.4050, P < 0.0001. Participants with salt intakes <9 g/d in SA did not meet the World Health Organization's recommended iodine intake of 150 µg/d, but this was not the case in Ghana.

CONCLUSIONS

Monitoring and surveillance of iodine status is recommended in countries that have introduced salt-reduction strategies, in order to prevent reemergence of iodine deficiency.

Omega-3 Fatty Acid and Iron Supplementation Alone, but Not in Combination, Lower Inflammation and Anemia of Infection in Mycobacterium tuberculosis-Infected Mice

Progressive inflammation and anemia are common in tuberculosis (TB) and linked to poor clinical outcomes. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have inflammation-resolving properties, whereas iron supplementation in TB may have limited efficacy and enhance bacterial growth. We investigated effects of iron and EPA/DHA supplementation, alone and in combination, on inflammation, anemia, iron status markers and clinical outcomes in Mycobacterium tuberculosis-infected C3HeB/FeJ mice. One week post-infection, mice received the AIN-93 diet without (control) or with supplemental iron (Fe), EPA/DHA, or Fe+EPA/DHA for 3 weeks. Mice supplemented with Fe or EPA/DHA had lower soluble transferrin receptor, ferritin and hepcidin than controls, but these effects were attenuated in Fe+EPA/DHA mice. EPA/DHA increased inflammation-resolving lipid mediators and lowered lung IL-1α, IFN-γ, plasma IL-1β, and TNF-α. Fe lowered lung IL-1α, IL-1β, plasma IL-1β, TNF-α, and IL-6. However, the cytokine-lowering effects in the lungs were attenuated with Fe+EPA/DHA. Mice supplemented with EPA/DHA had lower lung bacterial loads than controls, but this effect was attenuated in Fe+EPA/DHA mice. Thus, individually, post-infection EPA/DHA and iron supplementation lowered systemic and lung inflammation and mitigated anemia of infection in TB, but not when combined. EPA/DHA also enhanced bactericidal effects and could support inflammation resolution and management of anemia.

Duration of confinement and pen-type affect health-related measures of welfare in lactating sows

Temporary crating is considered as a step towards improved welfare in lactating sows. Therefore, the aim of this study was to investigate effects of confinement period (CP) and farrowing pen-type (PT) on health-related measures. Four hundred and thirteen sows were kept in five PT with four CP each: CP 0-sows were not confined; CP 3-sows were crated postpartum for three days; CP 4- and CP 6-sows were crated from a day prior to expected farrowing until day 4 and 6 postpartum, respectively. Alterations in different body regions were recorded when sows were moved to the pens and in weeks 1, 3 and 4 postpartum. CP 6-sows displayed significantly more lesions on their back than CP 0- and CP 3-sows. Odds ratios of teat lesions were markedly higher in CP 4-sows than in all other CP. Pen-type P (Pro Dromi) resulted in more neck/back/body side injuries, claw horn changes and lame sows compared to all other PT. High odds ratios were also found for neck injuries in PT K (Knick), shoulder sores in PT K and T (Trapez), injured teats in PT F (Flügel) and body side injuries in PT S (SWAP). The types of lesions found in the present study are similar to those reported for crates caused by pen structures. While an overall assessment of pig (S) production husbandry systems must also take piglet welfare into account, this study showed that keeping confinement periods as short as possible improves sow welfare and systems should be adapted to also cater for the needs of sows.

Breast milk and erythrocyte fatty acid composition of lactating women residing in a peri‑urban South African township

