Journal of Nutrition EB Program 2010 Abstracts

Home Help [Feedback] [For Subscribers] [Archive] [Search] [Contents]
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Purchase Article
Right arrow View Shopping Cart
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Black, R. E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Black, R. E.

© 2003 The American Society for Nutritional Sciences J. Nutr. 133:1485S-1489S, May 2003

Supplement: 11th International Symposium on Trace Elements in Man and Animals

Zinc Deficiency, Infectious Disease and Mortality in the Developing World 1 ,2

Robert E. Black3

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205

3 To whom correspondence should be addressed. E-mail: rblack{at}jhsph.edu.


   ABSTRACT
TOP
 ABSTRACT
DISCUSSION
 LITERATURE CITED
 
Zinc deficiency places children in many low-income countries at increased risk of illness and death from infectious diseases. Randomized controlled trials of zinc supplementation provide the best estimate of this risk through demonstrated preventive benefits. In six of nine trials that evaluated prevention of diarrhea, significantly lower incidence of diarrhea occurred in the zinc group than in the controls; a pooled analysis demonstrated 18% (95% confidence interval, 7–28%) less diarrhea. In five trials, a lower rate of pneumonia infection was found in the zinc-supplemented groups, and there was some indication of a preventive effect in three trials with a clinical malaria outcome. Zinc was also found to have a therapeutic benefit in seven trials of acute diarrhea and five of persistent diarrhea. Studies to evaluate the effect of zinc supplementation on mortality are under way, but a recently published study from India identified a 68% reduction in mortality in small-for-gestational-age term infants that were supplemented with zinc from 1 to 9 mo of age. The important effects of zinc deficiency are now clear, and nutrition programs should address this prevalent problem.

KEY WORDS: • child nutrition • diarrhea • malaria • pneumonia • zinc

Zinc deficiency, which appears to be widespread in developing countries, has long been recognized to impair growth and immune function (1, 2). Although effects on the immune system are known to occur with even mild zinc deficiency (3), the importance of this with regard to the risk of childhood infectious diseases has only recently become better understood (4). Observational studies provide some evidence of a relationship between low plasma-zinc concentration in children and higher risk of infectious diseases (5), but inferences from these studies are limited owing to a lack of adequate zinc-deficiency indicators at the individual level.

Randomized, controlled trials of zinc supplementation provide the best evidence for the roles of zinc in infectious diseases, which are presumably mediated through alterations in host defenses including epithelial barriers and immune responses. Results of these trials are reviewed and summarized with regard to effects on diarrhea, pneumonia and malaria incidence as well as on total child mortality. In addition to these preventive trials in which zinc was given on a routine, usually daily, basis for an extended period of time, there are other trials in which zinc was provided as an adjunct to therapy for acute or persistent diarrhea. This review is limited to published trials.

Prevention of infectious disease morbidity

The effects of zinc supplements on rates of diarrhea and pneumonia incidence have been well studied, and there is also some information on malaria incidence. In total, 11 trials are available for inclusion in this review (6– 17). Ten of these trials assess the effect of zinc supplementation on the incidence of diarrhea, five on the incidence of pneumonia and three on the incidence of malaria (Table 1). These trials were performed with preschool children who reside in typical developing country settings. Although the settings of these trials might be expected to include a substantial prevalence of zinc deficiency as would be expected in most developing countries, the populations of children were not preselected on the basis of zinc deficiency. Six of the trials were performed with all children in the targeted age group, whereas five of the trials had some enrollment restrictions (Table 1). Two of these trials employed children that were selected with at least a moderate degree of undernutrition, whereas one trial stratified the enrollment based on individuals who were or were not stunted. Two of the trials enrolled children after they had recovered from either acute or persistent diarrhea. Taken collectively, the studies were done in settings that represent a wide range of conditions with regard to nutritional status and risk of infectious diseases.


View this table:
[in this window]
[in a new window]
  		TABLE 1 Trials evaluating effects of zinc supplementation on preventing morbidity in children

 
These trials are consistent in showing that zinc-supplemented children have lower rates of diarrhea than control children (Table 2). Six of the nine studies had statistically significant differences between the zinc and control groups. A pooled analysis that includes most of these studies reveals the overall incidence of diarrhea in zinc-supplemented children to be 18% [95% confidence interval (CI), 7–28%] less than in children who did not receive zinc (18). This analysis shows trends (not statistically significant) that children with lower plasma zinc concentrations or wasting, or were female or in their second or later year of life (versus infants) have greater effects of zinc supplementation.


