Journal of Nutrition Community and International Nutrition

Adjusting for the Acute Phase Response Is Essential to Interpret Iron Status Indicators among Young Zanzibari Children Prone to Chronic Malaria and Helminth Infections [Community and International Nutrition]

Tue, 20 Oct 2009 10:01:51 PDT

The extent to which the acute phase response (APR) influences iron status indicators in chronic infections is not well documented. We investigated this relationship using reported recent fever and 2 acute phase proteins (APP), C-reactive protein (CRP), and -1-acid glycoprotein (AGP). In a sample of 690 children matched on age and helminth infection status at baseline, we measured plasma for AGP, CRP, ferritin, transferrin receptor (TfR), and erythropoietin (EPO) and whole blood for hemoglobin (Hb) concentration, zinc protoporphyrin (ZPP), and malaria parasite density, and we obtained maternal reports of recent fever. We then examined the influence of the APR on each iron status indicator using regression analysis with Hb as the outcome variable. Ferritin was inversely related to Hb in the APR-unadjusted model. Adjusting for the APR using reported recent fever alone was not sufficient to reverse the inverse Hb-ferritin relationship. However, using CRP and/or AGP resulted in the expected positive relationship. The best fit model included reported recent fever, AGP and CRP (R² = 0.241; P < 0.001). The best fit Hb-ZPP, Hb-TfR, and Hb-EPO models included reported recent fever and AGP but not CRP (R² = 0.253, 0.310, and 0.292, respectively; P < 0.001). ZPP, TfR, and EPO were minimally influenced by the APR, whereas ferritin was immensely affected. Reported recent fever alone cannot be used as a marker for the APR. Either AGP or CRP is useful for adjusting if only 1 APP can be measured. However, AGP best predicted the APR in this population.

Household Food Insecurity Is Associated with Childhood Malaria in Rural Haiti [Community and International Nutrition]

Tue, 20 Oct 2009 10:01:51 PDT

Haiti is the poorest country in the Western Hemisphere and is heavily affected by food insecurity and malaria. To find out if these 2 conditions are associated with each other, we studied a convenience sample of 153 women with children 1–5 y old in Camp Perrin, South Haiti. Household food insecurity was assessed with the 16-item Escala Latinoamericana y Caribeña de Seguridad Alimentaria (ELCSA) scale previously validated in the target communities. ELCSA's reference time period was the 3 mo preceding the survey and it was answered by the mother. Households were categorized as either food secure (2%; ELCSA score = 0), food insecure/very food insecure (42.7%; ELCSA score range: 1–10), or severely food insecure (57.3%; ELCSA score range: 11–16). A total of 34.0% of women reported that their children had malaria during the 2 mo preceding the survey. Multivariate analyses showed that severe food insecure was a risk factor for perceived clinical malaria (odds ratio: 5.97; 95% CI: 2.06–17.28). Additional risk factors for perceived clinical malaria were as follows: not receiving colostrum, poor child health (via maternal self-report), a child BMI <17 kg/m², and child vitamin A supplementation more than once since birth. Findings suggest that policies and programs that address food insecurity are also likely to reduce the risk of malaria in Haiti.

Nationally Representative Surveys Show Recent Increases in the Prevalence of Overweight and Obesity among Women of Reproductive Age in Bangladesh, Nepal, and India [Community and International Nutrition]

Balarajan, Y., Villamor, E. — Tue, 20 Oct 2009 10:01:51 PDT

Our aims in this study were to examine trends in the prevalence of overweight-obesity and underweight among women of reproductive age in 3 South Asian countries between 1996 and 2006 and to identify sociodemographic correlates of overweight in the most recent survey. Using nationally representative data from 8 Demographic and Health Surveys conducted in Bangladesh (n = 19,211), Nepal (n = 19,354), and India (n = 161,755), we examined the change in the prevalence rates of overweight-obesity (BMI ≥ 25 kg/m²) and underweight (BMI < 18.5 kg/m²) over a recent 7- to 10-y period among women aged 15–49 y. The prevalence of overweight-obesity increased substantially in all countries. Comparing the first to the latest survey in Bangladesh, the prevalence of overweight-obesity increased from 2.7 to 8.9% [age and parity-adjusted prevalence ratio (PR): 2.42; 95% CI: 1.88, 3.13]; in Nepal, from 1.6 to 10.1% [adjusted PR: 4.18; 95% CI: 3.00, 5.83]; and in India, from 10.6 to 14.8% [adjusted PR: 1.28; 95% CI: 1.20, 1.36]. These increases were observed in both rural and urban areas and were greater in rural areas. During the study period, the prevalence of underweight decreased substantially in Bangladesh and only modestly in Nepal and India. Overweight-obesity was positively related to age, higher socioeconomic status, and urban residence in all countries. In conclusion, while the prevalence of underweight has remained high in Bangladesh, Nepal, and India, the prevalence of overweight-obesity in women of reproductive age has risen between 1996 and 2006.