Data on breast milk fatty acid (FA) composition in South African lactating women in relation to their FA status, as well as on potential compositional changes within feed, are limited. The aim of this study was to assess the FA composition of breast milk sampled at three time points within feed, and to determine associations with red blood cell (RBC) total phospholipid FA levels in lactating South African mothers of 2-4-month-old breastfed infants. FA composition (% total FAs) was analyzed in RBC total phospholipids, and in fore-, mid-feed and hind-milk samples of lactating mothers (n = 100) of Black African descent living in a peri‑urban township. The mean age of the lactating women was 27.8 ± 6.8 years. Geometric mean (95% CI) breast milk SFA, MUFA and PUFA contents were 37.7 (37.3,38.1), 28.5 (27.9, 28.8), and 23.5 (23.2, 24.5)%, respectively. Breast milk DHA and AA contents were 0.25 (0.24, 3.71) and 0.81 (0.79, 0.83)%, respectively, in fore-, mid- and hind-milk combined. Maternal RBC EPA, DHA and AA levels were 0.37 (0.34, 0.40), 3.8 (3.6, 4.0) and 15.4 (14.8, 16.1)%, respectively. Women who reported to consume fish often (n = 3) had significantly higher RBC EPA levels than women who consumed fish sometimes (n = 56), never (n = 14) or rarely (n = 19). Breast milk DHA positively correlated with maternal RBC DHA, while no correlations were found between breast milk AA and maternal RBC AA. Breast milk ALA and DHA contents were significantly higher in mid-feed [ALA= 0.8 (0.2, 0.2), DHA=0.3 (0.2, 0.3)] and hind-milk [ALA=0.8 (0.8, 0.9), DHA=0.3 (0.3, 0.3)] than foremilk [ALA=0.8 (0.7, 0.9), DHA=0.2 (0.2, 0.3)]. In contrast, LA and AA contents remained constant within feed. In this sample of peri‑urban South African lactating mothers, breast milk was low in DHA and high in AA compared to global means. Breast milk DHA was associated with maternal RBC status, while breast milk AA was not. We further showed that breast milk ALA and DHA increased, while LA and AA remained unchanged within feed. This suggests that n-3 PUFA maybe preferentially transferred to breast milk within feed through biomagnification.

Adjusting Haemoglobin Values for Altitude Maximizes Combined Sensitivity and Specificity to Detect Iron Deficiency among Women of Reproductive Age in Johannesburg, South Africa

In South Africa, haemoglobin (Hb) is measured to screen for iron deficiency (ID). However, low levels of Hb are only a late stage indicator of ID. Furthermore, Hb values are generally not adjusted for altitude even though recommended by WHO. We determined the Hb threshold with the highest combined sensitivity and specificity for detecting ID among South African women living at 1700 m above sea level. In a cross-sectional study of 492 18-25-year-old women, we measured Hb and iron status biomarkers. Using receiver operating characteristic curves, we determined the Hb threshold with maximum Youden Index for detecting ID. This threshold of <12.35 g/dL resulted in a 37.2% anaemia prevalence (20.9% IDA), and sensitivity and specificity of 55.7% and 73.9%, respectively. The WHO altitude-adjusted threshold of <12.5 g/dL resulted in a 39% anaemia prevalence (21.3% IDA), and sensitivity and specificity of 56.8% and 70.8%, respectively. In contrast, using the unadjusted Hb cut-off of <12 g/dL resulted in a 18.5% anaemia prevalence (12.6% IDA), and sensitivity and specificity of 35.1% and 88.6%, respectively. In this sample of South African women of reproductive age an Hb threshold <12.35 g/dL had the highest combined sensitivity and specificity for detecting ID. The diagnostic performance of this Receiver operating characteristic curve-determined threshold was comparable to the altitude-adjusted threshold proposed by WHO. Thus, clinical and public health practice in South Africa should adopt adjustment of Hb for altitude to avoid underestimation of ID and missing women in need for intervention.

Missing data imputation via the expectation-maximization algorithm can improve principal component analysis aimed at deriving biomarker profiles and dietary patterns

Principal component analysis (PCA) is a popular statistical tool. However, despite numerous advantages, the good practice of imputing missing data before PCA is not common. In the present work, we evaluated the hypothesis that the expectation-maximization (EM) algorithm for missing data imputation is a reliable and advantageous procedure when using PCA to derive biomarker profiles and dietary patterns. To this aim, we used numerical simulations aimed to mimic real data commonly observed in nutritional research. Finally, we showed the advantages and pitfalls of the EM algorithm for missing data imputation applied to plasma fatty acid concentrations and nutrient intakes from real data sets deriving from the US National Health and Nutrition Examination Survey. PCA applied to simulated data having missing values resulted in biased eigenvalues with respect to the original data set without missing values. The bias between the eigenvalues from the original set of data and from the data set with missing values increased with number of missing values and appeared as independent with respect to the correlation structure among variables. On the other hand, when data were imputed, the mean of the eigenvalues over the 10 missing imputation runs overlapped with the ones derived from the PCA applied to the original data set. These results were confirmed when real data sets from the National Health and Nutrition Examination Survey were analyzed. We accept the hypothesis that the EM algorithm for missing data imputation applied before PCA aimed to derive biochemical profiles and dietary patterns is an effective technique especially for relatively small sample sizes.

