Jacques Berger

Effect of daily iron supplementation on iron status, cell-mediated immunity, and incidence of infections in 6-36 month old Togolese children

Objective: To assess the impact of a daily oral iron supplementation on hematological status, cell-mediated immunity and susceptibility to infections in children living in an environment where iron deficiency, malaria and other infections are frequent.Design: Randomized, double-blind iron supplementation including a placebo group.Setting: A village in Togo, West Africa.Subjects: Of the 229 6–36-month-old children of both sexes recruited, 197 with hemoglobin concentration ≥80u2005g/l were included and 163 completed the study.Intervention: Children received daily a placebo (n=79) or a dose of 2–3 mg of elemental iron per kg of body weight (n=84) for 3 months. Hematological, nutritional and immune status were assessed at the beginning and at the end of the supplementation period, and 6 months later. Morbidity was recorded throughout the study.Results: Iron supplementation had a significant and positive effect on iron status of children and no impact on the incidence of infections, especially malaria. Its probable effect on immune status was masked by interference of infections and their treatment, which contributed to improve hematological and immune status in both groups.Conclusion: According to the negative consequences of anemia and iron deficiency on global child development, control of iron deficiency by oral iron supplementation in young children has to be conducted, associated with prophylaxis and treatment of malaria and repeated deworming.Sponsorship: Program supported by IRD.European Journal of Clinical Nutrition (2000) 54, 29–35

Weekly iron supplementation is as effective as 5 day per week iron supplementation in Bolivian school children living at high altitude

Objective: To compare the efficacy of a daily and a weekly iron supplementation on the hematological status of anemic children living at high altitude. Design: Double blind iron supplementation trial including a placebo control group. Setting: A socioeconomically disadvantaged district of La Paz, Bolivia (altitude of 4000u2005m). Subjects: Anemic (hemoglobin concentration≤144u2005g/L), 3.3–8.3u2005y old children of both sexes. Intervention: Children received a placebo (n=57) or a dose of 3–4u2005mg of elemental iron per kg body weight (FeSO4 tablets) 1u2005d per week (n=58) or 5u2005d per week (n=58) for 16 weeks. Results: Hemoglobin and zinc erythrocyte protoporphyrin concentrations improved significantly in supplemented groups but not in the placebo group. Changes in hemoglobin during the study were not significantly different between supplemented groups (weekly group: 15.2±6.9u2005g/L and daily group: 18.6±11.1u2005g/L) but were different from the placebo group (0.5±7.1u2005g/L, P<0.001). At the end of the supplementation period, the hemoglobin distribution was Gaussian, and similar in both supplemented groups. Adjusting for the initial hemoglobin concentration, final hemoglobin and its changes were similar in both supplemented groups. Conclusion: Weekly iron supplementation is as efficacious as daily iron supplementation in improving iron status and correcting moderate iron deficiency anemia in Bolivian school children living at high altitude. Sponsorship: Program supported in part by ORSTROM, the French Ministry of Foreign Affairs and the National Secretarys Office of Health, Bolivia.

Efficacy of combined iron and zinc supplementation on micronutrient status and growth in Vietnamese infants

Objective:To evaluate the effect of combined iron–zinc supplementation on micronutrient status, growth and morbidity.Design:Randomized, double-masked, placebo-controlled supplementation trial.Setting:Rural district of Que Vo, in the Red River Delta in Vietnam.Subjects:A total of 915 breast-fed infants aged 4–7 months were included and 784 completed the study.Interventions:The Fe-group received daily and for a 6-month period 10u2009mg of iron, the Zn-group 10u2009mg zinc, the Fe–Zn group 10u2009mg iron+10u2009mg zinc and the placebo group a placebo. Hemoglobin (Hb), serum ferritin (SF) and zinc (SZn), and anthropometry were measured before and at the end of the intervention. Morbidity was recorded daily.Results:Changes of Hb and SF were higher in both Fe and Fe+Zn groups (respectively 22.6 and 20.6u2009g/l for Hb; 36.0 and 24.8u2009μg/l for SF) compared to Zn and placebo groups (Hb: 6.4 and 9.8u2009g/l; SF: −18.2 and −16.9u2009μg/l, P<0.0001). SZn increased more in Zn group (10.3u2009μmol/l) than in Fe+Zn group (8.0u2009μmol/l, P=0.03) and more in these groups compared to Fe and placebo groups (1.6 and 1.2u2009μmol/l, P<0.0001). Weight gain was higher in the Zn group. No significant effects of supplementations on growth in length or morbidity.Conclusions:Combined iron–zinc supplementation had a positive effect on iron and zinc status in infants. However, the positive effect of zinc alone on SZn and weight would indicate a negative interaction of iron when added to zinc supplements.Sponsorship:UNICEF New York.

