Adjusting soluble transferrin receptor concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Rohner F, Namaste SML, Larson LM, Addo OY, Mei Z, Suchdev PS, Williams AM, Sakr Ashour FA, Rawat R, Raiten DJ, Northrop-Clewes CA

June 2017 – American Journal of Clinical Nutrition

Iron deficiency is thought to be one of the most prevalent micronutrient deficiencies globally, but an accurate assessment in populations who are frequently exposed to infections is impeded by the inflammatory response, which causes iron-biomarker alterations. We assessed the relation between soluble transferrin receptor (sTfR) concentrations and inflammation and malaria in preschool children (PSC) and women of reproductive age (WRA) and investigated adjustment algorithms to account for these effects using cross-sectional data from the Biomarkers Reflecting the Inflammation and Nutritional Determinants of Anemia (BRINDA) project. The following 3 adjustment approaches were compared with estimated iron-deficient erythropoiesis (sTfR concentration >8.3 mg/L): 1) the exclusion of individuals with C-reactive protein (CRP) concentrations >5 mg/L or α-1-acid glycoprotein (AGP) concentrations >1 g/L, 2) the application of arithmetic correction factors, and 3) the use of regression approaches. The prevalence of elevated sTfR concentrations incrementally decreased as CRP and AGP deciles decreased for PSC and WRA, but the effect was more pronounced for AGP than for CRP. Depending on the approach used to adjust for inflammation, the estimated prevalence of iron-deficient erythropoiesis decreased by 4.4-14.6 and 0.3-9.5 percentage points in PSC and WRA, respectively, compared with unadjusted values. The correction-factor approach yielded a more modest reduction in the estimated prevalence of iron-deficient erythropoiesis than did the regression approach.


Adjusting total body iron for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project.

Mei Z, Namaste SML, Serdula M, Suchdev PS, Rohner F, Flores-Ayala R, Addo OY, Raiten DJ

June 2017 – American Journal of Clinical Nutrition

Total body iron (TBI) that is calculated from ferritin and soluble transferrin receptor (sTfR) allows for the evaluation of the full range of iron status from deficiency to excess. However, both ferritin and sTfR are affected by inflammation and malaria, which may require a statistical adjustment. TBI has been used to assess iron status in the United States, but its use worldwide and in settings with inflammation has been limited. We examine whether inflammation-adjusted ferritin and sTfR concentrations affect TBI values and the prevalence of low TBI (<0 mg/kg) in preschool children (PSC) and women of reproductive age (WRA) using cross-sectional data from the Biomarkers Reflecting the Inflammation and Nutritional Determinants of Anemia (BRINDA) project. TBI and the prevalence of low TBI were compared following 3 adjustment approaches for ferritin and sTfR: 1) the exclusion of individuals with inflammation (C-reactive protein concentration >5 mg/L or α-1-acid glycoprotein concentration >1 g/L), 2) the application of arithmetic correction factors, and 3) the use of regression correction. Regardless of the method that was used to adjust ferritin and sTfR for inflammation, the adjusted mean TBI decreased in both PSC and WRA compared with unadjusted values. Subsequently, inflammation-adjusted TBI increased the prevalence of low TBI by a median of 4-14 percentage points (pps) in PSC and 1-3 pps in WRA compared with unadjusted TBI. The regression approach resulted in a greater median increase than was achieved with the exclusion or correction-factor approaches, and accounting for malaria in addition to inflammation did not have an added effect on the prevalence estimates.


Adjusting ferritin concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Namaste SML, Rohner F, Huang J, Bhushan NL, Flores-Ayala R, Kupka R, Mei Z, Rawat R, Williams AM, Raiten DJ, Northrop-Clewes CA, Suchdev PS

June 2017 – American Journal of Clinical Nutrition

The accurate estimation of iron deficiency is important in planning and implementing interventions. Ferritin is recommended as the primary measure of iron status, but interpretability is challenging in settings with infection and inflammation. We assessed the relation between ferritin concentrations and inflammation and malaria in preschool children (PSC) (age range: 6–59 mo) and women of reproductive age (WRA) (age range: 15–49 y) and investigated adjustment algorithms to account for these effects using cross-sectional data from 15 surveys for PSC (n = 27,865) and 8 surveys for WRA (24,844), from the Biomarkers Reflecting the Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Several approaches were explored to estimate depleted iron stores, including a regression correction approach. Depending on the approach used to adjust for inflammation (CRP plus AGP), the estimated prevalence of depleted iron stores increased by 7–25 and 2–8 absolute median percentage points for PSC and WRA, respectively, compared with unadjusted values. Adjustment for malaria in addition to CRP and AGP did not substantially change the estimated prevalence of depleted iron stores. This approach appears to mathematically reflect the linear relation of ferritin concentrations with acute-phase proteins. More research is warranted to validate the proposed approaches, but this study contributes to the evidence base to guide decisions about how and when to adjust ferritin for inflammation.


Identification of a Hemolysis Threshold That Increases Plasma and Serum Zinc Concentration

Killilea DW, Rohner F, Ghosh S, Otoo GE, Smith L, Siekmann JH, King JC

May 2017 – Journal of Nutrition

Plasma or serum zinc concentration (PZC or SZC) is the primary measure of zinc status, but it is not established how much hemolysis can occur without changing PZC/SZC concentrations. To estimate the effect of hemolysis on PZC/SZC concentrations, this study calculated a hemolysis threshold and then compared it with results from an in vitro study and a population survey. This study found a 5% increase in PZC/SZC was calculated to result from the lysis of 1.15% of the erythrocytes in whole blood, corresponding to ~1 g hemoglobin/L added into the plasma or serum. Similarly, the addition of simulated hemolysate to control plasma in vitro caused a 5% increase in PZC when hemoglobin concentrations reached 1.1860.10 g/L. In addition, serum samples from a population nutritional survey were scored for hemolysis and analyzed for changes in SZC; samples with hemolysis in the range of 1–2.5 g hemoglobin/L showed an estimated increase in SZC of 6% compared with non-hemolyzed samples. Each approach indicated that a 5% increase in PZC/SZC occurs at ~1 g hemoglobin/L in plasma or serum. This concentration of hemoglobin can be readily identified directly by chemical hemoglobin assays or indirectly by direct spectrophotometry or matching to a color scale. A threshold of 1 g hemoglobin/L is recommended for PZC/SZC measurements to avoid increases in zinc caused by hemolysis. The use of this threshold may improve zinc assessment for monitoring zinc status and nutritional interventions.


Efficacy of iron-biofortified crops

Boy E, Haas JD, Petry N, Cercamondi CI, Gahutu JB, Mehta S, Finkelstein JL,Hurrell RF

April 2017 – African Journal of Food, Agriculture, Nutrition, and Development

Biofortification aims to increase the content of micronutrients in staple crops without sacrificing agronomic yield, making the new varieties attractive to farmers. Food staples that provide a major energy supply in low- and middle-income populations are the primary focus. The low genetic variability of iron in the germplasm of most cereal grains is a major obstacle on the path towards nutritional impact with these crops, which is solvable only by turning to transgenic approaches. However, biofortified varieties of common beans and pearl millet have been developed successfully and made available with iron contents as high as 100 mg/kg and 80 mg/kg, respectively, two to five times greater than the levels in the regular varieties. This brief review summarizes the research to date on the bioavailability and efficacy of iron-biofortified crops, highlights their potential and limitations, and discusses the way forward with multiple biofortified crop approaches suitable for diverse cultures and socio-economic milieu. Like post-harvest iron fortification, these biofortified combinations might provide enough iron to meet the additional iron needs of many iron deficient women and children that are not covered at present by their traditional diets.


Vitamin A Supplementation Programs and Country-Level Evidence of Vitamin A Deficiency

Wirth JP, Petry N, Tanumihardjo, SA, Rogers LM, McLean E, Greig A, Garrett GS, Klemm RDW, Rohner F

February 2017 – Nutrients

Vitamin A supplementation (VAS) programs targeted at children aged 6–59 months are implemented in many countries. By improving immune function, vitamin A (VA) reduces mortality associated with measles, diarrhea, and other illnesses. There is currently a debate regarding the relevance of VAS, but amidst the debate, researchers acknowledge that the majority of nationally-representative data on VA status is outdated. To address this data gap and contribute to the debate, we examined data from 82 countries implementing VAS programs, identified other VA programs, and assessed the recentness of national VA deficiency (VAD) data. We found that two-thirds of the countries explored either have no VAD data or data that were >10 years old (i.e., measured before 2006), which included twenty countries with VAS coverage ≥70%. Fifty-one VAS programs were implemented in parallel with at least one other VA intervention, and of these, 27 countries either had no VAD data or data collected in 2005 or earlier. To fill these gaps in VAD data, countries implementing VAS and other VA interventions should measure VA status in children at least every 10 years. At the same time, the coverage of VA interventions can also be measured. We identified three countries that have scaled down VAS, but given the lack of VA deficiency data, this would be a premature undertaking in most countries without appropriate status assessment. While the global debate about VAS is important, more attention should be directed towards individual countries where programmatic decisions are made.