Maternal iron-deficiency is associated with premature birth and higher birth weight despite routine antenatal iron supplementation in an urban South African setting: The NuPED prospective study

Background

Recent studies are suggesting a U-shaped relationship between antenatal iron exposure and birth outcomes. Little is known about the iron status and associated birth outcomes of pregnant women in South Africa. Our aim was to assess iron status at early, mid- and late pregnancy, and to determine associations with gestational age and birth weight in women in Johannesburg, South Africa.

Methods

In this prospective study of 250 pregnant women, we measured haemoglobin, biomarkers of iron status and inflammation at <18, 22 and 36 weeks of gestation, plus birth weight and gestational age at delivery. Associations of anaemia and iron status with birth outcomes were determined using regression models adjusted for confounders.

Results

At enrolment, the prevalence of anaemia, iron depletion (ID) and iron deficiency erythropoiesis (IDE) was 29%, 15% and 15%, respectively, and increased significantly with pregnancy progression. Anaemia and ID at 22 weeks, as well as IDE at 36 weeks were associated with higher birth weight (β = 135.4; 95% CI: 4.8, 266.1 and β = 205.4; 95% CI: 45.6, 365.1 and β = 178.0; 95% CI: 47.3, 308.7, respectively). Women in the lowest ferritin quartile at 22 weeks gave birth to babies weighing 312 g (95% CI: 94.8, 528.8) more than those in the highest quartile. In contrast, IDE at 22 weeks was associated with a higher risk for premature birth (OR: 3.57, 95% CI: 1.24, 10.34) and women in lower haemoglobin quartiles at <18 weeks had a shorter gestation by 7 days (β = -6.9, 95% CI: -13.3, -0.6) compared to those in the highest quartile.

Conclusion

Anaemia, ID and IDE prevalence increased during pregnancy despite routine iron supplementation. ID and anaemia at mid-pregnancy were associated with higher birth weight, while IDE was associated with premature birth. These results suggest that current antenatal screening and supplementation practices in South Africa need to be revisited.

Determining sample size adequacy for animal model studies in nutrition research: limits and ethical challenges of ordinary power calculation procedures

Animal models are widely used in the field of nutrition research. Scientifically and ethically sound experiments need an adequate number of experimental units. The use of 5-10 units is common, but such sample sizes can be justified for large effect sizes only. We reviewed animal model studies recently published in selected journals in the field of nutrition sciences. We performed a simulation study aimed at determining the adequate sample size for normality assessment. We then performed power calculations for a number of statistical tests commonly found in rodent model studies in nutrition research. Among the selected papers, sample sizes ranged from 6-18 units per group. None of them justified the sample size. However, such sample sizes do not allow for normality testing, thus, graphical approaches should be used. Parametric approaches result in higher statistical power when compared to their non-parametric counterparts. Repeated measures analysis should always be preferred, when possible.

Efficacy of novel small-quantity lipid-based nutrient supplements in improving long-chain polyunsaturated fatty acid status of South African infants: a randomised controlled trial

BACKGROUND/OBJECTIVES

The objective of this study was to investigate the efficacy of small-quantity lipid-based nutrient supplements (SQ-LNS) containing essential fatty acids (EFAs) with or without long-chain polyunsaturated fatty acids (LCPUFAs) in improving LCPUFA status in South African infants fed complementary food.

SUBJECTS/METHODS

Six-month-old infants (n = 750) were randomised to receive SQ-LNS, SQ-LNS-plus, or no supplement. Both SQ-LNSs contained micronutrients and EFAs. SQ-LNS-plus additionally contained the LCPUFAs arachidonic acid (AA) and docosahexaenoic acid (DHA), lysine, phytase and other nutrients. Plasma total phospholipid FA composition (% of total FAs) was measured at baseline (n = 353) and at 12 months (n = 293).

RESULTS

At baseline, geometric mean (95% CI) plasma DHA and AA were 4.1 (4.0-4.3) and 11.5 (11.2-11.8)% respectively, with significantly higher plasma DHA and AA in breastfed than non-breastfed infants. Infants receiving the SQ-LNS-plus had significantly higher plasma DHA (4.52 (4.3-4.9)) at 12 months than the controls (3.8 (3.6-4.0)), with a higher effect size in infants who no longer received breast milk (β = 1.148 (95% CI = 0.597, 1.699)) than in infants who were still breastfeeding (β = 0.544 (95% CI = 0.179, 0.909)). There was no effect of either of the two SQ-LNSs on plasma AA. Consequently, infants receiving the SQ-LNS-plus had a significantly lower plasma n-6 to n-3 PUFA ratio at 12 months than control infants did.