Multiple Micronutrients Including Iron Are Not More Effective Than Iron Alone for Improving Hemoglobin and Iron Status of Malian School Children [Community and International Nutrition]

Fri, 18 Sep 2009 10:01:30 PDT

Iron deficiency and anemia remain among the most important global public health problems facing school children. Helminth infections often peak at school age and aggravate nutritional risks. We conducted a 12-wk randomized controlled trial in 406 Malian anemic schoolchildren infected with Schistosoma hematobium to examine the effects of 2 doses of praziquantel (P) (40 mg/kg body weight), P + 60 mg/d iron (Fe), and/or a multiple micronutrient supplement (MM) that included 18 mg/d Fe. Supplements were administered to the children each school day (5 d/wk) throughout the study. Changes in hemoglobin (Hb), serum ferritin (SF), and serum transferrin receptors (s-TfR) were followed. We also examined interactions between Fe and MM supplements on Hb and SF concentrations and malaria incidence. The effects of Fe on Hb and SF concentrations were greater than the effects of P alone and MM with or without added Fe at 6 and 12 wk (P < 0.001). In all groups, s-TfR decreased at 6 and 12 wk compared with baseline. The decrease was most pronounced in the P + Fe group compared with the other 3 groups at wk 6 (P = 0.05). Fe and MM interacted negatively at wk 6 and 12 to affect Hb (β = –0.43, 95% CI = –0.77, –0.09; P = 0.01 and β = –0.47, 95% CI = –0.83, –0.11; P = 0.01, respectively) and SF (β = –0.42, 95% CI = –25.60, 12.31; P < 0.001, and β = –0.37, 95% CI = –0.63, –0.12; P = 0.004, respectively). Malaria incidence was higher in the groups treated with added Fe (relative risk: 1.66; 95% CI: 0.75, 3.67). In this context, MM with added iron were not more effective than Fe without MM. Fe supplementation of schoolchildren with 60 mg/d for anemia control should be considered carefully.

Health Canada's Proposed Discretionary Fortification Policy Is Misaligned with the Nutritional Needs of Canadians [Community and International Nutrition]

Sacco, J. E., Tarasuk, V. — Fri, 18 Sep 2009 10:01:30 PDT

Health Canada has proposed new fortification policies that will allow manufacturers to add vitamins and minerals to a wide variety of foods at their discretion and increase nutrient additions to breakfast cereals. Our objective was to examine the potential impact of these policies on nutrient inadequacies and excesses in the Canadian population. Using dietary intake data from the Canadian Community Health Survey, Cycle 2.2 (2004), usual intake distributions from food were estimated for vitamins A and C, folate, niacin, calcium, and magnesium for all age/sex groups. The prevalence of individuals with inadequate nutrient intake and the proportion of individuals with intakes above the tolerable upper intake level (UL) were assessed where possible, assuming full implementation of the proposed policies. To approximate a "mature market" scenario, consumption patterns of fortified foods in the United States were estimated and applied to Canadian intake data. Full implementation resulted in marked reductions in inadequate intakes of vitamin A, vitamin C, magnesium, and folate, and improvements in calcium intakes for some age/sex groups. However, it caused intakes of folate, niacin, vitamin A, and calcium to rise above the UL, particularly among younger age groups. Although increased food fortification may reduce the apparent prevalence of inadequate intakes for some nutrients, there is no evidence of inadequacies for niacin or several other nutrients slated for addition. Our modeling suggests that Health Canada's proposed policies are misaligned with the nutritional needs of the population, because they are not rooted in an assessment of current nutrient intake patterns.

A Responsive Feeding Intervention Increases Children's Self-Feeding and Maternal Responsiveness but Not Weight Gain [Community and International Nutrition]

Aboud, F. E., Shafique, S., Akhter, S. — Thu, 20 Aug 2009 10:02:30 PDT

Responsive complementary feeding, whereby the mother feeds her child in response to child cues and psychomotor abilities, is low in some countries and likely contributes to malnutrition. Interventions are needed to evaluate whether promoting responsive feeding would add any benefit. Using a cluster-randomized field trial, we evaluated a 6-session educational program that emphasized the practice of child self-feeding and maternal responsiveness. A total of 108 mothers and their 8- to 20-mo-old children in 19 clusters were randomly assigned to the intervention group and 95 in 18 clusters were assigned to the informational control group. Outcomes were assessed at pretest, postintervention, and follow-up. Research assistants, who were unaware of group assignment, observed and coded mother and child midday meal behaviors. At follow-up, the percent of self-fed mouthfuls was 47.8 ± 42.4 (mean ± SD) in the responsive feeding group children compared with 32.2 ± 41.0 in the controls (P = 0.01); likewise, the number of responsive verbalizations was 6.55 ± 5.9 in the responsive feeding mothers and 4.62 ± 4.5 in controls (P = 0.01). Intervention mothers recalled more messages. Mouthfuls of food eaten by children and weight were equivalent in the 2 groups. Lack of change in foods eaten and small quantities may explain the similarly low levels of weight gain. These results provide evidence that self-feeding and maternal verbal responsiveness, two developmentally important behaviors, can be increased by targeting specific behaviors with appropriate behavior change strategies of modeling and coached practice. Weight gain may require more nutritional input, especially in areas of high food insecurity.