View this table:
[in this window]
[in a new window]
  		TABLE 2 Effects of zinc in prevention of diarrhea, pneumonia, malaria and mortality in children

 
The five studies with available information are also consistent in showing that zinc-supplemented children have a lower incidence of pneumonia than control children (Table 2). In the pooled analysis, there was a 41% (95% CI, 17–59%) lower rate of pneumonia in zinc-supplemented children (18). A study that was more recently completed shows a statistically significant 26% reduction in the incidence of pneumonia as diagnosed by clinical examination by two physicians using specific predefined clinical criteria (17).

The information regarding the effects of zinc supplementation on malaria is more limited. Studies in the Gambia and Papua New Guinea reveal reductions of about one-third in the rate of visits to health facilities for a clinical syndrome consistent with malaria and confirmed by parasitologic examination of the blood. Given the extremely high rate of malaria parasitemia in some endemic populations, visits to health facilities with confirmed malaria are generally considered to be the most valid measure of malaria incidence and have been used by the World Health Organization (WHO) to estimate the malaria burden of disease (19). The third trial of zinc supplementation that examined an effect on malaria was done in Burkina Faso. This trial had only community-based surveillance of malaria and did not ascertain health-facility visits. The study found no effect of zinc supplementation on rates of fever as ascertained from household visits 6 d/wk. This may not be surprising in that the study in Papua New Guinea did not find an effect of zinc supplementation on "malaria" as ascertained from community-based surveillance but did find a significant benefit with regard to malaria visits to the health facilities (12).

Therapeutic effects for diarrhea

There are currently 12 published trials of zinc supplementation in the therapy of acute or persistent diarrhea that are available for review (20– 30). Seven of these trials are for acute diarrhea (Table 3). The five trials on persistent diarrhea are likely the only ones that will be available, because WHO has recommended that zinc be used in the treatment of persistent diarrhea, which makes controlled trials no longer appropriate. Five additional trials of zinc supplementation for acute diarrhea have been conducted. Although these are as-yet unpublished, they were reviewed in a recently published meeting report (31). Most find beneficial effects of zinc supplementation as do the published trials.


View this table:
[in this window]
[in a new window]
  		TABLE 3 Trials evaluating therapeutic effects of zinc in diarrhea

 
The trials on persistent diarrhea, i.e., episodes lasting >=14 d, demonstrate overall benefits of zinc supplementation (Table 4). Generally, the zinc-supplemented children have shorter-duration episodes, lower stool frequency or stool volume and importantly, in three of the four studies, a reduction in treatment failure or death. A meta-analysis of these five trials yields a statistically significant summary effect (32). Overall, in this analysis there is a 42% (95% CI, 10–63%) reduced rate of treatment failure or death. In a pooled analysis of these trials, the subgroups of children who are < 12 mo of age, wasted or male have statistically significant effects of zinc supplementation. The corresponding alternative groups have smaller beneficial effects that are not statistically significant (Table 4).


View this table:
[in this window]
[in a new window]
  		TABLE 4 Effects of zinc in therapy of acute and persistent diarrhea

 
Of the seven trials on acute diarrhea, all find that the episode duration is shorter in zinc-supplemented children, and four of these trials are individually statistically significant. Likewise, all of the five trials that measure an effect on diarrhea severity find that zinc-supplemented children have less diarrheal stool output than controls; three of these trials find statistically significant benefits. In a pooled analysis with original data from three of these trials, within subgroups by age (< 12 mo versus >= 12 mo), wasting (< -2z versus >= -2z weight per height) and sex, each subgroup has significant benefits of zinc supplementation. In subgroups of children with lower or higher initial plasma zinc concentrations, there are significant pooled effects in both groups, although the effects tend to be greater in the subgroup with lower plasma zinc concentration.