CONCLUSIONS

Our study suggests that the provision of SQ-LNS-plus is efficacious in improving plasma DHA status. Particularly, infants who are no longer breastfed may benefit most from LCPUFA-enriched SQ-LNS.

Associations of plasma total phospholipid fatty acid patterns with feeding practices, growth, and psychomotor development in 6-month-old South African infants

The objective of this study was to assess plasma fatty acid (FA) patterns of 6-month-old South African infants and to determine their association with feeding practices, growth, and psychomotor development. Plasma total phospholipid FA composition (% of total FAs) of 6-month-old infants (n = 353) from a peri-urban township was analysed, and principal component and factor analysis were performed to identify plasma FA patterns. Feeding practices, anthropometric measurements, and psychomotor development scores were determined. Four major plasma phospholipid FA patterns were identified: A plant-based C18 FA, a high n-6 long-chain polyunsaturated fatty acids (LCPUFA), a C16:1 and long-chain saturated fatty acid (SFA), and a high n-3 and low n-6 LCPUFA pattern. Formula feeding was associated with higher, whereas breastfeeding was associated with lower scores for the plant-based C18 FA and C16:1 and long-chain SFA patterns. On the other hand, breastfeeding, the consumption of cow's milk, and the consumption of semisolid foods were associated with higher scores, whereas formula feeding was associated with lower scores for the high n-6 LCPUFA pattern. Breastfeeding and the consumption of semisolids were also associated with higher high n-3 and low n-6 LCPUFA pattern scores. The C16:1 and long-chain SFA and high n-3 and low n-6 LCPUFA patterns were positively associated with psychomotor development scores. In 6-month-old South African infants, we identified distinct plasma FA patterns that presumably represent the FA quality of their diet and that are associated with psychomotor development. Our results suggest that breast milk is an important source of n-6 LCPUFAs and formula-fed infants may be at risk of inadequate LCPUFA intake.

Interventions to prevent iron deficiency during the first 1000 days in low-income and middle-income countries: recent advances and challenges

PURPOSE OF REVIEW

Iron deficiency remains highly prevalent in women and young children in low-income and middle-income countries. To prevent the potentially life-long consequences of iron deficiency when occurring during early life, the WHO recommends iron supplementation of pregnant women and young children. However, increasing evidence of limited efficacy and risk of current iron intervention strategies are cause of concern. This review aims to highlight recent advances and challenges of established and novel intervention strategies for the prevention of iron deficiency during the first 1000 days in low-income and middle-income countries.

RECENT FINDINGS

Recent meta-analyses and trials challenged the WHO's current recommendation to provide iron-folic acid rather than multiple micronutrient supplements during routine antenatal care. Furthermore, several studies explored optimal windows for iron supplementation, such as prior to conception. Studies are demonstrating that infectious and noninfectious inflammation is compromising the efficacy of iron interventions in vulnerable groups. Therefore, strategies addressing iron deficiency should focus on targeting infection and inflammation while simultaneously providing additional iron. Furthermore, both iron deficiency and iron supplementation may promote an unfavourable gut microbiota. Recent trials in infants indicate that the provision of a prebiotic together with iron may alleviate the adverse effects of iron on the gut microbiome and gut inflammation, and may even enhance iron absorption.

SUMMARY

Recent studies highlight the need for and potential of novel intervention strategies that increase the efficacy and limit the potential harm of universal iron supplementation.

Identification of patients with recent-onset psychosis in KwaZulu Natal, South Africa: a pilot study with traditional health practitioners and diagnostic instruments

PURPOSE

There is considerable variation in epidemiology and clinical course of psychotic disorders across social and geographical contexts. To date, very little data are available from low- and middle-income countries. In sub-Saharan Africa, most people with psychoses remain undetected and untreated, partly due to lack of formal health care services. This study in rural South Africa aimed to investigate if it is possible to identify individuals with recent-onset psychosis in collaboration with traditional health practitioners (THPs).