Accelerating salt iodization in Angola

Wirth JP, Jooste P, Costa C, Nsalambi CA, Futi M, Agbo S

December 2016 – IDD Newsletter

Over the past decade, Angola has made continuous efforts to enhance its salt iodization program. Salt iodization was made mandatory in 2008, and according to the existing survey and monitoring data, the majority of salt in Angola is iodized (although the adequacy of iodized salt is unknown). Despite these advances, there has not been a comprehensive and recent assessment of iodine status in children and women nor of the iodine content of table salt at the production sites or in the households. To address this information gap, a situation analysis of Angola’s salt iodization program was conducted in July 2016, and provides detailed recommendations to enhance the program moving forward. This situation analysis was followed by a workshop of salt producers and public health stakeholders in September 2016, and advocacy activities promoting the benefits of iodized salt were conducted in October 2016.


The Effect of Low Dose Iron and Zinc Intake on Child Micronutrient Status and Development during the First 1000 Days of Life: A Systematic Review and Meta-Analysis

Petry N, Olofin I, Boy E, Angel MD, Rohner F

December 2016 – Nutrients

Adequate supply of micronutrients during the first 1000 days is essential for normal development and healthy life. To investigate if interventions administering dietary doses of iron and zinc from conception to age 2 years have the potential to influence nutritional status and development of children, we conducted a systematic review and meta-analysis of randomized and quasi-randomized fortification, biofortification, and supplementation trials in women (pregnant and lactating) and children (6–23 months) delivering iron or zinc in doses up to the recommended nutrient intake (RNI) levels. Supplying iron or zinc during pregnancy had no effects on birth outcomes. There were limited or no data on the effects of iron/zinc during pregnancy and lactation on child iron/zinc status, growth, morbidity, and psychomotor and mental development. Delivering up to 15 mg iron/day during infancy increased mean hemoglobin by 4 g/L (p < 0.001) and mean serum ferritin concentration by 17.6 µg/L (p < 0.001) and reduced the risk for anemia by 41% (p < 0.001), iron deficiency by 78% (ID; p < 0.001) and iron deficiency anemia by 80% (IDA; p < 0.001), but had no effect on growth or psychomotor development. Providing up to 10 mg of additional zinc during infancy increased plasma zinc concentration by 2.03 µmol/L (p < 0.001) and reduced the risk of zinc deficiency by 47% (p < 0.001). Further, we observed positive effects on child weight for age z-score (WAZ) (p < 0.05), weight for height z-score (WHZ) (p < 0.05), but not on height for age z-score (HAZ) or the risk for stunting, wasting, and underweight.


High Awareness but Low Coverage of a Locally Produced Fortified Complementary Food in Abidjan, Coˆte d’Ivoire: Findings from a Cross-Sectional Survey

Leyvraz M, Rohner F, Konan AG, Esso LJCE, Woodruff BA, Norte A, Adiko AF, Bonfoh B, & Aaron GJ

November 2016 – PLOS ONE

As part of a broad effort to address poor complementary feeding practices among infants and young children in Côte d’Ivoire, an affordable, nutritious, and locally produced fortified complementary food product was launched in the Côte d’Ivoire in 2011. The objective of the current research was to assess various levels of coverage of the program and to identify coverage barriers. A cross-sectional household survey was conducted among caregivers of children less than 2-years of age living in Abidjan, Côte d’Ivoire. Four measures of coverage were assessed: “message coverage” (i.e., has the caregiver ever heard of the product?), “contact coverage” (i.e., has the caregiver ever fed the child the product?), “partial coverage” (i.e., has the caregiver fed the child the product in the previous month?), and “effective coverage” (i.e., has the caregiver fed the child the product in the previous 7 days?). A total of 1,113 caregivers with children between 0 and 23 months of age were interviewed. Results showed high message coverage (85.0%), moderate contact coverage (37.8%), and poor partial and effective coverages (8.8% and 4.6%, respectively). Product awareness was lower among caregivers from poorer households, but partial and effective coverages were comparable in both poor and non-poor groups. Infant and young child feeding (IYCF) practices were generally poor and did not appear to have improved since previous assessments. The results from the present study indicate that availability on the market and high awareness among the target population is not sufficient to achieve high and effective coverage. With market-based delivery models, significant efforts are needed to improve demand.


The Proportion of Anemia Associated with Iron Deficiency in Low, Medium, and High Human Development Index Countries: A Systematic Analysis of National Surveys

Petry N, Olofin I, Hurrell RF, Boy E, Wirth JP, Moursi M, Angel MD, Rohner F

November 2016 – Nutrients

Iron deficiency is commonly assumed to cause half of all cases of anemia, with hereditary blood disorders and infections such as hookworm and malaria being the other major causes. In countries ranked as low, medium, and high by the Human Development Index, we conducted a systematic review of nationally representative surveys that reported the prevalence of iron deficiency, iron deficiency anemia, and anemia among pre-school children and non-pregnant women of reproductive age. Using random effects meta-analyses techniques, data from 23 countries for pre-school children and non-pregnant women of reproductive age was pooled, and the proportion of anemia attributable to iron deficiency was estimated by region, inflammation exposure, anemia prevalence, and urban/rural setting. For pre-school children and non-pregnant women of reproductive age, the proportion of anemia associated with iron deficiency was 25.0% (95% CI: 18.0, 32.0) and 37.0% (95% CI: 28.0, 46.0), respectively. The proportion of anemia associated with iron deficiency was lower in countries where anemia prevalence was >40%, especially in rural populations (14% for pre-school children; 16% for non-pregnant women of reproductive age), and in countries with very high inflammation exposure (20% for pre-school children; 25% for non-pregnant women of reproductive age). Despite large heterogeneity, our analyses suggest that the proportion of anemia associated with iron deficiency is lower than the previously assumed 50% in countries with low, medium, or high Human Development Index ranking.


High Coverage and Utilization of Fortified Take-Home Rations among Children 6–35 Months of Age Provided through the Integrated Child Development Services Program: Findings from a Cross-Sectional Survey in Telangana, India

Leyvraz M, Wirth JP, Woodruff BA, Sankar R, Sodani PR, Sharma ND, Aaron GJ

October 2016 – PLOS ONE

The Integrated Child Development Services (ICDS) in the State of Telangana, India, freely provides a fortified complementary food product, Bal Amrutham, as a take-home ration to children 6–35 months of age. To assess the coverage, utilization, barriers, and drivers of the program, a two-stage, stratified cross-sectional cluster survey was conducted in randomly selected catchment areas of ICDS centers in Telangana. A total of 1,077 children 0-35 months were randomly selected and enrolled in the survey. The coverage of the fortified take-home ration was found to be high among the target population. Nearly all caregivers (93.7%) had heard of Bal Amrutham and 86.8% had already received the product for the target child. Among the children surveyed, 57.2% consumed the product regularly. The ICDS program’s services were not found to be a barrier to product coverage. In fact, the ICDS program was found to be widely available, accessible, accepted, and utilized by the population in both urban and rural catchment areas, as well as among poor and non-poor households. However, two barriers to optimal coverage were found: the irregular supply of the product to the beneficiaries and the intra-household sharing of the product. Although sharing was common, the product was estimated to provide the target children with significant proportions of the daily requirements of macro- and micronutrients.