Effects on child mortality

Diarrhea, pneumonia and malaria are the most common causes of death among children in developing countries. The consistent and sizeable effects of zinc supplementation on the incidence and severity of these infectious diseases logically leads to the hypothesis that there will be a reduction in child mortality with zinc supplementation. One recent study in India provides preliminary evidence that this is correct (33). A randomized, double-blind, controlled trial enrolled 1,154 full-term small-for-gestational-age infants to receive one of the following supplements: riboflavin; riboflavin and zinc (5 mg as sulfate); riboflavin, calcium, phosphorus, folate and iron; or riboflavin, zinc, calcium, phosphorus, folate and iron. Children were supplemented between 30 and 284 d of age and visited 6 d/wk to provide the supplement and conduct surveillance for illness and death. When the main effects of the zinc or the other micronutrients are examined by survival analysis, it is found that zinc supplementation is associated with a significantly lower mortality with a ratio of 0.32 (95 CI, 0.12–0.89). Calcium, phosphorus, folate and iron supplementation are not associated with a reduction in mortality.

The widespread demonstration that zinc supplements reduce the incidence of diarrhea and the two-thirds reduction in mortality that was found in the Indian study have led to the initiation of three large trials of zinc supplementation in India, Nepal and Zanzibar. All trials will evaluate the effect of zinc on child mortality, and the studies in India and Zanzibar will also assess the effects on hospitalizations from infectious diseases (diarrhea and pneumonia in both and malaria also in Zanzibar). Results are expected by 2004.


   DISCUSSION
TOP
 ABSTRACT
 DISCUSSION
LITERATURE CITED
 
The substantial prevalence of zinc deficiency in children in developing countries and its important consequences for higher rates of illness and death from infectious diseases in children in developing countries leads to the conclusion that the global burden of disease due to this nutritional problem is very large. This unnecessary burden can be reduced by existing means of improving the available zinc in the diet (34). Although this may be possible in some settings by using dietary modification, e.g., consumption of additional animal products or reduction in the consumption of foods that interfere with zinc absorption (35), in other settings such as in poor, vegetarian populations, this may prove difficult. Additional dietary approaches particularly including fortification are needed to address the problem of dietary inadequacy of zinc and other micronutrients such as iron (34). Supplements may play a role as well, and there is a need to understand more about the interactions of iron and other micronutrients when given together (36).

The efficacy of zinc in treating both persistent and acute diarrhea is now clear. Recommendations have already been made by WHO for its use in the treatment of persistent diarrhea. Furthermore, a WHO meeting in 2001 reviewed the studies presented here along with five as-yet unpublished studies (31). These unpublished studies reveal benefits that are consistent with those reported here and are briefly summarized in the meeting report. The report concludes that "there is now enough evidence demonstrating the efficacy of zinc supplementation on the clinical course of acute diarrhea." Although there is encouraging information from several large-scale, community-based studies that use zinc supplements to treat diarrhea, more information is needed on this in different settings. In particular, there is a need to understand how to promote zinc supplements to treat diarrhea without interfering with oral rehydration therapy, which will remain the mainstay of treatment. The meeting concludes that future studies should "investigate the feasibility, sustainability, and cost-effectiveness of different zinc delivery mechanisms and monitor variables, such as consumption of ORS (oral rehydration therapy), antibiotic use rate, non-diarrheal morbidity and overall mortality." It also indicates that it is important to determine the best formulation of zinc to minimize side effects and maximize adherence to therapy.

The important role of zinc deficiency in childhood infectious diseases is now clear. The challenge is to develop the public health response to address this deficiency and thereby improve child health.


   FOOTNOTES
 
1 Published in a supplement to The Journal of Nutrition. Presented as part of the 11th meeting of the international organization, "Trace Elements in Man and Animals (TEMA)," in Berkeley, California, June 2–6, 2002. This meeting was supported by grants from the National Institutes of Health and the U.S. Department of Agriculture and by donations from Akzo Nobel Chemicals, Singapore; California Dried Plum Board, California; Cattlemen's Beef Board and National Cattlemen's Beef Association, Colorado; GlaxoSmithKline, New Jersey; International Atomic Energy Agency, Austria; International Copper Association, New York; International Life Sciences Institute Research Foundation, Washington, D.C.; International Zinc Association, Belgium; Mead Johnson Nutritionals, Indiana; Minute Maid Company, Texas; Perrier Vittel Water Institute, France; U.S. Borax, Inc., California; USDA/ARS Western Human Nutrition Research Center, California and Wyeth-Ayerst Global Pharmaceuticals, Pennsylvania. Guest editors for the supplement publication were Janet C. King, USDA/ARS WHNRC and the University of California at Davis; Lindsay H. Allen, University of California at Davis; James R. Coughlin, Coughlin & Associates, Newport Coast, California; K. Michael Hambidge, University of Colorado, Denver; Carl L. Keen, University of California at Davis; Bo L. Lönnerdal, University of California at Davis and Robert B. Rucker, University of California at Davis. Back