METHODS

We developed a strategy to engage with THPs. Fifty THPs agreed to collaborate and were asked to refer help-seeking clients with recent-onset psychosis to the study. At referral, the THPs rated probability of psychosis ("maybe disturbed" or "disturbed"). A two-step diagnostic procedure was conducted, including the self-report Community Assessment of Psychic Experiences (CAPE) as screening instrument, and a semi-structured interview using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Accuracy of THP referrals, and test characteristics of the THP rating and the CAPE were calculated.

RESULTS

149 help-seeking clients were referred by THPs, of which 44 (29.5%) received a SCAN DSM-IV diagnosis of psychotic disorder. The positive predictive value of a THP "disturbed" rating was 53.8%. Test characteristics of the CAPE were poor.

CONCLUSION

THPs were open to identifying and referring individuals with possible psychosis. They recognized "being disturbed" as a condition for which collaboration with formal psychiatric services might be beneficial. By contrast, the CAPE performed poorly as a screening instrument. Collaboration with THPs is a promising approach to improve detection of individuals with recent-onset psychosis in rural South Africa.

Food or nutrient pattern assessment using the principal component analysis applied to food questionnaires. Pitfalls, tips and tricks

We considered the Blom's transformation, a statistical method aimed to normalise and standardise food intakes before principal component analysis. A simulation study was performed to evaluate the eigenvalue distribution of a correlation matrix under common conditions in food questionnaire analysis. The scree plot visual inspection and the Guttman-Kaiser (GK) criterion were compared to Horn's parallel analysis to evaluate their efficacy in food pattern identification. The scree plot results as a monotone continuous series when no food patterns are present. In this situation, about 50% of the eigenvalues assume a value higher than one, showing a first fallacy of the GK. When three food patterns are simulated a clear discontinuity appears after the third eigenvalue, showing that the scree-plot visual inspection is a suitable method to identify food patterns. Finally, according to the present work it appears that the GK generates a number of false-positive food patterns.

Nutrient patterns and their relation to anemia and iron status in 5- to 12-y-old children in South Africa

OBJECTIVE

The aim of this study was to assess nutrient patterns and their relation to anemia and iron status of school children using pooled data from three study populations in South Africa.

METHODS

Data from 5- to 12-y-old children (N = 578) from three independent studies conducted in two provinces in South Africa were pooled. Data used in the analysis were dietary intake, hemoglobin, and plasma ferritin concentrations. Nutrient patterns were determined using factor analysis. Logistic regression analysis was performed to determine relationships of nutrient patterns with anemia and iron deficiency.

RESULTS

In the pooled group, 13.8% of the children were anemic and 27.7% were iron deficient (ID). More than half of children did not meet the Estimated Average Requirement for various nutrients, including vitamins A, C, B₁₂, folate, and zinc, although only 17.7% of children had an iron intake below the requirements. Median intakes for vitamins A and C were lower for anemic than non-anemic children (P = 0.03 and 0.02, respectively) and for ID versus non-ID children (P = 0.03 and 0.046, respectively). Four nutrient patterns were identified: plant protein, carbohydrate, iron, and B vitamins; animal protein and saturated fat; vitamins A and B₁₂; and calcium and fiber. The vitamin A and B₁₂ nutrient pattern was associated with lower odds of being anemic (odds ratio, 0.63; 95% confidence interval, 0.49-0.91; P = 0.035).

CONCLUSION

The present results highlighted the potential role of the combination of dietary vitamin A and B₁₂ in the etiology of nutritional anemia in school-age children in South Africa. Nutrient pattern analysis may improve the understanding of the synergistic role of nutrients related to anemia and may assist in planning intervention strategies.

Nutrition during pregnancy and early development (NuPED) in urban South Africa: a study protocol for a prospective cohort

BACKGROUND

Adequate nutrition during pregnancy is important to ensure optimal birth outcomes, maternal health and offspring development. However, little is known about the dietary intake and nutritional status of pregnant women residing in urban South Africa. Therefore, the Nutrition during Pregnancy and Early Development (NuPED) cohort study was initiated to assess early nutrition-related exposures predictive of early childhood development in urban South Africa.