Situation analysis of salt iodization and iodine status in Angola

Iodine Global Network and GroundWork

September 2016 – Report Release, Luanda, Angola

The Iodine Global Network (IGN) has classified Angola’s iodine status as “insufficient” and has estimated that approximately 520,000 Angolan infants are at risk of iodine deficiency. Though the existing data sources indicate that iodine is a severe public health problem in Angola, there has not been a comprehensive and recent assessment of iodine status nor of the iodized salt sector. In order to compile all available data related to salt iodization program and iodine nutrition in Angola, IGN and GroundWork have collaborated undertaken a situation analysis. As documented in the report, the salt iodization program in Angola has made considerable strides over the past decade. Angola has established legislation and standards, a coordinating body, and promotional and awareness raising materials. Moreover, according to the existing survey and monitoring data, the majority of salt in Angola is iodized, although the adequacy of iodized salt is unknown. To build upon and sustain recent advances in Angola’s salt iodization program and expand the supply and coverage of adequately iodized salt, efforts are needed to review and strengthen the salt supply chain and generate updated evidence on the status of iodine nutrition in the population. Through these efforts, Angola can further its efforts to grow its domestic salt iodization industry and reduce iodine deficiency and its disorders.


Coverage of Adequately Iodized Salt Is Suboptimal and Rice Fortification Using Public Distribution Channels Could Reach Low-Income Households: Findings from a Cross-Sectional Survey of Anganwadi Center Catchment Areas in Telangana, India

Wirth JP, Leyvraz M, Sodani PR, Aaron GJ, Sharma ND, Woodruff BA

July 2016 – PLOS ONE

To assess the coverage of adequately iodized salt and the potential for rice fortification, we conducted a cross-sectional survey of children 0–35 months of age residing in the catchment areas of anganwadi centers in the state of Telangana, India. Iodine concentration of salt samples was tested using iodometric titration, and information on household rice consumption and Telangana’s rice sector was collected and interpreted. In households of selected children, 79% of salt samples were found to be adequately iodized. Salt brand and district were significant predictors of inadequately iodized salt. Daily rice consumption among children and women averaged 122 grams and 321 grams per day, respectively. Approximately 28% of households reported consuming rice produced themselves or purchased from a local farmer, 65% purchased rice from a market or shop, 6% got rice from a public distribution system site, and 2% obtained it from a rice mill. Due to the significant variation in the coverage of adequately iodized salt by district and brand, increasing the adequacy of iodization of smaller salt manufacturers will help achieve universal salt iodization in Telangana. Despite high consumption of rice, our findings suggest that large-scale market-based rice fortification is not feasible in Telangana. Distributing fortified rice via Telangana’s public distribution system may be a viable approach to target low-income households, but would only reach a small proportion of the population.


The Potential of Food Fortification to Add Micronutrients in Young Children and Women of Reproductive Age – Findings from a Cross-Sectional Survey in Abidjan, Côte d’Ivoire

Rohner F, Leyvraz M, Konan AG, Esso LJCE, Wirth JP, Norte A, Adiko AF, Bonfoh B, Aaron GJ

July 2016 – PLOS ONE

Large-scale food fortification is considered a cost-effective approach to deliver micronutrients, and fortification of salt (iodine), wheat flour (iron and folic acid), and vegetable oil (vitamin A) is mandatory in Côte d’Ivoire. A cross-sectional survey on households with at least one child 6–23 months was conducted to update coverage figures with adequately fortified food vehicles in Abidjan, the capital of and largest urban community in Côte d’Ivoire, and to evaluate whether additional iron and vitamin A intake is sufficient to bear the potential to reduce micronutrient malnutrition. Information on demographics and food consumption was collected, along with samples of salt and oil. Wheat flour was sampled from bakeries and retailers residing in the selected clusters. In Abidjan, 86% and 97% of salt and vegetable oil samples, respectively, were adequately fortified, while only 32% of wheat flour samples were adequately fortified, but all samples contained some added iron. There were no major differences in additional vitamin A and iron intake between poor and non-poor households. For vitamin A in oil, the additional percentage of the recommended nutrient intake was 27% and 40% for children 6–23 months and women of reproductive age, respectively, while for iron from wheat flour, only 13% and 19% could be covered. Fortification of vegetable oil clearly provides a meaningful additional amount of vitamin A. This is not currently the case for iron, due to the low fortification levels. Iron levels in wheat flour should be increased and monitored, and additional vehicles should be explored to add iron to the Ivorian diet.


Scale up of nutrition and health programs in Ethiopia and their overlap with reductions in child stunting

Wirth JP, Matji J, Woodruff BA, Chamois S, Getahun Z, White JM, Rohner F

May 2016 – Maternal & Child Nutrition

In Ethiopia, the national stunting prevalence and number of stunted children have decreased consistently since 2000. We compare regional differences and temporal patterns in stunting with large-scale program coverage to identify where and when programs may have led to reductions in stunting. Data from three national demographic and health surveys and population statistics illustrate, at the regional level, where andwhen the prevalence and number of stunted children changed since 2000.Reports from large-scale nutrition and health programs were used to identify ecologic associations between geographic program coverage and reductions in stunting. From 2000 to 2005, the decline in the national stunting prevalence was mainly a result of reductions in Oromiya, SNNP and Tigray. Few nutrition programs had high coverage during this time, and economic growth may have contributed to stunting reduction by increasing household wealth and investments in sanitation. From 2005 to 2011, declines in stunting prevalence in Amhara, SNNP, Somali and Oromiya were largely responsible for national reductions. Numerous programs were implemented at scale and could have plausibly improved stunting. While ecologic relationships suggest that economic growth and large-scale programs may have contributed to the reduction in stunting in Ethiopia, stunting did not decrease in all regions despite increased program coverage expansion of the health system.


Assessment of the WHO Stunting Framework using Ethiopia as a case study

Wirth JP, Rohner F Petry N Onyango AW, Matji J, Bailes A, de Onis M, Woodruff BA

May 2016 – Maternal & Child Nutrition

Poor linear growth in children <5 years old, or stunting, is a serious public health problem particularly in Sub-Saharan Africa. In 2013, the World Health Organization (WHO) released a conceptual framework on the Context, Causes and Consequences of Childhood Stunting (the ‘WHO framework’) that identifies specific and general factors associated with stunting. The framework is based upon a global review of data, and we have applied it to a country level analysis where health and nutrition policies are made and public health and nutrition data are collected. We reviewed the literature related to sub-optimal linear growth, stunting and birth outcomes in Ethiopia as a case study. We found consistent associations between poor linear growth and indicators of birth size, recent illness (e.g. diarrhoea and fever), maternal height and education. Other factors listed as causes in the framework such as inflammation, exposure to mycotoxins and inadequate feeding during and after illness have not been examined in Ethiopia, and the existing literature suggests that these are clear data gaps. Some factors associated with poor linear growth in Ethiopia are missing in the framework, such as household characteristics (e.g. exposure to indoor smoke). Examination of the factors included in the WHO framework in a country setting helps identifying data gaps helping to target further data collection and research efforts.


Determinants of stunting reduction in Ethiopia 2000 – 2011

Woodruff BA, Wirth JP, Bailes A, Matji J, Timmer A, Rohner F

May 2016 – Maternal & Child Nutrition

The prevalence of stunting in Ethiopia declined from 57% in 2000 to 44% in 2011, yet the factors producing this change are not fully understood. Data on 23,999 children 0–59 months of age from three Demographic and Health Surveys (DHS) from 2000, 2005, and 2011 were analyzed to assess the trends in stunting prevalence, mean height-for-age z-scores (HAZ) and the associations between potential factors and HAZ. Associations were determined separately using three separate generalized linear models for children age less than 6months, 6–23 months, and 24–59 months of age. Significant variables were then analyzed to determine if they showed an overall trend between the 2000 and 2011 surveys. In children<6months of age, only mother’s height was both a significant predictor of HAZ and showed a progressive, albeit non-significant, increase from 2000 to 2011. In children 6–23 months of age, only mother’s use of modern contraception showed substantial changes in a direction consistent with improving HAZ, but improvements in maternal nutrition status were observed from 2000 to 2005. For children 24–59 months of age a consistent and progressive change is seen in child’s diarrhea, fever, mother’s education, and the occurrence of open defecation. Our analysis demonstrated that factors associated with HAZ vary by child’s age and the dominant livelihood practice in the community. Variables that could have contributed to the decline of stunting in Ethiopia in children less than 5 years of age include markers of child health, mother’s nutritional status, mother’s educational level, and environmental hygiene.


