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Petry N, Wirth JP, Adu-Afarwuah S, Wegmuller R, Woodruff BA, Tanumihardjo SA, Bentil H, Donkor WES, Williams TN, Shahab-Ferdows S, Selenje L, Mahama A, Steiner-Asiedu M, Rohner F. Risk factors for anaemia among Ghanaian women and children vary by population group and climate zone. Matern Child Nutr 2021; 17:e13076. [PMID: 32945623 PMCID: PMC7988882 DOI: 10.1111/mcn.13076] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 07/27/2020] [Accepted: 08/11/2020] [Indexed: 12/12/2022]
Abstract
Anaemia has serious effects on human health and has multifactorial aetiologies. This study aimed to determine putative risk factors for anaemia in children 6-59 months and 15- to 49-year-old non-pregnant women living in Ghana. Data from a nationally representative cross-sectional survey were analysed for associations between anaemia and various anaemia risk factors. National and stratum-specific multivariable regressions were constructed separately for children and women to calculate the adjusted prevalence ratio (aPR) for anaemia of variables found to be statistically significantly associated with anaemia in bivariate analysis. Nationally, the aPR for anaemia was greater in children with iron deficiency (ID; aPR 2.20; 95% confidence interval [CI]: 1.88, 2.59), malaria parasitaemia (aPR 1.96; 95% CI: 1.65, 2.32), inflammation (aPR 1.26; 95% CI: 1.08, 1.46), vitamin A deficiency (VAD; aPR 1.38; 95% CI: 1.19, 1.60) and stunting (aPR 1.26; 95% CI: 1.09, 1.46). In women, ID (aPR 4.33; 95% CI: 3.42, 5.49), VAD (aPR 1.61; 95% CI: 1.24, 2.09) and inflammation (aPR 1.59; 95% CI: 1.20, 2.11) were associated with anaemia, whereas overweight and obese women had lower prevalence of anaemia (aPR 0.74; 95% CI: 0.56, 0.97). ID was associated with child anaemia in the Northern and Middle belts, but not in the Southern Belt; conversely, inflammation was associated with anaemia in both children and women in the Southern and Middle belts, but not in the Northern Belt. Anaemia control programmes should be region specific and aim at the prevention of ID, malaria and other drivers of inflammation as they are the main predictors of anaemia in Ghanaian children and women.
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Affiliation(s)
| | | | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Ghana
| | | | | | - Sherry A Tanumihardjo
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Helena Bentil
- Department of Nutrition and Food Science, University of Ghana, Legon, Ghana
| | - William E S Donkor
- GroundWork, Fläsch, Switzerland
- Department of Nutrition and Food Science, University of Ghana, Legon, Ghana
| | | | - Setareh Shahab-Ferdows
- USDA Agricultural Research Service Western Human Nutrition Research Center, Davis, California, USA
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2
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Rappaport AI, Karakochuk CD, Hess SY, Whitehead RD, Namaste SML, Dary O, Parker ME, Neufeld LM, Larson LM, Newton S, Wegmuller R, Moorthy D. Variability in haemoglobin concentration by measurement tool and blood source: an analysis from seven countries. J Clin Pathol 2020; 74:657-663. [PMID: 33023940 DOI: 10.1136/jclinpath-2020-206717] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 05/01/2020] [Revised: 07/22/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We explore factors such as the blood sampling site (capillary vs venous), the equipment (HemoCue vs automated haematology analyser) and the model of the HemoCue device (201+ vs 301) that may impact haemoglobin measurements in capillary and venous blood. METHODS Eleven studies were identified, and bias, concordance and measures of diagnostic performance were assessed within each study. FINDINGS Our analysis included 11 studies from seven countries (Cambodia, India, The Gambia, Ghana, Laos, Rwanda and USA). Samples came from children, men, non-pregnant women and pregnant women. Mean bias ranged from -8.7 to 2.5 g/L in Cambodian women, 6.2 g/L in Laotian children, 2.4 g/L in Ghanaian women, 0.8 g/L in Gambian children 6-23 months and 1.4 g/L in Rwandan children 6-59 months when comparing capillary blood on a HemoCue to venous blood on a haematology analyser. Bias was 8.3 g/L in Indian non-pregnant women and 2.6 g/L in Laotian children and women and 1.5 g/L in the US population when comparing capillary to venous blood using a HemoCue. For venous blood measured on the HemoCue compared with the automated haematology analyser, bias was 5.3 g/L in Gambian pregnant women 18-45 years and 11.3 g/L in Laotian children 6-59 months. CONCLUSION Our analysis found large variability in haemoglobin concentration measured on capillary or venous blood and using HemoCue Hb 201+ or Hb 301 or automated haematology analyser. We cannot ascertain whether the variation is due to differences in the equipment, differences in capillary and venous blood, or factors affecting blood collection techniques.
