C.E. West

Lack of improvement in vitamin A status with increased consumption of dark-green leafy vegetables

There is little evidence to support the general assumption that dietary carotenoids can improve vitamin A status. We investigated in Bogor District, West Java, Indonesia, the effect of an additional daily portion of dark-green leafy vegetables on vitamin A and iron status in women with low haemoglobin concentrations (< 130 g/L) who were breastfeeding a child of 3-17 months. Every day for 12 weeks one group (n = 57) received stir-fried vegetables, a second (n = 62) received a wafer enriched with beta-carotene, iron, vitamin C, and folic acid, and a third (n = 56) received a non-enriched wafer to control for additional energy intake. The vegetable supplement and the enriched wafer contained 3.5 mg beta-carotene, 5.2 mg and 4.8 mg iron, and 7.8 g and 4.4 g fat, respectively. Assignment to vegetable or wafer groups was by village. Wafers were distributed double-masked. In the enriched-wafer group there were increases in serum retinol (mean increase 0.32 [95% CI 0.23-0.40] mumol/L), breastmilk retinol (0.59 [0.35-0.84] mumol/L), and serum beta-carotene (0.73 [0.59-0.88] mumol/L). These changes differed significantly from those in the other two groups, in which the only significant changes were small increases in breastmilk retinol in the control-wafer group (0.16 [0.02-0.30] mumol/L) and in serum beta-carotene in the vegetable group (0.03 [0-0.06] mumol/L). Changes in iron status were similar in all three groups. An additional daily portion of dark-green leafy vegetables did not improve vitamin A status, whereas a similar amount of beta-carotene from a simpler matrix produced a strong improvement. These results suggest that the approach to combating vitamin A deficiency by increases in the consumption of provitamin A carotenoids from vegetables should be re-examined.

Supplementation with vitamin A and iron for nutritional anaemia in pregnant women in West Java, Indonesia

Nutritional anaemia, thought to be caused by iron deficiency, affects 50-70% of pregnant women in the developing world. The influence of vitamin A and iron supplementation was studied in anaemic pregnant women in West Java, in a randomised, double-masked, placebo-controlled field trial. 251 women aged 17-35 years, parity 0-4, gestation 16-24 weeks, and haemoglobin between 80 and 109 g/L were randomly allocated to four groups: vitamin A (2.4 mg retinol) and placebo iron tablets; iron (60 mg elemental iron) and placebo vitamin A; vitamin A and iron; or both placebos, all daily for 8 weeks. Maximum haemoglobin was achieved with both vitamin A and iron supplementation (12.78 g/L, 95% Cl 10.86 to 14.70), with one-third of the response attributable to vitamin A (3.68 g/L, 2.03 to 5.33) and two-thirds to iron (7.71 g/L, 5.97 to 9.45). After supplementation, the proportion of women who became non-anaemic was 35% in the vitamin-A-supplemented group, 68% in the iron-supplemented group, 97% in the group supplemented with both, and 16% in the placebo group. Improvement in vitamin A status may contribute to the control of anaemic pregnant women.

Zinc supplementation and stunted infants in Ethiopia: a randomised controlled trial