Anemia, Micronutrient Deficiencies, and Malaria in Children and Women in Sierra Leone Prior to the Ebola Outbreak – Findings of a Cross-Sectional Study

Wirth JP, Rohner F, Woodruff BA, Chiwile F, Yankson H, Koroma AS, Russel F, Sesay F, Dominguez E, Petry N, Shahab-Ferdows S, de Onis M, Hodges MH

May 2016 – PLOS ONE

To identify the factors associated with anemia and to document the severity of micronutrient deficiencies, a nationally representative cross-sectional survey was conducted in rural and urban areas of Sierra Leone. Household and individual data were collected, and blood samples from children and women were used to measure the prevalence of malaria, inflammation, and deficiencies of iron, vitamin A, folate, and vitamin B12. 839 children and 945 non-pregnant women were included in the survey. In children, the prevalence of anemia (76.3%), malaria (52.6%), and acute and chronic inflammation (72.6%) was high. However, the prevalence of vitamin A deficiency (17.4%) was moderate, and the prevalence of iron deficiency (5.2%) and iron-deficiency anemia (3.8%) were low. Malaria and inflammation were associated with anemia, yet they explained only 25% of the population-attributable risk. In women, 44.8%, 35.1%, and 23.6% were affected by anemia, malaria, or inflammation, respectively. The prevalence of iron deficiency (8.3%), iron-deficiency anemia (6.1%), vitamin A deficiency (2.1%) and vitamin B12 deficiency (0.5%) were low, while folate deficiency was high (79.2%). Iron deficiency, malaria, and inflammation were significantly associated with anemia, but explained only 25% of cases of anemia. Anemia in children and women is a severe public health problem in Sierra Leone, and other causes of anemia, such as hemoglobinopathies, should also be explored.


In Rwandese Women with Low Iron Status, Iron Absorption from Low-Phytic Acid Beans and Biofortified Beans Is Comparable, but Low-Phytic Acid Beans Cause Adverse Gastrointestinal Symptoms

Petry N, Rohner F, Gahutu JB, Campion B, Boy E, Tugirimana PL, Zimmerman MB, Zwahlen C, Wirth JP, and Moretti D.

March 2016 – Journal of Nutrition

Phytic acid (PA) is a major inhibitor of iron bioavailability from beans, and high PA concentrations might limit the positive effect of biofortified beans (BBs) on iron status. As low-phytic acid (lpa) bean varieties could increase iron bioavailability, we tested whether lpa beans provide more bioavailable iron than a BBs and control beans (CBs) (regular iron and PA concentrations) by comparing iron absorption in 25 nonpregnant young women with low iron status with the use of a multiple-meal crossover design. Iron absorption was measured with stable iron isotopes. The total amount of iron absorbed from lpa beans and BBs was 421 μg (95% CI: 234, 756 μg) and 431 μg (95% CI: 237, 786 μg), respectively, and did not significantly differ, but was >50% higher (P < 0.005) than from CBs (278 μg; 95% CI: 150, 499 μg). In our trial, the lpa beans were hard to cook, and their consumption caused transient adverse digestive side effects in ∼95% of participants. Gel electrophoresis analysis showed phytohemagglutinin L (PHA-L) residues in cooked lpa beans. In conclusion, BBs and lpa beans provided more bioavailable iron than control beans and could reduce dietary iron deficiency. Digestive side effects of lpa beans were likely caused by PHA-L, but it is unclear to what extent the associated digestive problems reduced iron bioavailability.


The Effects of an Oil and Wheat Flour Fortification Program on Pre-School Children and Women of Reproductive Age Living in Côte d’Ivoire, a Malaria-Endemic Area

Rohner F, Raso G, Aké-Tano SOP, Tschannen AB, Mascie-Taylor CGN, Northrop-Clewes CA

March 2016 – Nutrients

Anemia and micronutrient deficiencies are widespread in sub-Saharan Africa, but the impact of food fortification is still debated. The objective of this study was to estimate the iron and vitamin A status of preschool children (PSC) and women of reproductive age (WRA) in households consuming fortified oil and wheat flour. The survey was cross-sectional in a rural and an urban area. Data on demographics, socioeconomic status, and fortified foods were collected at households. Hemoglobin (Hb), retinol binding protein (RBP), ferritin, soluble transferrin receptors (sTfR), subclinical inflammation, and Plasmodium spp. infection data were collected. In PSC, vitamin A deficiency (VAD) was prevalent, but for each 1 mg retinol equivalents (RE)/kg of oil consumed, RBP increased by 0.37 µmol/L (p = 0.03). In WRA, there was no significant VAD in the population (0.7%). Anemia was found in 92.2% of rural and 56.3% of urban PSC (p < 0.001). PSC with access to adequately fortified flour had Hb concentrations 15.7 g/L higher than those who did not (p < 0.001). Hb levels increased by +0.238 g/L per mg/kg increase in iron fortification levels (p < 0.001). The national program fortifying vegetable oil with vitamin A and wheat flour with iron and folic acid may have contributed to improved micronutrient status of PSC from two areas in Côte d’Ivoire.


Iodine Status of Women of Reproductive Age in Sierra Leone and Its Association with Household Coverage with Adequately Iodized Salt

Rohner F, Wirth JP, Woodruff BA, Chiwile F, Yankson H, Sesay F, Koroma AS, Petry N, Pyne-Bailey S, Dominguez E, Kupka R, Hodges MH, & de Onis M.

February 2016 – Nutrients

Salt iodization programs are a public health success in tackling iodine deficiency. Yet, a large proportion of the world’s population remains at risk for iodine deficiency. In a nationally representative cross-sectional survey in Sierra Leone, household salt samples and women’s urine samples were quantitatively analyzed for iodine content. Salt was collected from 1123 households, and urine samples from 817 non-pregnant and 154 pregnant women. Household coverage with adequately iodized salt (ě15 mg/kg iodine) was 80.7%. The median urinary iodine concentration (UIC) of pregnant women was 175.8 µg/L and of non-pregnant women 190.8 µg/L. Women living in households with adequately iodized salt had higher median UIC (for pregnant women: 180.6 µg/L vs. 100.8 µg/L, respectively, p < 0.05; and for non-pregnant women: 211.3 µg/L vs. 97.8 µg/L, p < 0.001). Differences in UIC by residence, region, household wealth, and women’s education were much smaller in women living in households with adequately iodized salt than in households without. Despite the high household coverage of iodized salt in Sierra Leone, it is important to reach the 20% of households not consuming adequately iodized salt. Salt iodization has the potential for increasing equity in iodine status even with the persistence of other risk factors for deficiency.


Implementation of Multiple Irish Aid-Funded Orange Flesh Sweet Potato Projects

Petry N, Wirth JP, Siddle, B, Gaynor, M.

December 2015 – Sight and Life

Biofortification of sweet potatoes is a promising and sustainable agricultural approach to reduce vitamin A deficiency (VAD), particularly in remote areas where individuals have limited access to commercial markets and mainly rely on household-produced crops. Due to its large genetic variability, its favorable growing characteristics, and the high consumption in remote areas, the orange flesh sweet potato (OFSP) is one of the major targeted crops of biofortification initiatives. OFSP have high concentrations of provitamin A and are the most advanced biofortified crop in terms of research studies demonstrating bioavailability, efficacy, and effectiveness. Irish Aid has provided funding to five projects in Sub-Saharan Africa promoting and disseminating OFSP, a review was undertaken to better understand the common accomplishments and challenges of these five projects in order to identify common factors for success. The review found that the three following components of decentralized vine multiplication systems were indispensable for the successful OFSP projects: 1) growing large quantities of OFSP vines for dissemination by trained decentralized vine multipliers; 2) distributing vines to project farmers; and 3) teaching project farmers in OFSP growing techniques.


Sierra Leone Micronutrient Survey Report

Ministry of Health and Sanitation, UNICEF, WHO, HKI, GroundWork LLC

December 2015 – Report Release, Freetown, Sierra Leone

The 2013 Sierra Leone Micronutrient Survey (SLMS) is the first nationally-representative comprehensive micronutrient survey in Sierra Leone. Conducted by the Ministry of Health and Sanitation and nutrition partners (e.g. UNICEF, WHO, Helen Keller International, and others), the SLMS collected data on micronutrient deficiencies, anemia, and malaria of children <5 years of age, and non-pregnant women 15-49 years of age, and pregnant women. The SLMS was conducted prior to the Ebola outbreak in Sierra Leone, and the information collected by the SLMS will enable the government and international agencies to monitor the current status of national nutrition programs (e.g. salt iodization and vitamin A supplementation) and to plan future nutrition interventions. GroundWork supported the SLMS by designing the survey protocol, developing the questionnaires, training survey staff, analyzing data, and writing the report.