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Affiliation(s)
- Aviva I Rappaport
- Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING), Arlington, Virginia, USA.,School of Human Nutrition, McGill University, Sainte-Anne-de-Bellevue, Quebec, Canada
| | - Crystal D Karakochuk
- Food, Nutrition, and Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sonja Y Hess
- Institute for Global Nutrition, Department of Nutrition, University of California Davis, Davis, California, USA
| | - Ralph D Whitehead
- Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, Georgia, USA
| | - Sorrel M L Namaste
- The Demographic and Health Survey (DHS) Program, ICF, Rockville, Maryland, USA
| | - Omar Dary
- US Agency for International Development (USAID), Bureau of Global Health, Office of Maternal Child Health and Nutrition, Washington, DC, USA
| | - Megan E Parker
- Maternal, Newborn, Child Health and Nutrition, PATH, Seattle, Washington, USA
| | - Lynnette M Neufeld
- Knowledge Leadership, Global Alliance for Improved Nutrition, Geneva, Switzerland
| | - Leila M Larson
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, USA
| | - Sam Newton
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Rita Wegmuller
- GroundWork, Fläsch, Switzerland.,Medical Research Council Unit The Gambia, Keneba, The Gambia
| | - Denish Moorthy
- USAID Advancing Nutrition, John Snow Inc. Research and Training Institute, Arlington, Virginia, USA
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3
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Bah A, Muhammad AK, Wegmuller R, Verhoef H, Goheen MM, Sanyang S, Danso E, Sise EA, Pasricha SR, Armitage AE, Drakesmith H, Cross JH, Moore SE, Cerami C, Prentice AM. Hepcidin-guided screen-and-treat interventions against iron-deficiency anaemia in pregnancy: a randomised controlled trial in The Gambia. Lancet Glob Health 2019; 7:e1564-e1574. [PMID: 31607468 PMCID: PMC7109523 DOI: 10.1016/s2214-109x(19)30393-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/31/2019] [Accepted: 09/06/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND WHO recommends daily iron supplementation for pregnant women, but adherence is poor because of side-effects, effectiveness is low, and there are concerns about possible harm. The iron-regulatory hormone hepcidin can signal when an individual is ready-and-safe to receive iron. We tested whether a hepcidin-guided screen-and-treat approach to combat iron-deficiency anaemia could achieve equivalent efficacy to universal administration, but with lower exposure to iron. METHODS We did a three-arm, randomised, double-blind, non-inferiority trial in 19 rural communities in the Jarra West and Kiang East districts of The Gambia. Eligible participants were pregnant women aged 18-45 years at between 14 weeks and 22 weeks of gestation. We randomly allocated women to either WHO's recommended regimen (ie, a daily UN University, UNICEF, and WHO international multiple-micronutrient preparation [UNIMMAP] containing 60 mg iron), a 60 mg screen-and-treat approach (ie, daily UNIMMAP containing 60 mg iron for 7 days if weekly hepcidin was <2·5 μg/L or UNIMMAP without iron if hepcidin was ≥2·5 μg/L), or a 30 mg screen-and-treat approach (ie, daily UNIMMAP containing 30 mg iron for 7 days if weekly hepcidin was <2·5 μg/L or UNIMMAP without iron if hepcidin was ≥2·5 μg/L). We used a block design stratified by amount of haemoglobin at enrolment (above and below the median amount of haemoglobin on every enrolment day) and stage of gestation (14-18 weeks vs 19-22 weeks). Participants and investigators were unaware of the random allocation. The primary outcome was the amount of haemoglobin at day 84 and was measured as the difference in haemoglobin in each screen-and-treat group compared with WHO's recommended regimen; the non-inferiority margin was set at -5·0 g/L. The primary outcome was assessed in the per-protocol population, which comprised all women who completed the study. This trial is registered with the ISRCTN registry, number ISRCTN21955180. FINDINGS Between June 16, 2014, and March 3, 2016, 498 participants were randomised, of whom 167 were allocated to WHO's recommended regimen, 166 were allocated to the 60 mg per day screen-and-treat approach, and 165 were allocated to the 30 mg per day screen-and-treat approach. 78 participants were withdrawn or lost to follow-up during the study; thus, the per-protocol population comprised 140 women assigned to WHO's recommended regimen, 133 allocated to the 60 mg screen-and-treat approach, and 147 allocated to the 30 mg screen-and-treat approach. The screen-and-treat approaches did not exceed the non-inferiority margin. Compared with WHO's recommended regimen, the difference in the amount of haemoglobin at day 84 was -2·2 g/L (95% CI -4·6 to 0·1) with the 60 mg screen-and-treat approach and -2·7 g/L (-5·0 to -0·5) with the 30 mg screen-and-treat approach. Adherence, reported side-effects, and adverse events were similar between the three groups. The most frequent side-effect was stomachache, which was similar in the 60 mg screen-and-treat group (82 cases per 1906 person-weeks) and with WHO's recommended regimen (81 cases per 1974 person-weeks; effect 1·0, 95% CI 0·7 to 1·6); in the 30 mg screen-and-treat group the frequency of stomachache was slightly lower than with WHO's recommended regimen (58 cases per 2009 person-weeks; effect 0·7, 95% CI 0·5 to 1·1). No participants died during the study. INTERPRETATION The hepcidin-guided screen-and-treat approaches had no advantages over WHO's recommended regimen in terms of adherence, side-effects, or safety outcomes. Our results suggest that the current WHO policy for iron administration to pregnant women should remain unchanged while more effective approaches continue to be sought. FUNDING Bill & Melinda Gates Foundation and the UK Medical Research Council.