METHODS

The aims of this prospective cohort study are: 1) to assess dietary intake and nutritional status of urban pregnant women in Johannesburg, South Africa, and 2) to determine associations with birth outcomes, measures of maternal health, as well as measures of offspring health and development. Pregnant women (< 18 weeks' gestation) (n = 250) are being recruited from primary healthcare clinics in Johannesburg and are followed-up at a provincial hospital. Participants' dietary intake and nutrient status (focus on micronutrients and fatty acids) are assessed at < 18, 22 and 36 weeks' gestation. Additional assessments during pregnancy include anthropometric and blood pressure measurements, obstetric ultrasound screens, and assessments of food security, maternal fatigue, prenatal depression, allergy, immune function, morbidity and gestational diabetes. At birth, maternal and neonatal health is assessed and an umbilical cord blood sample collected. Maternal and offspring health is followed-up at 6 weeks, as well as at 6, ≈7.5 and 12 months after birth. Follow-up assessments of mothers include anthropometric measures, diet history, nutrient status, blood pressure, breast milk composition, and measures of postnatal depression and fatigue. Follow-up assessments of the offspring include feeding practices, nutrient status, measures of growth, psychomotor, socio-emotional and immune development, morbidity, allergy, as well as analysis of the gut microbiome and the epigenome.

DISCUSSION

Ensuring adequate nutrition during pregnancy is one of the key actions endorsed by the South African Government to promote optimal early childhood development in an effort to eradicate poverty. The results from this study may serve as a basis for the development of context-specific nutritional interventions which can improve birth outcomes and long-term quality of life of the mother and her offspring.

Iodine Status Assessment in South African Adults According to Spot Urinary Iodine Concentrations, Prediction Equations, and Measured 24-h Iodine Excretion

The iodine status of populations is conventionally assessed using spot urinary samples to obtain a median urinary iodine concentration (UIC) value, which is assessed against standard reference cut-offs. The assumption that spot UIC reflects daily iodine intake may be flawed because of high day-to-day variability and variable urinary volume outputs. This study aimed to compare iodine status in a sample of South African adults when determined by different approaches using a spot urine sample (median UIC (MUIC), predicted 24 h urinary iodine excretion (PrUIE) using different prediction equations) against measured 24 h urinary iodine excretion (mUIE). Both 24 h and spot urine samples were collected in a subsample of participants (n = 457; median age 55 year; range 18⁻90 year) in the World Health Organization Study on global AGEing and adult health (SAGE) Wave 2 in South Africa, in 2015. Kawasaki, Tanaka, and Mage equations were applied to assess PrUIE from predicted urinary creatinine (PrCr) and spot UIC values. Adequacy of iodine intake was assessed by comparing PrUIE and mUIE to the Estimated Average Requirement of 95 µg/day, while the MUIC cut-off was.

How will South Africa's mandatory salt reduction policy affect its salt iodisation programme? A cross-sectional analysis from the WHO-SAGE Wave 2 Salt & Tobacco study

OBJECTIVE

The WHO's global targets for non-communicable disease reduction recommend consumption of<5 g salt/day. In 2016, South Africa was the first country to legislate maximum salt levels in processed foods. South Africa's salt iodisation fortification programme has successfully addressed iodine deficiency but information is dated. Simultaneous monitoring of sodium reduction and iodine status is required to ensure compatibility of the two public health interventions.

DESIGN/SETTING/PARTICIPANTS

A nested cohort design within WHO's 2015 Study on global AGEing and adult health (n=2887) including individuals from households across South Africa. Randomly selected adults (n=875) provided 24-hour and spot urine samples for sodium and iodine concentration analysis (the primary and secondary outcome measures, respectively). Median 24-hour urinary iodine excretion (UIE) and spot urinary iodine concentrations (UIC) were compared by salt intakes of <5g/day, 5-9g/dayand >9 g/day.

RESULTS

Median daily sodium excretion was equivalent to 6.3 g salt/day (range 1-43 g/day); 35% had urinary sodium excretion values within the desirable range (<5 g salt/day), 37% had high values (5-9 g salt/day) and 28% had very high values (>9 g salt/day). Median UIC was 130 µg/L (IQR=58-202), indicating population iodine sufficiency (≥100 µg/L). Both UIC and UIE differed across salt intake categories (p<0.001) and were positively correlated with estimated salt intake (r=0.166 and 0.552, respectively; both p<0.001). Participants with salt intakes of <5 g/day were not meeting the Estimated Average Requirement for iodine intake (95 µg/day).

CONCLUSIONS

In a nationally representative sample of South African adults, the association between indicators of population iodine status (UIC and UIE) and salt intake, estimated using 24-hour urinary sodium excretion, indicate that low salt intakes may compromise adequacy of iodine intakes in a country with mandatory iodisation of table salt. The iodine status of populations undergoing salt reduction strategies needs to be closely monitored to prevent re-emergence of iodine deficiency.