RAIN+ Baseline Survey Report 2015

Concern Worldwide-Zambia, GroundWork LLC

October 2015 – Report Release, Lusaka, Zambia

Concern Worldwide is conducting a second phase of its Realigning Agriculture for Improved Nutrition (RAIN) project in Zambia’s Mumbwa District. This second phase (referred to as RAIN+) aims to improve nutrition and health outcomes for women and young children by providing integrated agriculture, nutrition, health, and women’s empowerment interventions. The objective of the baseline survey was to collect information on priority outcome and output indicators of the RAIN+ project related to agriculture, maternal, infant and young child feeding practices (MIYCF), gender equality, and water, sanitation, and hygiene (WASH). GroundWork supported the RAIN+ baseline survey by designing the survey protocol, training interviewers and supervisors, analyzing the data, and writing the report.


Comparative Validation of Five Quantitative Rapid Test Kits for the Analysis of Salt Iodine Content: Laboratory Performance, User- and Field-Friendliness

Rohner F, Kangambèga MO, Khan N, Kargougou R, Garnier D, Sanou I, Ouaro BD, Petry N, Wirth JP, & Jooste P.

September 2015 – PLOS ONE

To render national salt iodization programs sustainable and ensure adequate iodization levels, simple methods to quantitatively assess whether salt is adequately iodized are required. Several methods claim to be simple and reliable, and are available on the market or are in development. This work has validated the currently available quantitative rapid test kits (quantRTK) in a comparative manner for both their laboratory performance and ease of use in field settings. Laboratory performance parameters (linearity, detection and quantification limit, intra- and inter-assay imprecision) were conducted on 5 quantRTK. We assessed inter-operator imprecision using salt of different quality along with the comparison of 59 salt samples from across the globe; measurements were made both in a laboratory and a field setting by technicians and non-technicians. Most of the devices showed acceptable laboratory performance, but for some of the devices, use by non-technicians revealed poorer performance when working in a routine manner. Of the quantRTK tested, the iCheck1 and I-Reader1 showed most consistent performance and ease of use, and a newly developed paper-based method (saltPAD) holds promise if further developed.


Inflammatory and metabolic responses to high-fat meals with and without dairy products in men

Schmid A, Petry N, Walther B, Bütikofer U, Luginbühl W, Gille D, Chollet M, McTernan PG, Gijs MAM, Vionnet N, Pralong FP, Laederach K, Vergères G

May 2015 – British Journal of Nutrition

Postprandial inflammation is an important factor for human health since chronic low-grade inflammation is associated with chronic diseases. Dairy products have a weak but significant anti-inflammatory effect on postprandial inflammation. The objective of the present study was to compare the effect of a high-fat dairy meal (HFD meal), a high-fat non-dairy meal supplemented with milk (HFM meal) and a high-fat non-dairy
control meal (HFC meal) on postprandial inflammatory and metabolic responses in healthy men. A cross-over study was conducted in nineteen male subjects. Blood samples were collected before and 1, 2, 4 and 6 h after consumption of the test meals. Plasma concentrations of insulin, glucose, total cholesterol, LDL-cholesterol, HDL-cholesterol, TAG and C-reactive protein (CRP) were measured at each time point. IL-6, TNF-a and endotoxin concentrations were assessed at baseline and endpoint (6 h). Time-dependent curves of these metabolic parameters were plotted, and the net incremental AUC were found to be significantly higher for TAG and lower for CRP after consumption of the HFM meal compared with the HFD meal; however, the HFM and HFD meals were not different from the HFC meal. Alterations in IL-6, TNF-a and endotoxin concentrations were not significantly different between the test meals. The results suggest that full-fat milk and dairy products (cheese and butter) have no significant impact on the inflammatory response to a high-fat meal.


Azerbaijan Nutrition Survey Report

UNICEF, Ministry of Health, State Statistical Committee, GroundWork LLC

April 2015 – Report Launch, Baku, Azerbaijan

The 2013 AzNS is the first nationally-representative micronutrient assessment survey in Azerbaijan. Conducted by the Ministry of Health of the Republic of Azerbaijan, the State Statistical Committee of Azerbaijan, and the Azerbaijan office of the United Nations Children’s Fund (UNICEF), the AzNS collected data on anthropometric and micronutrient status of children < 5 years, non-pregnant women 15-49 years, and pregnant women. The AzNS 2013 will provide a baseline assessment for Azerbaijan’s national food fortification programme and other future nutrition programs. GroundWork LLC supported the AzNS by designing the survey protocol, developing the survey questionnaires, training phlebotomists, analyzing data and drafting the report.


The Potential of the Common Bean (Phaseolus vulgaris) as a Vehicle for Iron Biofortification

Petry N, Boy E, Wirth JP, Hurrell RF

February 2015 – Nutrients

Common beans are a staple food and the major source of iron for populations in Eastern Africa and Latin America. Bean iron concentration is high and can be further increased by biofortification. A major constraint to bean iron biofortification is low iron absorption, attributed to inhibitory compounds such as phytic acid (PA) and polyphenol(s) (PP). We have evaluated the usefulness of the common bean as a vehicle for iron biofortification. High iron concentrations and wide genetic variability have enabled plant breeders to develop high iron bean varieties (up to 10 mg/100 g). PA concentrations in beans are high and tend to increase with iron biofortification. Short-term human isotope studies indicate that iron absorption from beans is low, PA is the major inhibitor, and bean PP play a minor role. Multiple composite meal studies indicate that decreasing the PA level in the biofortified varieties substantially increases iron absorption. Fractional iron absorption from composite meals was 4%–7% in iron deficient women; thus the consumption of 100 g biofortified beans/day would provide about 30%–50% of their daily iron requirement. Beans are a good vehicle for iron biofortification, and regular high consumption would be expected to help combat iron deficiency (ID).


Phytic Acid Concentration Influences Iron Bioavailability from Biofortified Beans in Rwandese Women with Low Iron Status

Petry N, Egli I, Gahutu JB, Tugirimana PL, Boy E, Hurrell RF

September 2014 – Journal of Nutrition

The common bean is a staple crop in many African and Latin American countries and is the focus of biofortification initiatives. Bean iron concentration has been doubled by selective plant breeding, but the additional iron is reported to be of low bioavailability, most likely due to high phytic acid (PA) concentrations. To evaluate the impact of PA on iron bioavailability from iron-biofortified beans, a multiple-meal iron absorption crossover study was conducted in Rwandese women. Iron absorption was based on the erythrocyte incorporation of stable iron isotopes, and meals contained biofortified beans and control beans; beans tested either contained their native PA concentration and were dephytinized at ∼50% and >95%. The quantity of iron absorbed from the biofortified bean meals (406 μg) was 19% higher (P < 0.05) than that from the control bean meals. With ∼50% and >95% dephytinization, the quantity of iron absorbed from the biofortified bean meals increased to 599 and 746 μg, respectively, which was 37% (P < 0.005) and 51% (P < 0.0001) higher than from the control bean meals. PA strongly decreases iron bioavailability from iron-biofortified beans, and a high PA concentration is an important impediment to the optimal effectiveness of bean iron biofortification. Plant breeders should focus on lowering the PA concentration of high-iron beans.


Vitamin D status and associated factors of deficiency among Jordanian children of preschool age

Nichols EK, Khatib IM, Aburto NJ, Serdula MK, Scanlon KS, Wirth JP, Sullivan KM

September 2014 – European Journal of Clinical Nutrition

Vitamin D deficiency in children remains a global concern. Although literature exists on the vitamin D status and its risk factors among children in the Middle East, findings have yielded mixed results, and large, representative community studies are lacking. In a nationally representative survey of 1077 Jordanian children of preschool age (12-59 months) in Spring 2010, we measured 25(OH)D3 concentrations by liquid chromatography-tandem mass spectrometry and calculated prevalence ratios for deficiency associated with various factors. Results showed 19.8% deficiency (<12 ng/ml) and 56.5% insufficiency (<20 ng/ml). In adjusted models, prevalence of deficiency was higher for females compared with males and lower for children 24-35 months of age compared with children 12-23 months of age. In rural areas, there was no difference in prevalence of vitamin D deficiency between those whose mothers had/did not have vitamin D deficiency (P=0.312); however, in urban areas, prevalence of vitamin D deficiency was 3.18 times greater among those whose mothers were vitamin D deficient compared with those whose mothers were not deficient (P=0.000). Vitamin D deficiency and insufficiency pose significant public health problems in Jordanian children with female children disproportionately affected. Strong associations between vitamin D status in children and urban residency and maternal vitamin D status suggest that the behaviors related to sun exposure in urban mothers likely also affect the sun exposure and thus vitamin D status of their children.