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Affiliation(s)
- Amat Bah
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; LSHTM, London, UK
| | - Abdul Khalie Muhammad
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Rita Wegmuller
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; GroundWork, Flaesch, Switzerland
| | - Hans Verhoef
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands; LSHTM, London, UK
| | - Morgan M Goheen
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; University of North Carolina at Chapel Hill School of Medicine, Department of Microbiology and Immunology, Chapel Hill, NC, USA
| | - Saikou Sanyang
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Ebrima Danso
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Ebrima A Sise
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, and Department of Medical Biology, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew E Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - James H Cross
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; LSHTM, London, UK
| | - Sophie E Moore
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; Department of Women & Children's Health, King's College London, St Thomas' Hospital, London, UK
| | | | - Andrew M Prentice
- Medical Research Council (MRC) Unit The Gambia at London School of Hygiene & Tropical Medicine (LSHTM), Serrekunda, The Gambia; LSHTM, London, UK.
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Wessells KR, Zyba S, Woodhouse L, Ceesay K, Prentice A, Brown K, Wegmuller R. Exogenous Phytase Added to Lipid Based Nutrient Supplements Increases Fractional and Total Absorption of Zinc Among Young Gambian Children: A Randomized Controlled Trial (OR07-01-19). Curr Dev Nutr 2019. [DOI: 10.1093/cdn/nzz034.or07-01-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
Dietary phytate inhibits zinc absorption from composite meals in adults. The objective of this study was to investigate the efficacy of adding exogenous phytase to a small-quantity lipid based nutrient supplement (SQ-LNS) on zinc absorption among young children.
Methods
In a double-blind randomized controlled trial, intra-individual differences in fractional and total absorption of zinc (FAZ and TAZ, respectively) from SQ-LNS with and without phytase were measured in 30 asymptomatic 18–23 month old children in the Kiang West district of The Gambia. Using a cross-over design, children received for one day each test meals of a millet-based porridge with 20 g SQ-LNS containing 8 mg zinc and either: 1) exogenous phytase (∼500 phytase units (FTU)) or 2) no exogenous phytase. The test meals were provided on consecutive days in randomized order. FAZ was measured using a dual-stable isotope tracer ratio technique with 67 Zn and 70 Zn as oral tracers, randomized independently of SQ-LNS product, and 68 Zn as the intravenous tracer. TAZ was calculated as the product of total dietary zinc (TDZ) intake from test meals (i.e., porridge, SQ-LNS and stable isotope) and FAZ. FAZ and TAZ were compared for meals with and without phytase using mixed-models ANOVA with product, study day, and oral isotope allocation as fixed effects and individual child as a random effect.
Results
Twenty-six participants completed the study. The prevalence of stunting, underweight and wasting were 20%, 30% and 13%, respectively; no children had low plasma zinc concentrations (< 65 μg/dL). TDZ and phytate intakes from the test meals were 7.2 ± 2.2 mg and 182.9 ± 64.7 mg, respectively (phytate: zinc molar ratio = 2.4 ± 0.2). Mean FAZ increased from 8.6 ± 1.3% to 16.0 ± 1.3% when exogenous phytase was added to the SQ-LNS product (P = 0.0002). Mean TAZ from porridge test meals containing SQ-LNS with phytase was more than double that from test meals containing SQ-LNS without phytase (1.12 ± 0.07 mg and 0.52 ± 0.07 mg, respectively; P < 0.0001).