2 This work is funded in part by the Johns Hopkins Family Health and Child Survival Cooperative Agreement with the U.S. Agency for International Development. Back


   LITERATURE CITED
TOP
 ABSTRACT
 DISCUSSION
 LITERATURE CITED
 

1. Aggett, P. (1989) Severe zinc deficiency. In: Zinc in Human Biology (Mills, C., ed.), pp. 259–279. Springer-Verlag, London, U.K.

2. Brown, K., Peerson, J. & Allen, L. (1998) Effect of zinc supplementation on children's growth: a meta-analysis of intervention trials. Bibl. Nutr. Dieta. 54: 76–83.

3. Shankar, A. H. & Prasad, A. S. (1998) Zinc and immune function: the biological basis of altered resistance to infection. Am. J. Clin. Nutr. 68 (suppl. 2): 447S–463S.[Abstract]

4. Black, R. E. (2001) Zinc deficiency, immune function, and morbidity and mortality from infectious disease among children in developing countries. Food Nutr. Bull. 22: 155–162.

5. Bahl, R., Bhandari, N., Hambidge, K. M. & Bhan, M. K. (1998) Plasma zinc as a predictor of diarrhea and respiratory morbidity in children in an urban slum setting. Am. J. Clin. Nutr. 68 (suppl. 2): 414S–417S.[Abstract]

6. Bates, C. J., Evans, P. H., Dardeene, M., Prentice, A., Lunn, P. G., Northrop-Clewes, C. A., Hoare, S., Cole, T. J., Horan, S. J. & Longman, S. C. (1993) A trial of zinc-supplementation in young rural Gambian children. Br. J. Nutr. 69: 243–255.[Medline]

7. Ninh, X., Thissen, P., Collette, L., Gerard, G., Khoi, H. & Keteislegers, M. (1996) Zinc supplementation increases growth and circulating insulin-like growth factor 1 (IGR-1) in growth retarded Vietnamese children. Am. J. Clin. Nutr. 63: 413–418.

8. Sazawal, S., Black, R., Bhan, M., Jalla, S., Sinha, A. & Bhandari, N. (1997) Efficacy of zinc supplementation in reducing the incidence and prevalence of acute diarrhea—a community-based, double-blind, controlled trial. Am. J. Clin. Nutr. 66: 413–418.[Abstract/Free Full Text]

9. Sazawal, S., Black, R., Jalla, S., Mazumdar, S., Sinha, A. & Bhan, M. (1998) Zinc supplementation reduces the incidence of acute lower respiratory infections in infants and preschool children. A double-blind, controlled trial. Pediatrics 102: 1–5.[Abstract/Free Full Text]

10. Rosado, J., Lopez, P., Monoz, E., Martinez, H. & Allen, L. H. (1997) Zinc supplementation reduced morbidity, but neither zinc nor iron supplementation affected growth or body composition of Mexican preschoolers. Am. J. Clin. Nutr. 65: 13–19.[Abstract/Free Full Text]

11. Ruel, M., Rivera, J., Santizo, M., Lonnerdal, B. & Brown, K. (1997) The impact of zinc supplementation on morbidity from diarrhea and respiratory infections among young rural Guatemalan children. Pediatrics 99: 808–813.[Abstract/Free Full Text]

12. Shankar, A. H., Genton, B., Baisor, M., Paino, J., Tamja, S., Adiguma, T., Wu, L., Rare, L., Bannon, D., Tielsch, J. M., West, K. P., JR. & Aleprs, M. P. (2000) The influence of zinc supplementation on morbidity due to Plasmodium falciparum: a randomized trial in preschool children in Papua New Guinea. Am. J. Trop. Med. Hyg. 62: 663–669.[Abstract]

13. Meeks-Gardner, J., Witter, M. & Ramdath, D. (1998) Zinc supplementation effects on the growth and morbidity of undernourished Jamaican children. Eur. J. Clin. Nutr. 52: 34–39.[Medline]

14. Penny, M. E., Peerson, J. M., Marin, R. M., Duran, A., Lanata, C. F., Lönnerdal, B., Black, R. E. & Brown, K. H. (1999) Randomized community-based trial of the effect of zinc supplementation, with or without other micronutrients, on the duration of persistent diarrhea in Lima, Peru. J. Pediatr. 135: 208–217.