Iron Speciation in Beans (Phaseolus vulgaris) Biofortified by Common Breeding

Hoppler M, Egli I, Petry N, Gille D, Zeder C, Walczyk T, Blair MW, and Hurrell RF.

August 2014 – Journal of Food Science

With the aim of evaluating the potential of ferritin iron in plant breeding, we used species-specific isotope dilution mass spectrometry to quantify ferritin iron in bean varieties with a wide range of total iron content. Zinc, phytic acid, and polyphenols were also measured. Total iron concentration in 21 bean varieties ranged from 32 to 115 ppm and was positively correlated with concentrations of zinc (P = 0.001) and nonferritin bound iron (P < 0.001). Ferritin iron ranged from 13% to 35% of total iron and increased only slightly in high iron beans (P = 0.007). Concentrations of nonferritin bound iron and phytic acid were correlated (P = 0.001), although phytic acid:iron molar ratio decreased with increasing iron concentration (P = 0.003). Most iron in high iron beans was present as nonferritin bound iron, which confirms our earlier finding showing that ferritin iron in beans was lower than previously published. As the range of ferritin iron content in beans is relatively narrow, there is less opportunity for breeders to breed for high ferritin. The relevance of these findings to the extent of iron absorption depends on resolving the question of whether ferritin iron is absorbed or not to a greater extent than nonferritin bound iron.

IDD Newsletter_2014

Iodine biomarkers: a new interactive web interface

Raghavan R, Rohner F, Raiten DJ

August 2014 – IDD Newsletter

The Biomarkers of Nutrition for Development (BOND) project began in 2010 to improve data on micronutrient deficiencies and to facilitate the assessments of micronutrient deficiencies globally. One of the important objectives of the BOND project is to translate the existing evidence from expert panels to the wider audience through the BOND website. In an effort to disseminate information to organizations and professionals addressing iodine deficiency, BOND recently released the Iodine Query Based System – an interactive tool that advises users on the most appropriate biomarkers depending on their specific needs. In addition to recommending an iodine biomarker, the QBS informs users of lab methods and cut-off values for a given biomarker. In the future, BOND will launch similar query systems for folate, zinc, iron, vitamin A, and vitamin B12.


Biomarkers of Nutrition for Development—Iodine Review

Rohner F, Zimmermann M, Jooste P, Pandav C, Caldwell K, Raghavan R, Raiten DJ.

August 2014 – Journal of Nutrition

In phase I of the Biomarkers of Nutrition for Development (BOND) project, 6 nutrients (iodine, vitamin A, iron, zinc, folate, and vitamin B-12) were selected for their high public health importance because they typify the challenges faced by users in the selection, use, and interpretation of biomarkers. For each nutrient,an expert panel was constituted and charged with the development of a comprehensive review covering the respective nutrients biology, existing biomarkers, and specific issues of use with particular reference to the needs of the individual user groups. This review represents the first in the series of reviews and covers all relevant aspects of iodine biology and biomarkers. The article is organized to provide the reader with a full appreciation of iodines background history as a public health issue, its biology, and an overview of available biomarkers and specific considerations for the use and interpretation of iodine biomarkers across a range of clinical and population-based uses. The review also includes a detailed research agenda to address priority gaps in our understanding of iodine biology and assessment.


Micronutrient status in Jordan: 2002 and 2010

Serdula M, Nichols EK, Aburto NJ, Masa’d H, Obaid B, Wirth JP, Tarawneh M, Barham R, Hijawi B, Sullivan KM, and the Jordan Fortification Working Group

July 2014 – European Journal of Clinical Nutrition

Two national surveys were conducted in Jordon in 2002 and 2010 to investigate the micronutrient status in women and children. To determine the prevalence of anemia, iron and folate deficiency among women and children in 2010 and compare with the prevalence of anemia and iron deficiency in 2002. Venous blood samples were used to measure hemoglobin, ferritin and red blood cell folate. Among women in 2010, the prevalence of folate deficiency and insufficiency was 13.6% and 82.9%, respectively. Geometric mean serum ferritin was higher in 2010 compared with 2002 (21.3 ng/ml vs 18.3, P=0.01); there was no significant change in the prevalence of iron deficiency (35.1% vs 38.7%, P=0.17), iron deficiency anemia (19.1% vs 20.0%, P=0.61) or anemia (29.2% vs 29.3%, P=0.96). Among children, a significantly lower prevalence was observed in 2010 compared with 2002 for iron deficiency (13.7% vs 26.2% P<0.001) and iron deficiency anemia (4.8% vs 10.1%, P<0.001); a nonsignificant lower prevalence was observed for anemia (16.6% vs 20.2%, P=0.09). In 2010, approximately one of seven women was folate deficient and six out of seven were folate insufficient for the prevention of neural tube defects. Between 2002 and 2010, significant improvement was observed in the prevalence of iron deficiency in children, but not in women.


Polyphenols and Low Iron Bioavailability

Petry N

January 2014 – Polyphenols in Human Health and Disease

The negative impact on iron bioavailability from plant-based foods has largely been demonstrated in humans by iron isotope absorption studies, although their impact on the human iron status is still unclear.High concentrations of polyphenols can be found in numerous vegetables, legumes, fruits and beverages. It is commonly assumed that, depending on their structure, polyphenols form insoluble complexes with iron in the gut and thereby inhibit its absorption. However, the complex formation of polyphenols and iron depends not only on polyphenol structure, but also on pH and the concentration of polyphenols and iron in the solution. Both vitamin C and EDTA (although the latter to a lesser extent) have been shown to protect iron against complex formation with polyphenols and increase its absorption. This chapter studies the negative and positive health aspects of polyphenols on iron absorption and their consequences, by discussing the results of both single and multiple meal studies in an effort to measure the impact of polyphenols on iron absorption.


External Mill Monitoring of Wheat Flour Fortification Programs: An Approach for Program Managers Using Experiences from Jordan

Wirth JP, Nichols E, Masa’d H, Barham R, Johnson QJ, Serdula M.

November 2013 – Nutrients

The fortification of wheat flour with micronutrients is a common strategy to increase vitamin and mineral intake. While wheat flour mills are often inspected by agencies affiliated with national ministries to ensure compliance with national fortification standards, few countries use data derived from these inspections to construct an external monitoring system for use in program management and evaluation. This paper assesses the performance of the external monitoring system utilized in Jordan according to the US Centers for Disease Control and Prevention’s Updated Guidelines for Evaluating Public Health Surveillance Systems. The review concludes that the data required for the system is representative, simple to collect, and can be collected in a flexible manner. The external monitoring system is acceptable to participating agencies and millers and is stable due to mandatory fortification legislation which provides the legal framework for external monitoring. Data on production of fortified flour and utilization of premix can be provided in a timely manner, but on-site mill monitoring and flour sample collection are more challenging due to resource constraints. The frequent collection of a small number of indicators can provide fortification program managers with timely information with which to base decisions. Jordan’s external monitoring system successfully documented the performance of each mill and the entire flour fortification program, and can serve as a model for other national fortification programs considering external monitoring approaches.


Prevalence and public health relevance of micronutrient deficiencies and undernutrition in pre-school children and women of reproductive age in Côte d’Ivoire, West Africa

Rohner F, Northrop-Clewes C, Tschannen AB, Bosso PE, Kouassi-Gohou V, Erhardt JG, Bui M, Zimmermann MB, and Mascie-Taylor CGN.

September 2013 – Public Health Nutrition

To understand the prevalence and magnitude of nutritional deficiencies pre-school age children (pre-SAC) and non pregnant women of reproductive age (WRA) in Côte d’Ivoire, a national cross-sectional survey assessing maco/micronutrient status and infection (e.g. malaria) was conducted. In pre-SAC, anaemia was classified as a severe public health problem (72%), and was higher in rural areas (76 %) and the north (87 %). A quarter of pre-SAC suffered from vitamin A deficiency (inflammation-adjusted) and prevalence of undernutrition (assessed by stunting, wasting and underweight) was high. The prevalence of inflammation (67%) and malaria parasites (25%) were also of concern. In WRA, prevalence of malaria parasites (5 %) was low, but inflammation (34 %) was higher. Anaemia was a severe public health problem and prevalence differed by residency and eco-region. Inflammation-adjusted Fe deficiency was highest in urban areas (20 %). Nationally, folate deficiency was 86 %, higher in urban areas and varied by eco-region. Prevalence of vitamin B12 deficiency was low but higher in the rural areas and the north. Inflammation adjusted vitamin A deficiency was very low (1 %). Prevalence of inflammation, malaria parasites and micronutrient deficiencies were high in Côte d’Ivoire, particularly in pre-SAC. Nutritional interventions should be accompanied by strategies to reduce exposure to infections.