Conclusions
The addition of exogenous phytase to a meal of millet-based porridge with SQ-LNS improved both FAZ and TAZ. These results suggest that phytate reduction may be an important strategy to improve zinc absorption among young children.
Funding Sources
Nutriset, SAS.
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Affiliation(s)
| | | | - Leslie Woodhouse
- Agriculture Research Service, Western Human Nutrition Research Center, US Department of Agriculture
| | - Kabiru Ceesay
- MRC Unit The Gambia at London School of Hygiene & Tropical Medicine
| | - Andrew Prentice
- MRC Unit The Gambia at London School of Hygiene & Tropical Medicine
| | | | - Rita Wegmuller
- MRC Unit The Gambia at London School of Hygiene & Tropical Medicine
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5
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Darboe A, Danso E, Clarke E, Umesi A, Touray E, Wegmuller R, Moore SE, Riley EM, Goodier MR. Enhancement of cytokine-driven NK cell IFN-γ production after vaccination of HCMV infected Africans. Eur J Immunol 2017; 47:1040-1050. [PMID: 28383105 PMCID: PMC5888140 DOI: 10.1002/eji.201746974] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 01/31/2017] [Revised: 03/01/2017] [Accepted: 03/30/2017] [Indexed: 12/24/2022]
Abstract
Human cytomegalovirus (HCMV) infection drives the phenotypic and functional differentiation of NK cells, thereby influencing the responses of these cells after vaccination. NK cell functional differentiation is particularly advanced in African populations with universal exposure to HCMV. To investigate the impact of advanced differentiation on vaccine‐induced responses, we studied NK‐cell function before and after vaccination with Trivalent Influenza Vaccine (TIV) or diphtheria, tetanus, pertussis, inactivated poliovirus vaccine (DTPiP) in Africans with universal, lifelong HCMV exposure. In contrast to populations with lower prevalence of HCMV infection, no significant enhancement of NK‐cell responses (IFN‐γ, CD107a, CD25) occurred after in vitro re‐stimulation of post‐vaccination NK cells with TIV or DTPiP antigens compared to pre‐vaccination baseline cells. However, both vaccinations resulted in higher frequencies of NK cells producing IFN‐γ in response to exogenous IL‐12 with IL‐18, which persisted for up to 6 months. Enhanced cytokine responsiveness was restricted to less differentiated NK cells, with increased frequencies of IFN‐γ+ cells observed within CD56brightCD57−, CD56dimCD57−NKG2C− and CD56dimCD57−NKG2C+ NK‐cell subsets. These data suggest a common mechanism whereby different vaccines enhance NK cell IFN‐γ function in HCMV infected donors and raise the potential for further exploitation of NK cell “pre‐activation” to improve vaccine effectiveness.
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Affiliation(s)
- Alansana Darboe
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK.,MRC International Nutrition Group, Nutrition Theme, MRC Keneba, Cambridge, UK
| | - Ebrima Danso
- MRC International Nutrition Group, Nutrition Theme, MRC Keneba, Cambridge, UK
| | - Ed Clarke
- Vaccine and Immunity Theme, Infant Immunology, Medical Research Council Unit The Gambia, Cambridge, UK
| | - Ama Umesi
- Vaccine and Immunity Theme, Infant Immunology, Medical Research Council Unit The Gambia, Cambridge, UK
| | - Ebrima Touray
- Vaccine and Immunity Theme, Infant Immunology, Medical Research Council Unit The Gambia, Cambridge, UK
| | - Rita Wegmuller
- MRC International Nutrition Group, Nutrition Theme, MRC Keneba, Cambridge, UK
| | - Sophie E Moore
- MRC International Nutrition Group, Nutrition Theme, MRC Keneba, Cambridge, UK.,MRC Human Nutrition Research, Cambridge, UK
| | - Eleanor M Riley
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin R Goodier
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK
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6
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Bah A, Pasricha SR, Jallow MW, Sise EA, Wegmuller R, Armitage AE, Drakesmith H, Moore SE, Prentice AM. Serum Hepcidin Concentrations Decline during Pregnancy and May Identify Iron Deficiency: Analysis of a Longitudinal Pregnancy Cohort in The Gambia. J Nutr 2017; 147:1131-1137. [PMID: 28424258 PMCID: PMC5443464 DOI: 10.3945/jn.116.245373] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/06/2017] [Accepted: 03/20/2017] [Indexed: 01/01/2023] Open