BACKGROUND Stunting is highly prevalent in Ethiopia and many other developing countries but the reason for it is poorly understood. Zinc is essential for growth but diets in such countries often do not contain zinc in sufficient quantity or of sufficient bioavailability. Thus zinc deficiency may play a major role in stunting. The aim of the study was to investigate whether the low rate of linear growth of apparently healthy breastfed infants in a rural village in Ethiopia could be improved by zinc supplementation. METHODS A randomised, double-blind, placebo-controlled trial was done on apparently healthy breastfed infants aged 6-12 months. 100 non-stunted (length-for-age, Z score < -2) were matched for age and sex with 100 randomly selected stunted (> -2) infants. Infants, both stunted and non stunted, were matched by sex, age (within 2 months) and recumbent length (within 3 cm) for random assignment, to receive a zinc supplement (10 mg zinc per day, as zinc sulphate) or placebo, 6 days a week for 6 months. Anthropometric measurements were taken monthly, data on illness and appetite were collected daily, and samples of serum and hair were taken at the end of the intervention for the analysis of zinc. FINDINGS The length of stunted infants increased significantly more (p<0.001) when supplemented with zinc (7.0 cm [SE 1.1]) than with placebo (2.8 cm [0.9]); and the effect was greater (p<0.01) than in non-stunted infants (6.6 [0.9] vs 5.0 [0.8] cm for the zinc and placebo groups respectively, p<0.01). Zinc supplementation also increased the weight of stunted children (1.73 [0.39] vs 0.95 [0.39] kg for the corresponding placebo group, p<0.001) and of non-stunted children (1.19 [0.39] vs 1.02 [0.32] kg for the corresponding placebo group, p<0.05). Zinc supplementation resulted in a markedly lower incidence of anorexia and morbidity from cough, diarrhoea, fever, and vomiting in the stunted children. The total number of these conditions per child was 1.56 and 1.11 in the stunted and non-stunted zinc supplemented children versus 3.38 and 1.64 in the stunted and non-stunted placebo-treated children, respectively. At the end of the intervention period, the concentrations of zinc in serum and hair of stunted infants, who had not been supplemented with zinc, were lower than the respective concentrations of zinc in serum and hair of their non-stunted counterparts. INTERPRETATION Combating zinc deficiency can increase the growth rate of stunted children to that of non-stunted infants in rural Ethiopia. This would appear to be due, at least in part, to reduction in morbidity from infection and increased appetite.

Consequences of Revised Estimates of Carotenoid Bioefficacy for Dietary Control of Vitamin A Deficiency in Developing Countries

According to existing recommendations of the Food and Agriculture Organization (FAO)/World Health Organization (WHO), the amount of provitamin A in a mixed diet having the same vitamin A activity as 1 microg of retinol is 6 microg of beta-carotene or 12 microg of other provitamin A carotenoids. The efficiency of this conversion is referred to as bioefficacy. Recently, using data from healthy people in developed countries and based on a two-step process, the U.S. Institute of Medicine (IOM) derived new conversion factors. The first step established the bioefficacy of beta-carotene in oil at 2 microg having the same vitamin A activity as 1 microg of retinol; the second step established the bioavailability of beta-carotene in foods relative to that of beta-carotene in oil at 1:6. Thus, 2 microg of beta-carotene in oil or 12 microg of beta-carotene in mixed foods has the same vitamin A activity as 1 microg of retinol. Based on existing FAO food balance sheets and the FAO/WHO conversion rates, all populations should be able to meet their vitamin A requirements from existing dietary sources. However, using the new IOM conversion rates, populations in developing countries could not achieve adequacy. Additionally, field studies suggest that, instead of 12 microg, 21 microg of beta-carotene has the same vitamin A activity as 1 microg of retinol, which implies that effective vitamin A intake is even lower. Therefore, controlling vitamin A deficiency in developing countries requires not only vitamin A supplementation but also food-based approaches, including food fortification, and possibly the introduction of new strains of plants with enhanced vitamin A activity.

Interrelationship between vitamin A, iodine and iron status in schoolchildren in Shoa Region, Central Ethiopia

A total of 14,740 schoolchildren in seven provinces of Shoa Administrative Region in Central Ethiopia were surveyed for the prevalence of goitre, xerophthalmia and anaemia. Haemoglobin and packed cell volume were assessed in 966 children in one province while an in-depth study was conducted on 344 children in the same province and two others. Goitre, xerophthalmia (Bitots spots) and clinical anaemia were observed in 34.2, 0.91 and 18.6% respectively of the children. Most biochemical variables were within the normal range while those of haemoglobin (Hb), mean corpuscular Hb concentration (MCHC) and urinary I excretion were lower, and mean corpuscular volume, mean corpuscular Hb (MCH), and immunoglobulins G and M were higher. Hb was strongly correlated with retinol, ferritin, MCHC, MCH, packed cell volume and erythrocyte count while retinol formed a triad with transthyretin (TTR) and retinol-binding protein (RBP) which were all correlated with one another. Total and free thyroxin and total and free triiodothyronine were positively correlated as were the concentrations of the total and free hormones. Thyrotropin (TSH) was negatively correlated with total and free thyroxin and positively correlated with free triiodothyronine. Thyroxin and triiodothyronine in both free and combined forms were all correlated with thyroxin-binding globulin which in turn was negatively correlated with the triad retinol, RBP and TTR. The triad was also negatively correlated with C-reactive protein. Urinary I excretion was positively associated with total thyroxin and negatively associated with TSH. The anaemia found was not nutritional in origin but due to the effect of infestation with intestinal parasites and malaria.