Provision of a School Snack Is Associated with Vitamin B-12 Status, Linear Growth, and Morbidity in Children from Bogota, Colombia [Community and International Nutrition]

Thu, 20 Aug 2009 10:02:30 PDT

In 2004, Bogotá's Secretary of Education (SED) initiated a snack program in public primary schools. A midmorning food ration was provided free of charge to children to supplement 30 and 50% of their daily requirements of energy and iron, respectively. The purpose of this study, an observational investigation of 3202 children ages 5–12 y, was to examine whether the snack program improved children's nutritional and health status. We measured micronutrient levels (plasma ferritin and vitamin B-12, and erythrocyte folate), anthropometry, and reported morbidity during the first semester of the 2006 school year. After adjusting for socioeconomic status and other school interventions, children at schools receiving the snack (n = 1803) had greater increases in plasma vitamin B-12 (42 pmol/L; P < 0.0001) from baseline to 3 mo of follow-up than children at schools not receiving the snack (n = 1399). They also experienced a smaller decrease in height-for-age Z-scores than children who did not receive the snack (P = 0.001). Provision of the SED snack was associated with significantly fewer reported days with morbidity symptoms (e.g. cough with fever, diarrhea with vomiting), 44% fewer doctor visits (P = 0.02), and 23% fewer days of school absenteeism (P = 0.03). The snack was not related to ferritin or folate levels. In conclusion, provision of a school-administered snack was related to improved vitamin B-12 status and linear growth and decreased reported morbidity. Although provision of the snack was not related to BMI changes over a 4-mo period, snack components such as candy and sugar-sweetened beverages should be replaced with healthier options, as the rates of child overweight in Colombia are not negligible.

Some Indicators of Nutritional Status Are Associated with Activity and Exploration in Infants at Risk for Vitamin and Mineral Deficiencies [Community and International Nutrition]

Aburto, N. J., Ramirez-Zea, M., Neufeld, L. M., Flores-Ayala, R. — Thu, 20 Aug 2009 10:02:30 PDT

Severe malnutrition, both protein-energy and micronutrient deficiency, results in decreased activity, but the results regarding mild-to-moderate malnutrition are equivocal. Our objective in this investigation was to describe the activity and exploratory behavior of Mexican infants and describe the relationship among nutritional status, activity, and exploration in this population at high risk for mild-to-moderate micronutrient deficiency, but at low risk for severe malnutrition. The participants were infants, 4–12 mo old, of low socioeconomic status from 3 states in southern Mexico. We measured anthropometrics using standard techniques. We measured hemoglobin (Hb) concentration in the field and adjusted values for altitude before analysis. We measured activity and exploration by direct observation during 15 min of individual play in a novel environment. Cluster analysis generated mutually exclusive activity clusters and exploration clusters based on patterns of bodily movement and exploratory behavior, respectively. We categorized the clusters as higher or lower activity or higher or lower exploration. A higher Hb concentration and height-for-age Z-score (HAZ) significantly increased the odds of being in the high-activity cluster. Iron deficiency, stunting, and wasting significantly decreased the odds of being in the high-activity cluster. Higher HAZ and weight-for-age Z-score significantly increased the odds of being in a higher exploration cluster. In Mexican infants at risk for mild-to-moderate micronutrient deficiency but at low risk of severe malnutrition, some indicators of nutritional status were related to increased activity and exploration.

Food Insecurity among Volunteer AIDS Caregivers in Addis Ababa, Ethiopia Was Highly Prevalent but Buffered from the 2008 Food Crisis [Community and International Nutrition]

Maes, K. C., Hadley, C., Tesfaye, F., Shifferaw, S., Tesfaye, Y. A. — Thu, 20 Aug 2009 10:02:31 PDT

Our objective in this study was to assess the validity and dependability of the Household Food Insecurity Access Scale (HFIAS), which was developed for international use, among community health volunteers in Addis Ababa, Ethiopia. The HFIAS was translated into Amharic and subsequently tested for content and face validity. This was followed by a quantitative validation study based on a representative sample (n = 99) of female community volunteers (HIV/AIDS home-based caregivers), with whom the HFIAS was administered at 3 time points over the course of 2008, in the context of the local and global "food crisis." By pooling observations across data collection rounds and accounting for intra-individual correlation in repeated measures, we found that the HFIAS performed well according to standards in the field. We also observed slight amelioration in reported food insecurity (FI) status over time, which seems paradoxical given the increasing inaccessibility of food over the same time period due to inflating prices and disappearing food aid. We attempted to resolve this paradox by appealing to self-report–related phenomena that arise in the context of longitudinal study designs: 1) observation bias, in which respondents change their reports according to changing expectations of the observer-respondent relationship or change their behavior in ways that ameliorate FI after baseline self-reports; and 2) "response shift," in which respondents change their reports according to reassessment of internal standards of FI. Our results are important for the validation of FI tools and for the sustainability of community health programs reliant on volunteerism in sub-Saharan Africa.