Abstract
Background: Antenatal anemia is a risk factor for adverse maternal and fetal outcomes and is prevalent in sub-Saharan Africa. Less than half of antenatal anemia is considered responsive to iron; identifying women in need of iron may help target interventions. Iron absorption is governed by the iron-regulatory hormone hepcidin. Objective: We sought to characterize changes in hepcidin and its associations with indexes of iron stores, erythropoiesis, and inflammation at weeks 14, 20, and 30 of gestation and to assess hepcidin’s diagnostic potential as an index of iron deficiency. Methods: We measured hemoglobin and serum hepcidin, ferritin, soluble transferrin receptor (sTfR), and C-reactive protein (CRP) at 14, 20, and 30 wk of gestation in a cohort of 395 Gambian women recruited to a randomized controlled trial. Associations with hepcidin were measured by using linear regression, and hepcidin’s diagnostic test accuracy [area under the receiver operating characteristic curve (AUCROC), sensitivity, specificity, cutoffs] for iron deficiency at each time point was analyzed. Results: The prevalence of anemia increased from 34.6% at 14 wk of gestation to 50.0% at 20 wk. Hepcidin concentrations declined between study enrollment and 20 wk, whereas ferritin declined between 20 and 30 wk of gestation. The variations in hepcidin explained by ferritin, sTfR, and CRP declined over pregnancy. The AUCROC values for hepcidin to detect iron deficiency (defined as ferritin <15 μg/L) were 0.86, 0.83, and 0.84 at 14, 20, and 30 wk, respectively. Hepcidin was superior to hemoglobin and sTfR as an indicator of iron deficiency. Conclusions: In Gambian pregnant women, hepcidin appears to be a useful diagnostic test for iron deficiency and may enable the identification of cases for whom iron would be beneficial. Hepcidin suppression in the second trimester suggests a window for optimal timing for antenatal iron interventions. Hemoglobin does not effectively identify iron deficiency in pregnancy. This trial was registered at www.isrctn.com as ISRCTN49285450.
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Affiliation(s)
- Amat Bah
- Medical Research Council (MRC) Unit The Gambia-MRC International Nutrition Group, Banjul, Gambia;
| | - Sant-Rayn Pasricha
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Momodou W Jallow
- Medical Research Council (MRC) Unit The Gambia-MRC International Nutrition Group, Banjul, Gambia
| | - Ebrima A Sise
- Medical Research Council (MRC) Unit The Gambia-MRC International Nutrition Group, Banjul, Gambia
| | - Rita Wegmuller
- Medical Research Council (MRC) Unit The Gambia-MRC International Nutrition Group, Banjul, Gambia
| | - Andrew E Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Sophie E Moore
- Division of Women's Health, King's College London, London, United Kingdom; and
| | - Andrew M Prentice
- MRC Unit The Gambia-MRC International Nutrition Group and London School of Hygiene and Tropical Medicine, London, United Kingdom
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7
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Abstract
In light of evidence that high-dose iron supplements lead to a range of adverse events in low-income settings, the safety and efficacy of lower doses of iron provided through biological or industrial fortification of foodstuffs is reviewed. First, strategies for point-of-manufacture chemical fortification are compared with biofortification achieved through plant breeding. Recent insights into the mechanisms of human iron absorption and regulation, the mechanisms by which iron can promote malaria and bacterial infections, and the role of iron in modifying the gut microbiota are summarized. There is strong evidence that supplemental iron given in nonphysiological amounts can increase the risk of bacterial and protozoal infections (especially malaria), but the use of lower quantities of iron provided within a food matrix, ie, fortified food, should be safer in most cases and represents a more logical strategy for a sustained reduction of the risk of deficiency by providing the best balance of risk and benefits. Further research into iron compounds that would minimize the availability of unabsorbed iron to the gut microbiota is warranted.
