Pattanee Winichagoon

Adiposity in women and children from transition countries predicts decreased iron absorption, iron deficiency and a reduced response to iron fortification

Background:Overweight is increasing in transition countries, while iron deficiency remains common. In industrialized countries, greater adiposity increases risk of iron deficiency. Higher hepcidin levels in obesity may reduce dietary iron absorption. Therefore, we investigated the association between body mass index (BMI) and iron absorption, iron status and the response to iron fortification in populations from three transition countries (Thailand, Morocco and India).Methods:In Thai women (n=92), we examined the relationship between BMI and iron absorption from a reference meal containing ∼4 mg of isotopically labeled fortification iron. We analyzed data from baseline (n=1688) and intervention (n=727) studies in children in Morocco and India to look for associations between BMI Z-scores and baseline hemoglobin, serum ferritin and transferrin receptor, whole blood zinc protoporphyrin and body iron stores, and changes in these measures after provision of iron.Results:In the Thai women, 20% were iron deficient and 22% were overweight. Independent of iron status, a higher BMI Z-score was associated with decreased iron absorption (P=0.030). In the Indian and Moroccan children, 42% were iron deficient and 6.3% were overweight. A higher BMI Z-score predicted poorer iron status at baseline (P<0.001) and less improvement in iron status during the interventions (P<0.001).Conclusions:Adiposity in young women predicts lower iron absorption, and pediatric adiposity predicts iron deficiency and a reduced response to iron fortification. These data suggest the current surge in overweight in transition countries may impair efforts to control iron deficiency in these target groups. Interactions of the ‘double burden’ of malnutrition during the nutrition transition may have adverse consequences.

Only a small proportion of anemia in northeast Thai schoolchildren is associated with iron deficiency

BACKGROUND Iron deficiency is assumed to be the major cause of anemia in northeast Thailand, but other factors may be involved. OBJECTIVE We determined the prevalence of anemia among schoolchildren in northeast Thailand and the role of hemoglobinopathies, selected micronutrient deficiencies, and other factors in hemoglobin status. DESIGN Blood samples were collected from 567 children aged 6-12.9 y attending 10 primary schools for the determination of a complete blood count and hemoglobin type [Hb AA (normal hemoglobin), Hb AE (heterozygous for Hb type E), and Hb EE (homozygous for Hb type E)] and the measurement of serum ferritin, transferrin receptor, retinol, vitamin B-12, and plasma and erythrocyte folate concentrations. Children with a C-reactive protein concentration > or = 10 mg/L (n = 12), which indicated infection, were excluded. RESULTS The prevalence of anemia was 31%. Age, hemoglobin type, and serum retinol were the major predictors of hemoglobin concentration. Hb AA and Hb AE children with anemia had lower (P < 0.01) hematocrit, mean cell volume, and serum retinol values than did their nonanemic counterparts; no significant differences in serum ferritin were found by hemoglobin type. Only 16% (n = 22) of the anemic Hb AA and Hb AE children were iron deficient. Hb AA and Hb AE children with a serum retinol concentration <0.70 micromol/L (n = 14) had a significantly higher geometric mean serum ferritin concentration than did those with a retinol concentration > or = 0.70 micromol/L (P = 0.009); no significant difference in transferrin receptor concentrations was found between these 2 groups. CONCLUSIONS Hemoglobinopathies, suboptimal vitamin A status, and age were the major predictors of hemoglobin concentration. The contribution of iron deficiency to anemia was low, and its detection was complicated by coexisting suboptimal vitamin A status.

Risk of zinc, iodine and other micronutrient deficiencies among school children in North East Thailand.