15. Umeta, M., West, C. E., Haider, J., Deurenberg, P. & Hautvast, J. G. (2000) Zinc supplementation and stunted infants in Ethiopia: a randomized controlled trial. Lancet 355: 2021–2026.[Medline]

16. Muller, O., Becher, H., van Zweeden, A. B., Ye, Y., Diallo, D. A., Konate, A. T., Gbangou, A., Kouate, B. & Gareene, M. (2001) Effect of zinc supplementation on malaria and other causes of morbidity in west African children: randomized double blind placebo controlled trial. BMJ 322: 1567–1573.[Abstract/Free Full Text]

17. Bhandari, N., Bahl, R., Taneja, S., Strand, T., Molbak, K., Ulvik, R. J., Sommerfelt, H. & Bhan, M. K. (2002) Routine zinc supplementation prevents pneumonia in children 6 months to 3 years of age: a randomized controlled trail in an urban slum. BMJ 324: 1358–1360.[Abstract/Free Full Text]

18. Zinc Investigators' Collaborative Group: Bhutta, Z. A., Black, R. E., Brown, K. H., Meeks-Gardner, J., Gore, S., Hidayat, A., Khatun, F., Martorell, R., Ninh, N. X., Penny, M. E., Rosado, J. L., Roy, S. K., Ruel, M., Sazawal, S. & Shankar, A. (1999) Prevention of diarrhea and pneumonia by zinc supplementation in children in developing countries: pooled analysis of randomized controlled trials. J. Pediatr. 135: 689–697.[Medline]

19. Snow, R. W., Craig, M., Deichmann, U. & Marsh, K. (1999) Estimating mortality, morbidity and disability due to malaria among Africa's non-pregnant population. Bull. World Health Organ. 77: 624–640.[Medline]

20. Sachdev, H. P. S., Mittal, N. K., Mittal, S. K. & Yadav, H. S. (1998) A controlled trial on utility of oral zinc supplementation in acute dehydrating diarrhea in infants. J. Pediatr. Gastroenterol. Nutr. 7: 877–878.

21. Sachdev, H. P. S., Mittal, N. K. & Yadav, H. S. (1990) Oral zinc supplementation in persistent diarrhoea in infants. Ann. Trop. Paediatr. 10: 63–69.[Medline]

22. Sazawal, S., Black, R. E., Bhan, M. K., Ghandari, N., Sinha, A. & Jalla, S. (1995) Zinc supplementation in young children with acute diarrhea in India. N. Engl. J. Med. 333: 839–844.[Abstract/Free Full Text]

23. Roy, S. K., Tomkins, A. M., Akramuzzaman, S. M., Behrens, R. H., Haider, R., Mahalanabis, D. & Fuchs, G. (1997) Randomised controlled trial of zinc supplementation in malnourished Bangladeshi children with acute diarrhoea. Arch. Dis. Child. 77: 196–200.[Abstract/Free Full Text]

24. Roy, S. K., Tomkins, A. M., Mahalanabis, D., Akramuzzaman, S. M., Haider, R., Behrens, R. H. & Fuchs, G. (1998) Impact of zinc supplementation on persistent diarrhoea in malnourished Bangladeshi children. Acta Paediatr. 87: 1235–1239.[Medline]

25. Hidayat, A., Achadi, A., Sunoto & Soedarmo, S. P. (1998) The effect of zinc supplementation in children under three years of age with acute diarrhea in Indonesia. Med. J. Indonesia 7: 237–241.

26. Bhutta, Z. A., Nizami, S. Q. & Isani, Z. (1999) Zinc supplementation in malnourished children with persistent diarrhea in Pakistan. Pediatrics 103: 1–9.[Abstract/Free Full Text]

27. Faruque, A. S. G., Mahalanabis, D., Haque, S. S., Fuchs, G. J. & Habte, D. (1999) Double-blind, randomized, controlled trial of zinc or vitamin A supplementation in young children with acute diarrhoea. Acta Paediatr. 88: 54–60.