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Affiliation(s)
- Andrew M Prentice
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
| | - Yery A Mendoza
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Dora Pereira
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Carla Cerami
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Rita Wegmuller
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Anne Constable
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Jörg Spieldenner
- A.M. Prentice, D. Pereira, C. Cerami, and R. Wegmuller are with the Medical Research Council (MRC) Unit The Gambia, Fajara, Banjul, The Gambia. A.M. Prentice and R. Wegmuller are with the MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom. Y.A. Mendoza, A. Constable, and J. Spieldenner are with the Nestlé Research Centre, Lausanne, Switzerland. D. Pereira is with the Department of Pathology, University of Cambridge, Cambridge, United Kingdom. C. Cerami is with the Division of Infectious Diseases, Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Shimakawa Y, Lemoine M, Njai HF, Bottomley C, Ndow G, Goldin RD, Jatta A, Jeng-Barry A, Wegmuller R, Moore SE, Baldeh I, Taal M, D'Alessandro U, Whittle H, Njie R, Thursz M, Mendy M. Natural history of chronic HBV infection in West Africa: a longitudinal population-based study from The Gambia. Gut 2016; 65:2007-2016. [PMID: 26185161 DOI: 10.1136/gutjnl-2015-309892] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 06/15/2015] [Accepted: 06/25/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND The natural history of chronic HBV infection in sub-Saharan Africa is unknown. Data are required to inform WHO guidelines that are currently based on studies in Europe and Asia. METHODS Between 1974 and 2008, serosurveys were repeated in two Gambian villages, and an open cohort of treatment-naive chronic HBV carriers was recruited. Participants were followed to estimate the rates of hepatitis B e (HBeAg) and surface antigen (HBsAg) clearance and incidence of hepatocellular carcinoma (HCC). In 2012-2013, a comprehensive liver assessment was conducted to estimate the prevalence of severe liver disease. RESULTS 405 chronic carriers (95% genotype E), recruited at a median age of 10.8 years, were followed for a median length of 28.4 years. Annually, 7.4% (95% CI 6.3% to 8.8%) cleared HBeAg and 1.0% (0.8% to 1.2%) cleared HBsAg. The incidence of HCC was 55.5/100 000 carrier-years (95% CI 24.9 to 123.5). In the 2012-2013 survey (n=301), 5.5% (95% CI 3.4% to 9.0%) had significant liver fibrosis. HBV genotype A (versus E), chronic aflatoxin B1 exposure and an HBsAg-positive mother, a proxy for mother-to-infant transmission, were risk factors for liver fibrosis. A small proportion (16.0%) of chronic carriers were infected via mother-to-infant transmission; however, this population represented a large proportion (63.0%) of the cases requiring antiviral therapy. CONCLUSIONS The incidence of HCC among chronic HBV carriers in West Africa was higher than that in Europe but lower than rates in East Asia. High risk of severe liver disease among the few who are infected by their mothers underlines the importance of interrupting perinatal transmission in sub-Saharan Africa.
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Affiliation(s)
- Yusuke Shimakawa
- Medical Research Council (MRC) Unit, Banjul, The Gambia
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Unité d'Épidémiologie des Maladies Émergentes, Institut Pasteur, Paris, France
| | - Maud Lemoine
- Medical Research Council (MRC) Unit, Banjul, The Gambia
- Department of Hepatology, Imperial College London, London, UK
| | | | - Christian Bottomley
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Gibril Ndow
- Medical Research Council (MRC) Unit, Banjul, The Gambia
- The Gambia Hepatitis Intervention Study, IARC, c/o MRC Unit, Banjul, The Gambia
| | - Robert D Goldin
- Department of Hepatology, Imperial College London, London, UK
| | | | | | - Rita Wegmuller
- MRC International Nutrition Group, MRC Keneba, West Kiang, The Gambia
| | - Sophie E Moore
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- MRC International Nutrition Group, MRC Keneba, West Kiang, The Gambia
| | | | - Makie Taal
- Ministry of Health and Social Welfare, Banjul, The Gambia
| | - Umberto D'Alessandro
- Medical Research Council (MRC) Unit, Banjul, The Gambia
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Hilton Whittle
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Ramou Njie
- Medical Research Council (MRC) Unit, Banjul, The Gambia
- The Gambia Hepatitis Intervention Study, IARC, c/o MRC Unit, Banjul, The Gambia
| | - Mark Thursz
- Department of Hepatology, Imperial College London, London, UK
| | - Maimuna Mendy
- International Agency for Research on Cancer (IARC), Lyon, France
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9
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Ramakrishnan G, Wright M, Alam M, Naylor C, Kabir M, Zerin A, Ferdous T, Pedersen K, Hennig BJ, Donowitz JR, Wegmuller R, Haque R, Petri WA, Herbein J, Gilchrist CA. Rapid assessment of tetanus vaccine-induced immunity in Bangladesh and the Gambia. Diagn Microbiol Infect Dis 2016; 87:272-274. [PMID: 27916543 DOI: 10.1016/j.diagmicrobio.2016.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 05/05/2016] [Revised: 10/28/2016] [Accepted: 11/19/2016] [Indexed: 02/08/2023]
Abstract
We have developed recombinant fragment C based rapid point of care dipstick devices to assess tetanus immunization status using plasma or whole blood. The devices demonstrated specificity of 0.90 and sensitivity of 0.90 (whole blood)/0.94 (plasma) at field sites in Bangladesh and The Gambia when compared to a commercial ELISA with the immune cut-off titer set as ≥0.1IU/mL.