Particulate matter chemical component concentrations and sources in settings of household solid fuel use

Particulate matter (PM) air pollution derives from combustion and non-combustion sources and consists of various chemical species that may differentially impact human health and climate. Previous reviews of PM chemical component concentrations and sources focus on high-income urban settings, which likely differ from the low- and middle-income settings where solid fuel (ie, coal, biomass) is commonly burned for cooking and heating. We aimed to summarize the concentrations of PM chemical components and their contributing sources in settings where solid fuel is burned. We searched the literature for studies that reported PM component concentrations from homes, personal exposures, and direct stove emissions under uncontrolled, real-world conditions. We calculated weighted mean daily concentrations for select PM components and compared sources of PM determined by source apportionment. Our search criteria yielded 48 studies conducted in 12 countries. Weighted mean daily cooking area concentrations of elemental carbon, organic carbon, and benzo(a)pyrene were 18.8 μg m^-3 , 74.0 μg m^-3 , and 155 ng m^-3 , respectively. Solid fuel combustion explained 29%-48% of principal component/factor analysis variance and 41%-87% of PM mass determined by positive matrix factorization. Multiple indoor and outdoor sources impacted PM concentrations and composition in these settings, including solid fuel burning, mobile emissions, dust, and solid waste burning.

Amyloid fibril systems reduce, stabilize and deliver bioavailable nanosized iron

Iron-deficiency anaemia (IDA) is a major global public health problem. A sustainable and cost-effective strategy to reduce IDA is iron fortification of foods, but the most bioavailable fortificants cause adverse organoleptic changes in foods. Iron nanoparticles are a promising solution in food matrices, although their tendency to oxidize and rapidly aggregate in solution severely limits their use in fortification. Amyloid fibrils are protein aggregates initially known for their association with neurodegenerative disorders, but recently described in the context of biological functions in living organisms and emerging as unique biomaterial building blocks. Here, we show an original application for these protein fibrils as efficient carriers for iron fortification. We use biodegradable amyloid fibrils from β-lactoglobulin, an inexpensive milk protein with natural reducing effects, as anti-oxidizing nanocarriers and colloidal stabilizers for iron nanoparticles. The resulting hybrid material forms a stable protein-iron colloidal dispersion that undergoes rapid dissolution and releases iron ions during acidic and enzymatic in vitro digestion. Importantly, this hybrid shows high in vivo iron bioavailability, equivalent to ferrous sulfate in haemoglobin-repletion and stable-isotope studies in rats, but with reduced organoleptic changes in foods. Feeding the rats with these hybrid materials did not result in abnormal iron accumulation in any organs, or changes in whole blood glutathione concentrations, inferring their primary safety. Therefore, these iron-amyloid fibril hybrids emerge as novel, highly effective delivery systems for iron in both solid and liquid matrices.

Chemical Composition, but Not Specific Surface Area, Affects Calcium Retention of Nanostructured Calcium Compounds in Growing Rats

Background: Low dietary calcium intake and bioavailability may adversely affect bone health. Reducing the size of calcium compounds increases their specific surface area (SSA, expressed as m²/g) and may increase calcium dissolution and bioavailability.Objective: We investigated the influence of SSA and chemical composition on the bioavailability of calcium and compared in vitro calcium dissolution with in vivo absorption.Methods: Calcium dissolution was measured in 0.1 M phosphoric acid, whereas color and pH changes of foods were assessed as indicators for potential sensory performance. Calcium absorption, retention, and fractional retention were measured over a 5-d balance study in growing Sprague-Dawley male rats after 21 d of feeding. Femoral and vertebral bone mineral density (BMD) and extensive tissue histology were assessed at study end. The influence of SSA on calcium bioavailability was assessed by comparing the groups fed pure calcium carbonate (CaCO₃) with increasing SSAs of 3, 36, and 64 m²/g (CaCO₃_3, CaCO₃_36 and CaCO₃_64), whereas chemical composition was assessed by comparing the smallest CaCO₃_64, a 50:50 wt:wt percent solution mixture of CaCO₃ and hydroxyapatite_94, and pure hydroxyapatite_100.Results: In vivo, fractional calcium retention from hydroxyapatite_100 (mean ± SEM: 54.86% ± 0.95%/5 d) was significantly greater than from CaCO₃_64 (49.66% ± 1.15%/5 d) (P = 0.044). Increasing SSA of the pure CaCO₃ did not significantly improve calcium retention. Across all 5 groups, there were no significant differences in BMD or tissue calcification by histology. In vitro calcium dissolution did not correlate with SSA or calcium absorption. In selected food matrixes, hydroxyapatite_100 caused less color change and/or smaller pH increase than did the other calcium compounds.Conclusions: Our findings suggest that chemical composition rather than SSA is a predictor of nanostructured calcium bioavailability and that in vitro dissolution of nanostructured calcium does not predict in vivo absorption. Although its phosphorus content may limit use in some populations, nanostructured hydroxyapatite may be a promising calcium compound for food fortification.