Introduction:Micronutrient deficiencies during childhood can contribute to impairments in growth, immune competence, and mental and physical development, and the coexistence of several such deficiencies can adversely affect the efficacy of single micronutrient interventions.Objective:To assess the prevalence of zinc and iodine deficiency and their interrelationships with vitamin A deficiency and anemia and associations with socio-economic status, hemoglobin type, and anthropometry in a cross-sectional study.Setting:A total of 10 primary schools in North East Thailand.Methods:Non-fasting venipuncture blood samples and casual urine samples were collected from 567 children aged 6–13 years. Anthropometric measures and serum zinc, albumin, C-reactive protein and urinary iodine, are reported here and integrated with published data on vitamin A, anemia, and socio-economic status.Results:Of the children, 57% had low serum zinc and 83% had urinary iodine levels below the 100 μg/l cutoff. Suboptimal serum zinc and urinary iodine concentrations may result from low intakes of zinc and iodized salt. Significant risk factors for low serum zinc were serum retinol <1.05 μmol/l and being male. Those for urinary iodine <100 μg/l were height-for-age score>median and being female. For serum retinol <1.05 μmol/l, risk factors were low hemoglobin, low serum zinc, and <9 years, and for low hemoglobin indicative of anemia risk factors were <9 years, AE hemoglobinopathy, and serum retinol <1.05 μmol/l. Of the children, 60% were at risk of two or more coexisting micronutrient deficiencies, most commonly suboptimal urinary iodine and low serum zinc.Conclusion:The findings emphasize the need for multimicronutrient interventions in North East Thailand.

Urinary Iodine Concentrations Indicate Iodine Deficiency in Pregnant Thai Women but Iodine Sufficiency in Their School-Aged Children

The median urinary iodine concentration (UI) in school-aged children is recommended for assessment of iodine nutrition in populations. If the median UI is adequate in school-aged children, it is usually assumed iodine intakes are also adequate in the remaining population, including pregnant women. But iodine requirements sharply increase during pregnancy. In this study, our aim was to measure UI in pairs of pregnant women and their school-aged children from the same family, who were sharing meals, to directly assess whether a household food basket that supplies adequate iodine to school-aged children also meets the needs of pregnant women. UI was measured in spot urine samples from pairs (n = 302) of healthy pregnant mothers and their school-aged children in metropolitan Bangkok, Thailand. A dietary questionnaire was completed. The UI [median (range)] in the pregnant women {108 (11-558) microg/L [0.85 (0.086-4.41) micromol/L]} were lower than those of their school-aged children {200 (25-835) microg/L [1.58 (0.20-6.52) micromol/L]} (P < 0.001), indicating optimal iodine status in the children but mild-to-moderate iodine deficiency in their pregnant mothers. The estimated iodine intakes in the 2 groups were in the range of 130-170 microg/d. There was a modest positive correlation between UI in the pairs (r = 0.253; P < 0.01). A higher frequency of seafood meals was a significant predictor of UI in both groups, but household use of iodized salt was not. These data suggest the median UI in school-aged children should not be used as a surrogate for monitoring iodine status in pregnancy in central Thailand; pregnant women should be directly monitored.

Multi-Micronutrient–Fortified Biscuits Decreased Prevalence of Anemia and Improved Micronutrient Status and Effectiveness of Deworming in Rural Vietnamese School Children

Concurrent micronutrient deficiencies are prevalent among Vietnamese school children. A school-based program providing food fortified with multiple micronutrients could be a cost-effective and sustainable strategy to improve health and cognitive function of school children. However, the efficacy of such an intervention may be compromised by the high prevalence of parasitic infestation. To evaluate the efficacy of school-based intervention using multi-micronutrient-fortified biscuits with or without deworming on anemia and micronutrient status in Vietnamese schoolchildren, a randomized, double-blind, placebo-controlled trial was conducted among 510 primary schoolchildren, aged 6-8 y, in rural Vietnam. Albendazole (Alb) (400 mg) or placebo was given at baseline. Nonfortified or multi-micronutrient-fortified biscuits including iron (6 mg), zinc (5.6 mg), iodine (35 microg), and vitamin A (300 microg retinol equivalents) were given 5 d/wk for 4 mo. Multi-micronutrient fortification significantly improved the concentrations of hemoglobin (+1.87 g/L; 95% CI: 0.78, 2.96), plasma ferritin (+7.5 microg/L; 95% CI: 2.8, 12.6), body iron (+0.56 mg/kg body weight; 95% CI: 0.29, 0.84), plasma zinc (+0.61 micromol/L; 95% CI: 0.26, 0.95), plasma retinol (+0.041 micromol/L; 95% CI: 0.001, 0.08), and urinary iodine (+22.49 micromol/L; 95% CI: 7.68, 37.31). Fortification reduced the risk of anemia and deficiencies of zinc and iodine by >40%. Parasitic infestation did not affect fortification efficacy, whereas fortification significantly enhanced deworming efficacy, with the lowest reinfection rates in children receiving both micronutrients and Alb. Multi-micronutrient fortification of biscuits is an effective strategy to improve the micronutrient status of Vietnamese schoolchildren and enhances effectiveness of deworming.