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Affiliation(s)
- Girija Ramakrishnan
- Department of Medicine/Division of Infectious Disease and International Health, University of Virginia, Charlottesville, VA, USA
| | | | - Masud Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh (icddr,b)
| | - Caitlin Naylor
- Nutrition Theme, MRC Unit The Gambia (MRCG), Banjul, The Gambia
| | - Mamun Kabir
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh (icddr,b)
| | - Ayesha Zerin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh (icddr,b)
| | - Tahsin Ferdous
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh (icddr,b)
| | | | - Branwen J Hennig
- Nutrition Theme, MRC Unit The Gambia (MRCG), Banjul, The Gambia; MRC International Nutrition Group, London, School of Hygiene & Tropical Medicine, London, UK
| | - Jeffrey R Donowitz
- Division of Pediatric Infectious Diseases, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond
| | - Rita Wegmuller
- Nutrition Theme, MRC Unit The Gambia (MRCG), Banjul, The Gambia; MRC International Nutrition Group, London, School of Hygiene & Tropical Medicine, London, UK
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh (icddr,b)
| | - William A Petri
- Department of Medicine/Division of Infectious Disease and International Health, University of Virginia, Charlottesville, VA, USA
| | | | - Carol A Gilchrist
- Department of Medicine/Division of Infectious Disease and International Health, University of Virginia, Charlottesville, VA, USA.
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10
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Bah A, Wegmuller R, Cerami C, Kendall L, Pasricha SR, Moore SE, Prentice AM. A double blind randomised controlled trial comparing standard dose of iron supplementation for pregnant women with two screen-and-treat approaches using hepcidin as a biomarker for ready and safe to receive iron. BMC Pregnancy Childbirth 2016; 16:157. [PMID: 27411564 PMCID: PMC4944263 DOI: 10.1186/s12884-016-0934-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 07/28/2015] [Accepted: 06/14/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Until recently, WHO recommended daily iron supplementation for all pregnant women (60 mg/d iron combined with 400ug/d folic acid) where anaemia rates exceeded 40 %. Recent studies indicate that this may pose a risk to pregnant women. Therefore, there is a need to explore screen-and-treat options to minimise iron exposure during pregnancy using an overall lower dosage of iron that would achieve equivalent results as being currently recommended by the WHO. However, there is a lack of agreement on how to best assess iron deficiency when infections are prevalent. Here, we test the use of hepcidin a peptide hormone and key regulator of iron metabolism, as a potential index for 'safe and ready to receive' iron. DESIGN/METHODS This is a 3-arm randomised-controlled proof-of-concept trial. We will test the hypothesis that a screen-and-treat approach to iron supplementation using a pre-determined hepcidin cut-off value of <2.5 ng/ml will achieve similar efficacy in preventing iron deficiency and anaemia at a lower iron dose and hence will improve safety. A sample of 462 pregnant women in rural Gambia will be randomly assigned to receive: a) UNU/UNICEF/WHO international multiple micronutrient preparation (UNIMMAP) containing 60 mg/d iron (reference arm); b) UNIMMAP containing 60 mg/d iron but based on a weekly hepcidin screening indicating if iron can be given for the next 7 days or not; c) or UNIMMAP containing 30 mg/d iron as in (b) for 12 weeks in rural Gambia. The study will test if the screen-and-treat approach is non-inferior to the reference arm using the primary endpoint of haemoglobin levels at a non-inferiority margin of 0.5 g/dl. Secondary outcomes of adverse effects, compliance and the impact of iron supplementation on susceptibility to infections will also be assessed. DISCUSSION This trial is expected to contribute towards minimising the exposure of pregnant women to iron that may not be needed and therefore potentially harmful. If the evidence in this study shows that the overall lower dosage of iron is non-inferior to 60 mg/day iron, this may help decrease side-effects, improve compliance and increase safety. The potential for the use of hepcidin for a simple point-of-care (PoC) diagnostic for when it is most safe and effective to give iron may improve maternal health outcomes. TRIAL REGISTRATION ISRCTN21955180.