Iron deficiency, cell-mediated immunity and infection among 6–36 month old children living in rural Togo

Abstract Relationships between iron deficiency, cell-mediated immunity (CMI) and morbidity were studied in 220 children in rural south Togo. Iron deficiency was defined by abnormal values of at least two biochemical indicators of iron status viz. (i) plasmat ferritin, (ii) transferrin saturation, (iii) erythrocyte protophorphyrin. In children without any sign of inflammation, the percentage of B lymphocytes was higher in iron-deficient than in iron-sufficient children (26.7±2.9 vs 18.1±1.5). Mature T lymphocyte and helper-inducer T lymphocyte percentages were lower (51.6±3.7 vs 62.2±1.6 and 32.5±2.4 vs 38.7±1.4, p

Assessment of iron deficiency in the context of the obesity epidemic: importance of correcting serum ferritin concentrations for inflammation

BACKGROUNDnThe correction of serum ferritin (SF) concentrations for inflammation because of infectious or parasitic diseases was recently proposed, especially in developing countries, but in many countries, adiposity has become the main cause of inflammation.nnnOBJECTIVEnWe assessed, overall and by adiposity status, the bias in the estimation of iron deficiency (ID) on the basis of uncorrected SF.nnnDESIGNnA cross-sectional survey in 2010 in Rabat-Salé, Morocco, used a random sample of 811 women aged 20-49 y. Adiposity was assessed by body mass index (BMI) (in kg/m²) (normal: BMI <25; overweight: BMI ≥25 to <30; obese: BMI ≥30), waist circumference, and body fat. Inflammation was indicated by a C-reactive protein (CRP) concentration >2 mg/L. ID was indicated by an SF concentration <15 μg/L. The correction factor of SF for inflammation was derived from our sample. Differential effects of SF correction on ID status on the basis of adiposity were assessed by models that included adiposity × correction interactions and accounted for the within-subject correlation.nnnRESULTSnThe prevalence of overweight was 33.0% and of obesity was 34.0%. Inflammation (42.3%) was strongly linked with adiposity (20.1%, 37.6%, and 68.4% in normal, overweight, and obese subjects, respectively; P < 0.0001). SF increased from a CRP concentration >2 mg/L. The correction factor of SF was 0.65. The prevalence of ID (37.2% compared with 45.2%; difference -8.0%, P < 0.0001) was underestimated by not correcting SF, and the difference increased with adiposity (-2.9%, -8.5%, and -12.4% in normal, overweight, and obese subjects, respectively; P-interaction < 0.0001). Analogous results were observed for other adiposity measures.nnnCONCLUSIONnIn developing countries where ID remains prevalent but rates of obesity are already high, corrected SF should be used when assessing ID status, even if infectious or parasitic diseases are no longer widespread. This trial was registered at clinicaltrials.gov as NCT01844349.

Vegetable oil of poor quality is limiting the success of fortification with vitamin A in Egypt.