Sex differences in prevalence of anaemia and iron deficiency in infancy in a large multi-country trial in South-East Asia.

To evaluate effects of Fe supplementation and sex on the prevalence of anaemia and Fe status in infants in South-East Asia, biochemical data from four parallel, randomized, double-blind trials with Fe and/or Zn supplementation in infants (n 2452) in Indonesia, Thailand and Vietnam was pooled. At recruitment (5 months of age), Hb concentrations were slightly but significantly lower in boy infants compared with girl infants (108.7 g/l v. 111.4 g/l, P = 0.04). At 11 months of age, boy infants not receiving Fe had significantly lower Hb (106.2 g/l v. 111.0 g/l, P < 0.001) and lower serum ferritin concentrations (14.3 microg/l v. 21.1 g/l, P < 0.001) than girl infants not receiving Fe. Consequently, boy infants had a relative risk of 1.6 (95% CI 1.3, 2.1) to be anaemic, and of 3.3 (95% CI 2.1, 5.0) for having Fe deficiency anaemia compared with girl infants. Fe supplementation significantly increased Hb concentrations in both boys and girls. There was no sex difference in Fe status in infants receiving Fe for 6 months. This study shows that the markedly higher risk for anaemia and Fe deficiency indicates higher Fe requirements in boy than in girl infants. In South-East Asia, standard infant feeding practices do not provide sufficient Fe to meet requirements of infants, especially boys. Current daily recommended intake for Fe in infancy is the same for boy and girl infants however. Our findings suggest that in especially the second half of infancy, Fe requirements for boy infants are approximately 0.9 mg/d higher than for girl infants.

Prevention and Control of Anemia: Thailand Experiences

Thailand has addressed nutrition in national development policy since the mid-1970s, including efforts to reduce iron deficiency anemia. Nutritional improvement has been implemented as an integral part of primary health care and community development extending beyond government services to include community participation. Utilization of village health volunteers has been a crucial feature of the program. Available data indicate that anemia rates have declined among pregnant women and preschool children, although there has been no formal evaluation of the program effect. Universal iron supplementation has been the major strategy for pregnant women, using village health volunteers to encourage continuation of the antenatal care schedule and encouraging a preventive approach by health service providers. Program obstacles have included lack of access to iron tablets by some populations and lack of understanding of the importance of anemia. Womens compliance was complicated by fear of having a large fetus, forgetfulness and side effects. Weekly iron supplementation of school children was piloted in 2000, and is now being extended. Other strategies utilized to address iron deficiency include food fortification, dietary improvement and complementary public health measures. Program monitoring and evaluation require strengthening to assess the effectiveness of intervention strategies and provide proper data for decision-making.