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Affiliation(s)
- Amat Bah
- />MRC Unit The Gambia & MRC International Nutrition Group, PO Box 273, Banjul, The Gambia
| | - Rita Wegmuller
- />MRC Unit The Gambia & MRC International Nutrition Group, PO Box 273, Banjul, The Gambia
| | - Carla Cerami
- />MRC Unit The Gambia & MRC International Nutrition Group, PO Box 273, Banjul, The Gambia
| | | | - Sant-Rayn Pasricha
- />The Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DS UK
| | - Sophie E. Moore
- />MRC Human Nutrition Research, Elsie Widdowson Laboratory, 120 Fulbourn Road, Cambridge, CB1 9NL UK
| | - Andrew M. Prentice
- />MRC Unit The Gambia & MRC International Nutrition Group, PO Box 273, Banjul, The Gambia
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11
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Pinkaew S, Wegmuller R, Wasantwisut E, Winichagoon P, Hurrell RF, Tanumihardjo SA. Triple-fortified rice containing vitamin A reduced marginal vitamin A deficiency and increased vitamin A liver stores in school-aged Thai children. J Nutr 2014; 144:519-24. [PMID: 24500930 DOI: 10.3945/jn.113.182998] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Vitamin A (VA)-fortified rice is a potential intervention strategy to prevent VA deficiency in at-risk populations. Hot-extruded, triple-fortified rice grains with added VA, zinc, and iron were produced by hot extrusion technology and their ability to improve VA status was tested in Thai schoolchildren. The fortification levels were 10 mg of iron, 9 mg of zinc, and 1.05 mg of VA/g extruded rice. A paired stable isotope dilution technique with labeled ¹³C₂-retinyl acetate (¹³C-RID) was used to quantify VA pool size at the beginning and end of the feeding period. Fifty healthy schoolchildren with a serum retinol (SR) concentration of >0.7 μmol/L were randomly assigned to 2 groups to receive either triple-fortified rice (n = 25) or natural rice (n = 25) for 2 mo as part of the daily school meal. The fortified grains, mixed 1:50 with regular rice, were estimated to provide an extra 890 μg of VA/d, 5 d/wk. ¹³C₂-retinyl acetate (1.0 μmol) was administered orally to each child before and at the end of the feeding period to estimate total body reserves (TBRs) of VA, which increased significantly (P < 0.05) in the intervention group from 153 ± 66 μmol retinol at baseline to 269 ± 148 μmol retinol after 2 mo of feeding. There was no change in the TBRs of VA in the control group (108 ± 67 vs. 124 ± 89 μmol retinol) (P = 0.22). Serum retinol remained unchanged in both groups. We conclude that VA-fortified, hot-extruded rice is an efficacious vehicle to provide additional VA to at-risk populations, and that the efficacy of VA-fortified foods can be usefully monitored by the ¹³C-RID measurement of TBRs of VA but not by changes in SR concentration.
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Affiliation(s)
- Siwaporn Pinkaew
- Laboratory for Human Nutrition, Institute of Food, Nutrition, and Health, ETH, Zurich, Switzerland
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12
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Pinkaew S, Winichagoon P, Hurrell RF, Wegmuller R. Extruded rice grains fortified with zinc, iron, and vitamin A increase zinc status of Thai school children when incorporated into a school lunch program. J Nutr 2013; 143:362-8. [PMID: 23303870 DOI: 10.3945/jn.112.166058] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Iron (Fe), zinc (Zn), and vitamin A (VA) deficiencies are common among children in developing countries and often occur in the same individual. Rice is widely consumed in the developing countries of Asia and the low phytate in polished rice makes it ideal for Zn and Fe fortification. Triple-fortified rice grains with Zn, Fe, and VA were produced using hot extrusion technology. The main objective of the present study was to determine the impact of triple-fortified extruded rice on Zn status in school children in Southern Thailand. Although serum zinc was the main outcome indicator, Fe and VA status were also assessed. School children with low serum zinc (n = 203) were randomized to receive either triple-fortified rice (n = 101) or natural control rice (n = 102) as a component of school lunch meals for 5 mo. Serum Zn, hemoglobin, serum ferritin, serum retinol, and C-reactive protein were measured at baseline and at the end of the study. After the intervention, serum Zn increased (P < 0.05) in both the fortification (11.3 ± 1.3 μmol/L) and control (10.6 ± 1.4 μmol/L) groups, most likely due to the proper implementation of the school lunch and school milk programs, with the increase greater in the group receiving the triple-fortified rice (P < 0.05). Because the children were not Fe or VA deficient at baseline, there was no change in Fe or VA status. We conclude that Zn fortification of extruded rice grains is efficacious and can be used to improve Zn status in school children.
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Affiliation(s)
- Siwaporn Pinkaew
- Laboratory for Human Nutrition, Institute of Food, Nutrition and Health, ETH Zurich, Zurich, Switzerland
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13
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Pinkaew S, Wegmuller R, Hurrell R. Vitamin A stability in triple fortified extruded, artificial rice grains containing iron, zinc and vitamin A. Int J Food Sci Technol 2012. [DOI: 10.1111/j.1365-2621.2012.03091.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wegmuller R, Zimmermann M, Hurrell R. Dual Fortification of Salt with Iodine and Encapsulated Iron Compounds: Stability and Acceptability Testing in Morocco and Cote d'Ivoire. J Food Sci 2003. [DOI: 10.1111/j.1365-2621.2003.tb07031.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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