Background Fortification of vegetable oil with vitamin A is considered a cost-effective and simple to implement strategy, but the stability of vitamin A remains a limiting factor. To account for losses of vitamin A, oil producers add an overage. Optimizing the amount of this overage can result in considerable savings for industry and government while ensuring a supply of adequately fortified oil to consumers. Objectives To estimate vitamin A losses in oil with different chemical characteristics. Methods Samples of fortified oils with different chemical characteristics were collected from two Egyp- tian companies (oil A and B) and stored for 1 month. Vitamin A levels were analyzed periodically during stor- age to determine losses over time, and peroxide values were determined. Results Fortified oil B, with a high peroxide value (5.8 mEq/kg), exposed to sunlight had significantly higher losses of vitamin A after 4 weeks than fortified oil A, with a low peroxide value (0.4 mEq/kg): 31.1% vs. 19.7% (p < .001), respectively. In semidark conditions, the vitamin A losses after 4 weeks in fortified oil B and fortified oil A were significantly different: 26.1% and 0.7% (p < .001), respectively. In an accelerated storage test, the vitamin A loss in 8 days was 48.3% for fortified oil B and 4.2% for fortified oil A (p < .001). Conclusions This study shows a significant effect of peroxide level (one indicator of the quality of oil) on the stability of vitamin A, regardless of storage conditions. To optimize and sustain vitamin A levels in fortified oil, governments and industries should minimize the perox- ide level to less than 2 mEq/kg at production.

An Assessment of the Impact of Fortification of Staples and Condiments on Micronutrient Intake in Young Vietnamese Children

Targeted fortification programs for infants and young children are an effective strategy to prevent micronutrient deficiencies in developing countries, but the role of large-scale fortification of staple foods and condiments is less clear. Dietary modeling in children aged 6–60 months was undertaken, based on food consumption patterns described in the 2009 national food consumption survey, using a 24-h recall method. Consumption data showed that the median intake of a child for iron, vitamin A and zinc, as a proportion of the Vietnamese Recommended Dietary Allowance (VRDA), is respectively 16%–48%, 14%–49% and 36%–46%, (depending on the age group). Potential fortification vehicles, such as rice, fish/soy sauces and vegetable oil are consumed daily in significant amounts (median: 170 g/capita/day, 4 g/capita/day and 6 g/capita/day, respectively) by over 40% of the children. Vegetable oil fortification could contribute to an additional vitamin A intake of 21%–24% of VRDA recommended nutrient intake, while fortified rice could support the intakes of all the other micronutrients (14%–61% for iron, 4%–11% for zinc and 33%–49% of folate requirements). Other food vehicles, such as wheat flour, which is consumed by 16% of children, could also contribute to efforts to increase micronutrient intakes, although little impact on the prevalence of micronutrient deficiencies can be expected if used alone. The modeling suggests that fortification of vegetable oil, rice and sauces would be an effective strategy to address micronutrient gaps and deficiencies in young children.

The High Prevalence of Anemia in Cambodian Children and Women Cannot Be Satisfactorily Explained by Nutritional Deficiencies or Hemoglobin Disorders

Background: Anemia is highly prevalent in Cambodian women and children, but data on causes of anemia are scarce. We performed a national micronutrient survey in children and women that was linked to the Cambodian Demographic Health Survey 2014 (CDHS-2014) to assess the prevalence of micronutrient deficiency, hemoglobin disorders and intestinal parasite infection. Methods: One-sixth of households from the CDHS-2014 were selected for a follow-up visit for the micronutrient survey. Households were visited from two weeks to two months after the CDHS-2014 visit. Data on micronutrient status were available for 1512 subjects (792 children and 720 women). Results: Anemia was found in 43% of the women and 53% of the children. Hemoglobin disorders affected >50% of the population, with Hemoglobin-E the most prevalent disorder. Deficiencies of iron (ferritin < 15 g/L), vitamin A (retinol-binding-protein (RBP) < 0.70 mol/L) or vitamin B12 (<150 pmol/L) were not prevalent in the women (<5% for all), whereas 17.8% of the women had low concentrations of folic acid (<10 nmol/L). In the children, the prevalence of iron, vitamin A, vitamin B12 or folic acid deficiency was <10%. Zinc deficiency, hookworm infection and hemoglobinopathy were significantly associated with anemia in children, whereas in the women none of the factors was significantly associated with anemia. Iron deficiency anemia (IDA) was more prevalent in children <2 years, but in older children and women, the prevalence of IDA was <5%. The most prevalent, preventable causes of anemia were hookworm infection and zinc and folic acid deficiency. Over 40% of the anemia was not caused by nutritional factors. Conclusion: The very high prevalence of anemia in Cambodian women and children cannot be explained solely by micronutrient deficiencies and hemoglobin disorders. Micronutrient interventions to improve anemia prevalence are likely to have limited impact in the Cambodian setting. The focus of current interventions to reduce the high prevalence of anemia in children and women should be broadened to include zinc and folic acid as well as effective anti-hookworm measures.