Influence of Prenatal and Postnatal Growth on Intellectual Functioning in School-aged Children

OBJECTIVE To assess the relative influence of size at birth, infant growth, and late postnatal growth on intellectual functioning at 9 years of age. DESIGN A follow-up, cross-sectional study. SETTING Three districts in Khon Kaen province, northeast Thailand. PARTICIPANTS A total of 560 children, or 92% of former participants of a trial of iron and/or zinc supplementation during infancy. MAIN EXPOSURES Prenatal (size at birth), early infancy (birth to 4 months), late infancy (4 months to 1 year), and late postnatal (1 to 9 years) growth. Multiple-stage least squares analyses were used to generate uncorrelated residuals of postnatal growth. MAIN OUTCOME MEASURES Intellectual functioning was measured at 9 years using the Wechsler Intelligence Scale for Children and the Ravens Colored Progressive Matrices (Pearson). Analyses included adjustment for maternal, household, and school characteristics. RESULTS Significant relationships were found between growth and IQ (Wechsler Intelligence Scale for children, third edition, Thai version), but only up to 1 year of age; overall, growth was not related to the Ravens Colored Progressive Matrices. The strongest and most consistent relationships were with length (birth, early infancy, and late infancy); for weight, only early infancy gain was consistently related to IQ. Head circumference at birth was not collected routinely; head circumference at 4 months (but not head circumference growth thereafter) was related to IQ. Late postnatal growth was not associated with any outcome. CONCLUSION Physical growth in early infancy (and, to a lesser extent, physical growth in late infancy and at birth) is associated with IQ at 9 years of age. Early infancy may be a critical window for human development.

Does zinc deficiency play a role in stunting among primary school children in NE Thailand

Stunting in school-age years may result in a decrease in adult size, and thus reduced work capacity and adverse reproductive outcomes. We have compared the mean intakes of energy, protein and selected growth-limiting nutrients in fifty-eight stunted children and 172 non-stunted controls drawn from 567 children aged 6-13 years attending ten rural schools in NE Thailand. Control children were selected randomly after stratifying children by age in each school. Dietary data were calculated from 24-h recalls using nutrient values from Thai food composition data and chemical analysis. Inter-relationships between stunting and sociodemographic, anthropometric and biochemical variables were also examined. Biochemical variables investigated were serum albumin, zinc, ferritin, transferrin receptor and retinol, and iodine in casual urine samples. Significantly more males than females were stunted (males, n 38, 65.5% v. females, n 20. 34.5%: P=0.025). Stunted males had lower mean intakes of energy, protein, calcium, phosphorus and zinc, and a lower mean (95% CI) serum zinc (9.19 (8.53, 9.84) v. 9.70 (8.53, 9.29) micromol/1) than non-stunted males; no other biochemical differences were noted. Stunted males also had a lower mean arm muscle area (P= 0.015), after adjusting for age, than non-stunted males. In conclusion, the lower dietary intakes of the stunted males compared to their non-stunted counterparts may be associated with anorexia and hypogeusia induced by zinc deficiency. Hence, zinc deficiency may be a factor limiting linear growth, especially among boys in NE Thailand, but more research is needed to establish whether other factors also play a role.

Thailand nutrition in transition: situation and challenges of maternal and child nutrition.

Double burden of malnutrition (DBMN), the coexistence of under- and overnutrition in the same population, is an emerging public health concern in developing countries, including Thailand. This paper aims to review the maternal and child nutrition situation and trends as the country moved from a low-income to a middle-income country, using data from large scale national surveys. Protein-energy malnutrition and micronutrient deficiencies predominantly affected mothers and children prior to the 1980s. The situation greatly improved during the 1980s- 1990s, with the implementation of multi-sectoral policies and programs focusing on poverty alleviation and primary health care. Economic development, improved access to health services and effective community-based nutrition programs contributed to these positive trends. However, the prevalence of low birth weight remained at 8- 10%, while stunting and underweight declined to about 10% by the 1990s, with small change thereafter. The prevalence of anemia among pregnant women and children decreased by half and vitamin A deficiency is no longer a public health problem. Iodine deficiency, especially during pregnancy is still a major concern. As the country progressed in terms of economic and social development, overnutrition among women and children affected all socio-economic levels. Changes in lifestyles, food access and eating patterns are observed both in urban and rural areas. Although efforts have been made to address these challenges, harmonized policy and strategic programs that address DBMN in the complex social and economic environment are urgently needed. Early life undernutrition should be considered along with measures to address obesity and chronic diseases in children.