Efficacy of iron-fortified whole maize flour on iron status of schoolchildren in Kenya: a randomised controlled trial

BACKGROUND Sodium iron edetic acid (NaFeEDTA) might be a more bioavailable source of iron than electrolytic iron, when added to maize flour. We aimed to assess the effect, on childrens iron status, of consumption of whole maize flour fortified with iron as NaFeEDTA or electrolytic iron. METHODS 516 children, aged 3-8 years, from four schools in Marafa, Kenya, were randomly assigned to four groups. All were given the same amount of porridge five times a week. The porridge for one group was made from unfortified whole maize flour; for the other three groups it was fortified with either high-dose NaFeEDTA (56 mg/kg), low-dose NaFeEDTA (28 mg/kg), or electrolytic iron (56 mg/kg). Concentrations of haemoglobin, plasma ferritin, and transferrin receptor were analysed in samples taken at baseline and at the end of the 5-month intervention. The primary outcome was iron-deficiency anaemia. We analysed data on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT00386074. FINDINGS The prevalence of iron-deficiency anaemia in children given unfortified flour was 10%. Compared with placebo, the prevalence of iron-deficiency anaemia in children given flour fortified with high-dose NaFeEDTA, low-dose NaFeEDTA, and electrolytic iron changed by -89% (95% CI -97% to -49%), -48% (-77% to 20%), and 59% (-18% to 209%), respectively. Consumption of high-dose NaFeEDTA improved all measured iron-status indicators. Low-dose NaFeEDTA decreased the prevalence of iron deficiency but did not noticeably change the prevalence of anaemia. Electrolytic iron did not improve any of these iron-status indicators. Children who were iron-deficient at baseline benefited more from high-dose and low-dose NaFeEDTA than those with sufficient iron at baseline. INTERPRETATION Consumption of whole maize flour fortified with NaFeEDTA caused modest, dose-dependent improvements in childrens iron status. Fortification with electrolytic iron did not improve their iron status. Therefore, in high-phytate flours, NaFeEDTA is more suitable than electrolytic iron for supplementation of iron in the diet.

Intermittent administration of iron and sulfadoxine-pyrimethamine to control anaemia in Kenyan children: a randomised controlled trial

BACKGROUND Iron supplementation is recommended for children at high risk of anaemia, but its benefits may not outweigh the associated risk of malaria in areas of seasonal transmission. We investigated the effect on haemoglobin concentrations of intermittent administration of iron supplements and sulfadoxine-pyrimethamine in symptom-free children under intense health surveillance. METHODS In a trial of two by two factorial design, 328 anaemic Kenyan children were randomly assigned either iron or placebo and sulfadoxine-pyrimethamine or placebo (82 to each group). Primary outcomes were haemological indicators of iron status and inflammation at the end of the follow-up, and occurrence of malaria attacks. Morbidity surveillance consisted of medical examinations every 4 weeks, continuous passive case detection, and visits twice a week to community health-workers. Analyses were by intention to treat. FINDINGS After 12 weeks, the groups assigned iron plus sulfadoxine-pyrimethamine, iron alone, or sulfadoxine-pyrimethamine alone had higher haemoglobin concentrations than the group assigned placebo (treatment effect adjusted for prognostic factors at baseline: 11.1 g/L [95% CI 7.5 to 14.7]; 10.7 g/L [7.1 to 14.3]; and 3.1 g/L [-0.5 to 6.7]). Administration of iron plus sulfadoxine-pyrimethamine also lowered the proportion with anaemia from 100% at baseline to 36% at 12 weeks, and of iron deficiency from 66% at baseline to 8% at 12 weeks. Survival analysis showed no evidence of substantially increased risk of malaria after iron supplementation. INTERPRETATION Iron supplementation gives substantial health benefits, which may outweigh possible inherent risks caused by malaria. A larger study than ours is needed to assess benefits and risks of intermittent administration of sulfadoxine-pyrimethamine in reducing the incidence of malaria attacks in areas of seasonal malaria transmission.