A Double Burden of Overall or Central Adiposity and Anemia or Iron Deficiency Is Prevalent but with Little Socioeconomic Patterning among Moroccan and Tunisian Urban Women

In North Africa, overnutrition has dramatically increased with the nutrition transition while micronutrient deficiencies persist, resulting in clustering of opposite types of malnutrition that can present a unique difficulty for public health interventions. We assessed the magnitude of the double burden of malnutrition among urban Moroccan and Tunisian women, as defined by the coexistence of overall or central adiposity and anemia or iron deficiency (ID), and explored the sociodemographic patterning of individual double burden. In cross-sectional surveys representative of the region around the capital city, we randomly selected 811 and 1689 nonpregnant women aged 20-49 y in Morocco and Tunisia, respectively. Four double burdens were analyzed: overweight (body mass index ≥25 kg/m(2)) or increased risk abdominal obesity (waist circumference ≥80 cm) and anemia (blood hemoglobin <120 g/L) or ID (C-reactive protein-corrected serum ferritin <15 μg/L). Adjusted associations with 9 sociodemographic factors were estimated by logistic regression. The prevalence of overweight and ID was 67.0% and 45.2% in Morocco, respectively, and 69.5% and 27.0% in Tunisia, respectively, illustrating the population-level double burden. The coexistence of overall or central adiposity with ID was found in 29.8% and 30.1% of women in Morocco, respectively, and in 18.2% and 18.3% of women in Tunisia, respectively, quite evenly distributed across age, economic, or education groups. Generally, the rare, associated sociodemographic factors varied across the 4 subject-level double burdens and the 2 countries and differed from those usually associated with adiposity, anemia, or ID. Any double burden combining adiposity and anemia or ID should therefore be taken into consideration in all women. This trial was registered at clinicaltrials.gov as NCT01844349.

Impact of Multi-Micronutrient Fortified Rice on Hemoglobin, Iron and Vitamin A Status of Cambodian Schoolchildren: a Double-Blind Cluster-Randomized Controlled Trial

In Cambodia, micronutrient deficiencies remain a critical public health problem. Our objective was to evaluate the impact of multi-micronutrient fortified rice (MMFR) formulations, distributed through a World Food Program school-meals program (WFP-SMP), on the hemoglobin concentrations and iron and vitamin A (VA) status of Cambodian schoolchildren. The FORISCA-UltraRice+NutriRice study was a double-blind, cluster-randomized, placebo-controlled trial. Sixteen schools participating in WFP-SMP were randomly assigned to receive extrusion-fortified rice (UltraRice Original, UltraRice New (URN), or NutriRice) or unfortified rice (placebo) six days a week for six months. Four additional schools not participating in WFP-SMP were randomly selected as controls. A total of 2440 schoolchildren (6–16 years old) participated in the biochemical study. Hemoglobin, iron status, estimated using inflammation-adjusted ferritin and transferrin receptors concentrations, and VA status, assessed using inflammation-adjusted retinol-binding protein concentration, were measured at the baseline, as well as at three and six months. Baseline prevalence of anemia, depleted iron stores, tissue iron deficiency, marginal VA status and VA deficiency were 15.6%, 1.4%, 51.0%, 7.9%, and 0.7%, respectively. The strongest risk factors for anemia were hemoglobinopathy, VA deficiency, and depleted iron stores (all p < 0.01). After six months, children receiving NutriRice and URN had 4 and 5 times less risk of low VA status, respectively, in comparison to the placebo group. Hemoglobin significantly increased (+0.8 g/L) after three months for the URN group in comparison to the placebo group; however, this difference was no longer significant after six months, except for children without inflammation. MMFR containing VA effectively improved the VA status of schoolchildren. The impact on hemoglobin and iron status was limited, partly by sub-clinical inflammation. MMFR combined with non-nutritional approaches addressing anemia and inflammation should be further investigated.