Genetic Reduction of Phytate in Common Bean (Phaseolus vulgaris L.) Seeds Increases Iron Absorption in Young Women

Petry N, Egli I, Campion B, Nielsen E, and Hurrell R.

July 2013 – Journal of Nutrition

Iron bioavailability from common beans is negatively influenced by phytic acid and polyphenols. Newly developed low-PA (lpa) beans with 90% less PA and variable PPs might improve iron bioavailability. The aim of this study was to evaluate the influence of lpa beans on iron bioavailability in women (n = 20). We compared iron absorption from 4 different beans using a paired, double meal, crossover design. Iron absorption was measured as erythrocyte incorporation of stable iron isotopes from 2 lpa bean lines, one high in PPs and one low in PPs. The other 2 beans used were their parents with a normal PA concentration, one high in PPs and one low in PPs. Fractional iron absorption from the lpa bean high in PPs was 6.1%, which was 60 and 130% higher compared with the parent high in PPs (P < 0.001) and low in PPs (P < 0.001), respectively. The total amount of iron absorbed per test meal from the lpa bean high in PPs (372 μg) was 60 and 163% higher compared with the parent high in PPs (P < 0.001) and low in PPs (P < 0.001), respectively. Fractional iron absorption from the lpa line low in PPs (4%) was 50% higher and the total amount of iron absorbed per test meal (261 μg) was 85% higher than iron from the parent low in PPs (P < 0.001). There was no difference between the lpa beans high or low in PPs or between the parents high or low in PPs. A 90% reduction in PA leads to an increase in bioavailable iron from beans, independent of the PP concentration. The lpa mutation could be a key tool for improving iron bioavailability from beans.

FNB June 2013

Infant and young child feeding practices in urban Philippines and their associations with stunting, anemia, and deficiencies of iron and vitamin A

Rohner F, Woodruff BA, Aaron GJ, Yakes EA, Lebanan MA, Rayco-Solon P, and Saniel OP.

June 2013 – Food and Nutrition Bulletin

To improve the understanding of contributors associated with the nutritional status of children 6 to 23 months of age living in urban areas of the Philippines, a cross-sectional survey was conducted covering five urban centers in the Philippines. Data on infant and young child feeding and nutritional status (including wasting, stunting, underweight, anemia, iron deficiency, and vitamin A deficiency) were collected for 1,784 children. Among children from urban and predominantly poor and very poor households, 26% were stunted, 18% were underweight, and 5% were wasted. Forty-two percent were anemic, 28% were iron deficient, and 3% were vitamin A deficient. About half of the children were breastfed within an hour after birth, were breastfed at the time of the survey, and had been continuously breastfed up to 1 year of age. Of the factors investigated, low socio-economic status, use of cheaper cooking fuel, and nonuse of multivitamins were all independently associated with stunting. The prevalence of anemia, iron deficiency, and vitamin A deficiency were independently associated with the same factors and poorer sanitation facilities, lower maternal education, current unemployment, and inflammation. These factors merit attention in future programming, and interventions may include promotion of the timely introduction of appropriate fortified complementary foods, the use of affordable multiple micronutrient preparations, and measures to reduce infection.


Anaemia in infancy in rural Bangladesh: contribution of iron deficiency, infections and poor feeding practices

Rawat R, Saha KK, Kennedy A, Rohner F, Ruel M, Menon P.

June 2013 – British Journal of Nutrition

Few data exist on the aetiology of anaemia and iron deficiency (ID) during early infancy in South Asia. The present study aimed to determine the contribution of ID, infections and feeding practices to anaemia in Bangladeshi infants aged 6-11 months. Multivariate logistic regression was used to identify risk factors for anaemia and ID, and population attributable fractions (PAF) were computed to estimate the proportion of anaemia that might be prevented by the elimination of individual risk factors. It was found that 68 % of the infants were anaemic, 56 % were Fe deficient, and one-third had evidence of subclinical infections. ID and subclinical infections were major risk factors for anaemia, in addition to age and male sex. Similarly, subclinical infections, age and male sex were significant risk factors for ID. Previous-day consumption of Fe-rich foods was very low and not associated with anaemia or ID. The PAF of anaemia attributable to ID was 67 % (95 % CI 62, 71) and that of subclinical infections was 16 % (95 % CI 11, 20). These results suggest that a multipronged strategy that combines improvements in dietary Fe intake alongside infection control strategies is needed to prevent anaemia during infancy in Bangladesh.

Retinol-RBP Poster-Hidden Hunger-March 2013

Are analytical differences the reason for discrepancies between the absolute values of retinol and retinol-binding protein in human serum?

Erhardt JG and Rohner F

March 2013, Poster Presentation – International Congress on Hidden Hunger, Stuttgart, Germany

The WHO estimates that vitamin A (VA) deficiency globally affects over 190 million preschool age children. A reliable measurement of the VA status is thus essential to determine the public health relevance of VA deficiency and to assess the impact of interventions aiming to reduce VA deficiency. The currently most common VA assessment method is serum retinol by HPLC, but the measurement of retinol-binding protein (RBP) is gaining importance. It can be measured much more efficiently and easily combined with indicators for the iron and infectious status. Yet, to date, there is still uncertainty whether the absolute values of both measurements are directly comparable, and varying thresholds for defining VA deficiency are proposed. The results of this study indicate that the often observed differences between the absolute values of RBP and retinol are caused by analytical differences and can be minimized by using the same calibrators for both methods. This calls for caution prior to establishing separate thresholds for RBP and retinol, as this may induce confusion within the program managers implementing VA interventions in developing countries.

FNB_Dec 2012 suppl cover

Lessons learned from national food fortification projects: Experiences from Morocco, Uzbekistan, and Vietnam

Wirth J, Laillou A, Rohner F, Northrop-Clewes C, Macdonald B, and Moench-Pfanner R

December 2012, Food and Nutrition Bulletin

Fortification of staple foods has been repeatedly recommended as an effective approach to reduce micronutrient deficiencies. With the increased number of fortification projects globally, there is a need to share practical lessons learned relating to their implementation and responses to project-related and external challenges. In this regards, the achievements, challenges, lessons learned, and management responses associated with national fortification projects in Morocco, Uzbekistan, and Vietnam were documented, utilizing independent end-of-project evaluations reports, national policy documents, project reports from the Global Alliance for Improved Nutrition (GAIN) and other stakeholders, industry assessments, and peer reviewed articles, were used to document the current responses to challenges and future project plans. All projects had key achievements related to the development of fortification standards and the procurement of equipment for participating industry partners. Mandatory fortification of wheat flour was a key success in Morocco and Uzbekistan. Ensuring the quality of fortified foods was a common challenge experienced across the projects, as were shifts in consumption patterns and market structures. Adjustments were made to the projects’ design to address the challenges faced.

FNB_Dec 2012 suppl cover

Validation of a user-friendly and rapid method for quantifying iodine content of salt

Rohner F, Garrett G, Laillou A, Frey S, Mothes R, Schweigert F, and Locatelli-Rossi L

December 2012, Food and Nutrition Bulletin

Despite considerable progress made in the past decade through salt iodization programs, over 2 billion people worldwide still have inadequate iodine intake, with devastating consequences for brain development and intellectual capacity. To optimize these programs with regard to salt iodine content, careful monitoring of salt iodine content is essential, but few methods are available to quantitatively measure iodine concentration in a simple, fast, and safe way.  To address this gap, the validation of a newly developed device that quantitatively measures the content of potassium iodate in salt in a simple, safe, and rapid way was assessed by examined independently and in comparison with iodometric titration, using salt samples from several countries. Comparison with the iodometric method showed high agreement between the methods (R2 = 0.978; limits of agreement, –10.5 to 10.0 mg/kg). Therefore, the device offers a field- and user-friendly solution to quantifying potassium iodate salt content reliably. For countries that use potassium iodide in salt iodization programs, further validation is required.


Improvement of the Vietnamese Diet for Women of Reproductive Age by Micronutrient Fortification of Staples Foods and Condiments

Laillou A, Berger J, Le BM, Pham VT, Le TH, Nguyen CK, Panagides D, Rohner F, Wieringa F, Moench-Pfanner R.