28. Dutta, P., Mitra, U., Datta, A., Niyogi, S. K., Dutta, S., Manna, B., Basak, M., Mahapatra, T. S. & Bhattacharya, S. K. (2000) Impact of zinc supplementation in malnourished children with acute watery diarrhoea. J. Trop. Pediatr. 46: 259–263.[Abstract/Free Full Text]

29. Khatun, U. H. F. (1998) Impact of Zinc and Vitamin A Supplementation in Malnourished Hospitalized Children Suffering from Persistent Diarrhoea. Doctoral thesis, University of Dhaka, Institute of Nutrition and Food Science, Dhaka, Bangladesh.

30. Strand, T. A., Chandyo, R. K., Bahl, R., Sharma, P. R., Adhikari, R. K., Bhandari, N., Ulvik, R. J., Molbak, K., Bhan, M. K. & Sommerfelt, H. (2002) Effectiveness and efficacy of zinc for the treatment of acute diarrhea in young children. Pediatrics 109: 898–903.[Abstract/Free Full Text]

31. Fontaine, O. (2001) Report of a meeting, New Delhi, 7–8 May 2001. Effect of zinc supplementation on clinical course of acute diarrhoea. J. Health Popul. Nutr. 19: 338–346.

32. Zinc Investigators' Collaborative Group: Bhutta, Z. A., Bird, S. M., Black, R. E., Brown, K. H., Gardner, J. M., Hidayat, A., Khatun, F., Martorell, R., Ninh, N. X., Penny, M. E., Rosado, J. L., Roy, S. K., Ruel, M., Sazawal, S. & Shankar, A. (2000) Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled analysis of randomized controlled trials. Am. J. Clin. Nutr. 72: 1516–1522.[Abstract/Free Full Text]

33. Sazawal, S., Black, R. E., Menon, V. P., Dinghra, P., Caulfield, L. E., Dhingra, U. & Bagati, A. (2001) Zinc supplementation in infants born small for gestational age reduces mortality: a prospective, randomized, controlled trial. Pediatrics 108: 1280–1286.[Abstract/Free Full Text]

34. Black, R. E. (2002) Consequences of zinc deficiency on human health and alternatives for programmatic intervention. In: Public Health Issues in Infant and Child Nutrition. Nestle Nutrition Workshop Series, Pediatric Program, vol. 48, pp. 97–110. Nestec Ltd., Vevey, Switzerland.

35. Gibson, R. S., Yeudall, F., Drost, N., Mtitimuni, B. & Cullinan, T. (1998) Dietary interventions to prevent zinc deficiency. Am. J. Clin. Nutr. 68(suppl. 2.): 484S–487S.[Abstract]

36. Allen, L. H. (1998) Zinc and micronutrient supplements for children. Am. J. Clin. Nutr. 68 (suppl. 2): 495S–498S.[Abstract]




This article has been cited by other articles:


Home page
 J. Nutr.Home page
C. L. Coles, J. B. Sherchand, S. K. Khatry, J. Katz, S. C. LeClerq, L. C. Mullany, and J. M. Tielsch
Zinc Modifies the Association between Nasopharyngeal Streptococcus pneumoniae Carriage and Risk of Acute Lower Respiratory Infection among Young Children in Rural Nepal
J. Nutr., December 1, 2008; 138(12): 2462 - 2467.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Clin. Nutr.Home page
P. Kelly, M. Katubulushi, J. Todd, R. Banda, V. Yambayamba, M. Fwoloshi, I. Zulu, E. Kafwembe, F. Yavwa, I. R Sanderson, et al.
Micronutrient supplementation has limited effects on intestinal infectious disease and mortality in a Zambian population of mixed HIV status: a cluster randomized trial
Am. J. Clinical Nutrition, October 1, 2008; 88(4): 1010 - 1017.
[Abstract] [Full Text] [PDF]

Home page
 J Trop PediatrHome page
M. H. Dabbaghmanesh, A. Sadegholvaad, F. Zarei, and G. Omrani
Zinc Status and Relation to Thyroid Hormone Profile in Iranian Schoolchildren
J Trop Pediatr, February 1, 2008; 54(1): 58 - 61.
[Abstract] [Full Text] [PDF]