Development of a method for quantitation of retinol and retinyl palmitate in human serum using high-performance liquid chromatography–atmospheric pressure chemical ionization–mass spectrometry

A method for the quantitative analysis of the vitamin A compounds all-trans-retinol and all-trans-retinyl palmitate was developed using high-performance liquid chromatography-atmospheric pressure chemical ionization-mass spectrometry (APCI-LC-MS). Unlike previous quantitative mass spectrometric methods for vitamin A, HPLC separations were carried out using a C30 reversed-phase column instead of GC separation. Because no sample hydrolysis or derivatization was necessary, retinyl palmitate was preserved for analysis instead of being hydrolyzed to retinol. Human serum was analyzed following simple hexane extraction without saponification or any additional purification. A comparison of APCI and electrospray ionization showed that only APCI produced a linear response over all four orders of magnitude of retinol and three orders of magnitude of retinyl palmitate concentrations. Selected ion monitoring of the fragment ion of m/z 269 was used for APCI quantitation of both retinol and retinyl palmitate, since it was the base peak and the only abundant ion in the mass spectra of both compounds and the internal standard, retinyl acetate. The ion of m/z 269 corresponded to loss of water, loss of palmitic acid, or elimination of acetic acid from the protonated molecules of retinol, retinyl palmitate and retinyl acetate, respectively. The limit of detection of APCI-LC-MS for all-trans-retinol and all-trans-retinyl palmitate was determined to be approximately 34 fmol/microliter and 36 fmol/microliter (0.670 pmol all-trans-retinol and 0.720 pmol all-trans-retinyl palmitate injected in 20 microliters on-column), respectively. The limit of quantitation was approximately 500 fmol/microliter and 250 fmol/microliter (10 pmol and 5 pmol injected in 20 microliters on-column) for retinol and retinyl palmitate, respectively.

The effect of semipurified diets containing different proportions of either casein or soybean protein on the concentration of cholesterol in whole serum, serum lipoproteins and liver in male and female rats.

Male and female lean Zucker strain rats were fed cholesterol-enriched semipurified diets containing 2 levels (20% and 50%, w/w) of either casein or soybean protein for a period of 14 weeks. In the female rats, the feeding of casein diets resulted in significantly higher levels of serum cholesterol than when diets containing soybean protein were fed. In addition, the hypercholesterolemic effect of dietary casein could be enhanced by increasing the proportion of this protein in the diet. Modulations in the proportion of dietary soybean protein did not significantly affect the serum cholesterol levels. In the male rats, however, no such differential effects were observed, indicating a difference between male and female rats in susceptibility to the induction of changes in serum cholesterol levels by dietary means. Upon feeding casein diets, both the male and female rats exhibited a shift of cholesterol from the high density lipoproteins to the lipoproteins with a lower density. This effect was more pronounced in the female than in the male rats. Liver cholesterol concentrations were markedly affected by modulations both in the type and proportion of dietary protein in both sexes. The concentration of cholesterol in the liver of the rats was highest in those fed the 50% casein diet and progressively lower in the animals on diets containing 20% casein, 20% soybean protein and 50% soybean protein.

Intake of micronutrients high in animal-source foods is associated with better growth in rural Kenyan school children.

Observational studies have shown that children in developing countries consuming diets containing high amounts of bioavailable nutrients, such as those found in animal-source foods, grow better. The present study investigated which specific nutrients from the diet of Kenyan school children predicted their growth. The children (n 544, median age 7 years) participated in a 2-year long food supplementation study with animal-source foods. Height gain during the intervention period was positively predicted by average daily intakes of energy from animal-source foods, haem Fe, preformed vitamin A, Ca and vitamin B12. Weight gain was positively predicted by average daily intakes of energy from animal-source foods, haem Fe, preformed vitamin A, Ca and vitamin B12. Gain in mid-upper-arm muscle area was positively predicted by average daily intakes of energy from animal-source foods and vitamin B12. Gain in mid-upper-arm fat area was positively predicted by average daily intakes of energy from animal-source foods. Gain in subscapular skinfold thickness was not predicted by any of the nutrient intakes. Negative predictors of growth were total energy and nutrients that are contained in high amounts in plant foods. The study shows that growth was positively predicted by energy and nutrients that are provided in high amounts and in a bioavailable form in meat and milk, and their inclusion into the diets of children in developing countries should be part of all food-based programmes in order to improve micronutrient status and growth.