Iodine status and associations with feeding practices and psychomotor milestone development in six-month-old South African infants

Iodine is important for normal growth and psychomotor development. While infants below 6 months of age receive iodine from breast milk or fortified infant formula, the introduction of complementary foods poses a serious risk for deteriorating iodine status. This cross-sectional analysis assessed the iodine status of six-month-old South African infants and explored its associations with feeding practices and psychomotor milestone development. Iodine concentrations were measured in infant (n = 386) and maternal (n = 371) urine (urinary iodine concentration [UIC]), and in breast milk (n = 257 [breast milk iodine concentrations]). Feeding practices and psychomotor milestone development were assessed in all infants. The median (25th-75th percentile) UIC in infants was 345 (213-596) μg/L and was significantly lower in stunted (302 [195-504] μg/L) than non-stunted (366 [225-641] μg/L) infants. Only 6.7% of infants were deficient. Maternal UIC (128 [81-216] μg/L; r_s  = 0.218, p < 0.001) and breast milk iodine concentrations (170 [110-270] μg/kg; r_s  = 0.447, p < 0.0001) were associated with infant UIC. Most infants (72%) were breastfed and tended to have higher UIC than non-breastfed infants (p = 0.074). Almost all infants (95%) consumed semi-solid or solid foods, with commercial infant cereals (60%) and jarred infant foods (20%) being the most common solid foods first introduced. Infants who reported to consume commercial infant cereals ≥4 days weekly had significantly higher UIC (372 [225-637] μg/L) than those reported to consume commercial infant cereals seldom or never (308 [200-517] μg/L; p = 0.023). No associations between infant UIC and psychomotor developmental scores were observed. Our results suggest that iodine intake in the studied six-month-old infants was adequate. Iodine in breast milk and commercial infant cereals potentially contributed to this adequate intake.

Breast-Milk Iodine Concentrations, Iodine Status, and Thyroid Function of Breastfed Infants Aged 2-4 Months and Their Mothers Residing in a South African Township

OBJECTIVE

Lactating women and their infants are susceptible to iodine deficiency and iodine excess. In South Africa, no data exist on the iodine status and thyroid function of these vulnerable groups.

METHODS

In a cross-sectional study, urinary iodine concentrations (UIC), thyroid function, and breast-milk iodine concentrations (BMIC) were assessed in 100 lactating women from a South African township and their 2-4-month-old breastfed infants. Potential predictors of UIC, thyroid function, and BMIC, including household salt iodine concentrations (SIC) and maternal sodium excretion, were also investigated.

RESULTS

The median (25th-75th percentile) UIC was 373 (202-627) μg/L in infants and 118 (67-179) μg/L in mothers. Median household SIC was 44 (27-63) ppm. Household SIC and maternal urinary sodium excretion predicted UIC of lactating mothers. Median BMIC was 179 (126-269) μg/L. Age of infants, SIC, and maternal UIC predicted BMIC. In turn, infant age and BMIC predicted UIC of infants. Forty-two percent of SIC values were within the South African recommended salt iodine fortification level at production of 35-65 ppm, whilst 21% of SIC were >65 ppm. Thyroid-stimulating hormone, total thyroxine, and thyroglobulin concentrations in the dried whole blood spot specimens from the infants were 1.3 (0.8-1.9) mU/L, 128±33 mmol/L, and 77.1 (56.3-105.7) μg/L, respectively, and did not correlate with infant UIC or BMIC.

CONCLUSION

Our results suggest that the salt fortification program in South Africa provides adequate iodine to lactating women and indirectly to their infants via breast milk. However, monitoring of salt iodine content of the mandatory salt iodization program in South Africa is important to avoid over-iodization of salt.