Home page
 Journals of Gerontology Series A: Biological Sciences and Medical SciencesHome page
C. F. Hodkinson, M. Kelly, H. D. Alexander, I. Bradbury, P. J. Robson, M. P. Bonham, J. M. O'Connor, C. Coudray, J. J. Strain, and J. M. W. Wallace
Effect of Zinc Supplementation on the Immune Status of Healthy Older Individuals Aged 55-70 Years: The ZENITH Study
J. Gerontol. A Biol. Sci. Med. Sci., June 1, 2007; 62(6): 598 - 608.
[Abstract] [Full Text] [PDF]

Home page
 Am J Trop Med HygHome page
S. A. RICHARD, N. ZAVALETA, L. E. CAULFIELD, R. E. BLACK, R. S. WITZIG, and A. H. SHANKAR
Zinc and iron supplementation and malaria, diarrhea, and respiratory infections in children in the peruvian Amazon.
Am J Trop Med Hyg, July 1, 2006; 75(1): 126 - 132.
[Abstract] [Full Text] [PDF]

Home page
 Arch. Dis. Child.Home page
P Boran, G Tokuc, E Vagas, S Oktem, and M K Gokduman
Impact of zinc supplementation in children with acute diarrhoea in Turkey
Arch. Dis. Child., April 1, 2006; 91(4): 296 - 299.
[Abstract] [Full Text] [PDF]

Home page
 J. Nutr.Home page
A. H. Baqui, C. L. F. Walker, K. Zaman, S. E. Arifeen, H. R. Chowdhury, M. A. Wahed, R. E. Black, and L. E. Caulfield
Weekly Iron Supplementation Does Not Block Increases in Serum Zinc Due to Weekly Zinc Supplementation in Bangladeshi Infants
J. Nutr., September 1, 2005; 135(9): 2187 - 2191.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Clin. Nutr.Home page
C. F. Walker, K. Kordas, R. J Stoltzfus, and R. E Black
Interactive effects of iron and zinc on biochemical and functional outcomes in supplementation trials
Am. J. Clinical Nutrition, July 1, 2005; 82(1): 5 - 12.
[Abstract] [Full Text] [PDF]

Home page
 Clin. Microbiol. Rev.Home page
F. Qadri, A.-M. Svennerholm, A. S. G. Faruque, and R. B. Sack
Enterotoxigenic Escherichia coli in Developing Countries: Epidemiology, Microbiology, Clinical Features, Treatment, and Prevention
Clin. Microbiol. Rev., July 1, 2005; 18(3): 465 - 483.
[Abstract] [Full Text] [PDF]

Home page
 J. Nutr.Home page
C. M. Smuts, C. J. Lombard, A. J. S. Benade, M. A. Dhansay, J. Berger, L. T. Hop, G. Lopez de Romana, J. Untoro, E. Karyadi, J. Erhardt, et al.
Efficacy of a Foodlet-Based Multiple Micronutrient Supplement for Preventing Growth Faltering, Anemia, and Micronutrient Deficiency of Infants: The Four Country IRIS Trial Pooled Data Analysis
J. Nutr., March 1, 2005; 135(3): 631S - 638S.
[Abstract] [Full Text] [PDF]

Home page
 Int J EpidemiolHome page
C. F Lanata, I. Rudan, C. Boschi-Pinto, L. Tomaskovic, T. Cherian, M. Weber, and H. Campbell
Methodological and quality issues in epidemiological studies of acute lower respiratory infections in children in developing countries
Int. J. Epidemiol., December 1, 2004; 33(6): 1362 - 1372.
[Abstract] [Full Text] [PDF]

Home page
 Int J EpidemiolHome page
G. Raso, A. Luginbuhl, C. A Adjoua, N. T Tian-Bi, K. D Silue, B. Matthys, P. Vounatsou, Y. Wang, M.-E. Dumas, E. Holmes, et al.
Multiple parasite infections and their relationship to self-reported morbidity in a community of rural Cote d'Ivoire
Int. J. Epidemiol., October 1, 2004; 33(5): 1092 - 1102.
[Abstract] [Full Text] [PDF]

Home page
 J. Nutr.Home page
M. L. Failla
Trace Elements and Host Defense: Recent Advances and Continuing Challenges
J. Nutr., May 1, 2003; 133(5): 1443S - 1447.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Purchase Article
Right arrow View Shopping Cart
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Black, R. E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Black, R. E.

Home Help [Feedback] [For Subscribers] [Archive] [Search] [Contents]
Copyright © 2003 by American Society for Nutrition