November 2012, PLoS One

A micronutrient survey carried out in 2010 among randomly selected Vietnamese women in reproductive age indicated that anemia and micronutrient deficiencies are still prevalent. The objective of this study was thus to analyze the dietary micronutrient intakes of these women, to select the food vehicles to be fortified and to calculate their contributions to meet the recommended nutrient intake (RNI) for iron, zinc, vitamin A and folic acid. Consumption data showed that the median intake was 38.4% of the RNI for iron, 61.1% for vitamin A and 91.8% for zinc. However, more than 50% of the women had daily zinc consumption below the RNI. Rice and vegetable oil were consumed daily in significant amounts (median: 320.4 g/capita/day and 8.6 g/capita/day respectively) by over 90% of the women, making them suitable vehicles for fortification. Based on consumption data, fortified vegetable oil could contribute to an additional vitamin A intake of 27.1% of the RNI and fortified rice could increase the intake of iron by 41.4% of the RNI, zinc by 15.5% and folate by 34.1%. Other food vehicles, such as fish and soy sauces and flavoring powders, consumed respectively by 63% and 90% of the population could contribute to increase micronutrient intakes if they are properly fortified and promoted. Wheat flour was consumed by 39% of the women and by less than 20% women from the lowest socioeconomic strata. Therefore, the fortification of edible vegetable oils with vitamin A and of rice with iron, zinc and folic acid are the most promising fortification strategies to increase micronutrient intakes of women in reproductive age in Vietnam.

FNB Sept 2012 regular issue cover

Performance of iron spot test with Arabic bread made from fortified white wheat flour.

Nichols E, Aburto N, Masa’d H, Wirth J, Sullivan K, Serdula M.

September 2012, Food and Nutrition Bulletin

The iron spot test (IST) is a simple qualitative technique for determining the presence of added iron in fortified flour. IST performance in bread has never been investigated. If found to perform well, the IST has the potential to provide a field-friendly method for testing bread and thus support the monitoring and evaluation of flour fortification programs. To assess the performance of the IST in Arabic bread made from white wheat flour, bread samples were collected from 1,737 households during a national micronutrient survey in Jordan. A subsample of Arabic bread (n = 44) was systematically selected for testing by both the IST and spectrophotometry (criterion reference). Performance measures (sensitivity, specificity, and positive and negative predictive values) were calculated using five cutoffs to define the presence of added iron, including ≥ 15.0 ppm (approximate level of natural iron in Arabic bread) and four additional cutoffs based on test performance. The iron contents of samples testing negative by IST ranged from 10.4 to 18.4 ppm, with one outlier at 41.0 ppm, which was excluded from subsequent analyses. The iron contents of samples testing positive by IST ranged from 16.1 to 38.4 ppm. With the exception of negative predictive values for the two lowest cutoffs (≥ 15.0 and ≥ 16.1 ppm), all performance measures exceeded 83.3%. These results show promise for the IST as an inexpensive, field-friendly method for testing bread that could have a useful role in the monitoring and evaluation process for flour fortification programs.

FNB Sept 2012 regular issue cover

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

Laillou A, Hafez SA, Mahmoud AH, Mansour M, Rohner F, Fortin S, Berger J, Ibrahim NA, and Moench-Pfanner R.

September 2012, Food and Nutrition Bulletin

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. To estimate vitamin A losses in oil with different chemical characteristics, samples of fortified oils with different chemical characteristics were collected from two Egyptian companies (oil A and B) and stored for 1 month. Vitamin A levels were analyzed periodically during storage to determine losses over time, and peroxide values were determined. 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 semi-dark 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). Based on these results, the 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 peroxide level to less than 2 mEq/kg at production.


Applying Dietary Assessment Methods for Food Fortication and Other Nutrition Programs

Coates J, Colaiezzi B, Fiedler J, Wirth J, Lividini K, Rogers B.

September 2012, GAIN Working Paper Series

Dietary assessment data are essential for designing, implementing and evaluating food fortification and other food-based nutrition programs. Planners and managers must understand the validity, usefulness and cost tradeoffs of employing alternative dietary assessment methods to obtain requisite programming information, but little guidance exists for doing so. This paper strives to fill this gap in the literature while providing practical guidance to inform programming decisions. Twenty-five semi-structured expert interviews were conducted and literature reviewed for scientific and operational information on four of the most common dietary assessment methods used in nutrition programming: Twenty-four hour recall (24HR), Food Frequency Questionnaires/Fortification Rapid Assessment Tool (FFQ/FRAT), Food Balance Sheets (FBS), and Household Consumption and Expenditure Surveys (HCES).

FNB Sept 2012 suppl cover

A program needs-driven approach to selecting dietary assessment methods for decision-making in food fortification programs


September 2012, Food and Nutrition Bulletin

Dietary assessment data are essential for designing, monitoring, and evaluating food fortification and other food-based nutrition programs. Planners and managers must understand the validity, usefulness, and cost tradeoffs of employing alternative dietary assessment methods, but little guidance exists. To assess the tradeoffs of using alternative dietary methods for food fortification programming, twenty-five semistructured expert interviews were conducted and literature was reviewed for information on the validity, usefulness, and cost of using 24-hour recalls, Food Frequency Questionnaires/ Fortification Rapid Assessment Tool (FFQ/FRAT), Food Balance Sheets (FBS), and Household Consumption and Expenditures Surveys (HCES) for program stage-specific information needs. Criteria were developed and applied to construct relative rankings of the four methods. The following results were identified: Needs assessment: HCES offers the greatest suitability at the lowest cost for estimating the risk of inadequate intakes, but relative to 24-hour recall compromises validity. Design: HCES should be used to identify vehicles and to estimate coverage and likely impact due to its low cost and moderate-to-high validity. Baseline assessment: 24-hour recall should be applied using a representative sample. Monitoring: A simple, low-cost FFQ can be used to monitor coverage. Impact evaluation: 24-hour recall should be used to assess changes in nutrient intakes. FBS have low validity relative to other methods for all programmatic purposes.


Vitamin D status and determinants of deficiency among non-pregnant Jordanian women of reproductive age.


June 2012, European Journal of Clinical Nutrition

While sunlight is an important vitamin D source, previous investigations among women whose culture encourages skin covering have been small, not nationally representative, or both. We investigated serum 25-hydroxyvitamin D (25(OH)D(3)) status and factors associated with deficiency in a nationally representative survey of 2013 Jordanian women of reproductive age in Spring 2010. We measured 25(OH)D(3) concentrations by liquid chromatography-tandem mass spectrometry and calculated prevalence ratios for deficiency associated with skin covering and other factors. Results showed 60.3% (95% CI: 57.1-63.4%) deficiency (12 ng/ml) and 95.7% (95% CI: 94.4-96.8%) insufficiency (20 ng/ml) among women. Prevalence of deficiency was 1.60 times higher for women who covered with a scarf/hijab (95% CI: 1.06-2.40, P = 0.024) and 1.87 times higher for women who wore full cover, or a niqab (95% CI: 1.20-2.93, P = 0.006), compared with the women who did not wear a scarf/hijab or niqab.


Comparison of a possession score and a poverty index in predicting anaemia and undernutrition in pre-school children and women of reproductive age in rural and urban Côte d’Ivoire.


June 2012, Public Health Nutrition

This article determines whether a possession score or a poverty index best predicts undernutrition and anaemia in women of reproductive age (15-49 years; WRA) and children aged 6-59 months living in Côte d’Ivoire. These socio-economic measures were compared for their ability to predict anaemia and malnutrition in women and children. Using data from a nationally representative survey conducted in Côte d’Ivoire in 2007, the poverty index showed a stronger relationship with nutritional status than the possession score; mean Hb difference between the poorest and wealthiest quintiles in children and WRA was 8·2 g/l and 6·5 g/l, respectively (13·9 % and 19·8 % difference in anaemia, respectively; P < 0·001), and Z-scores and BMI were significantly better in the wealthiest quintile (P < 0·001).


Mapping malaria risk among children in Cote d’Ivoire using Bayesian geo-statistical models.


May 2012, Malaria Journal

Using different data sources, a systematic review was carried out to compile and georeference survey data on Plasmodium spp. infection prevalence in Cote d’Ivoire, focusing on children aged 16 years. The period from 1988 to 2007 was covered. A suite of Bayesian geo-statistical logistic regression models was fitted to analyse malaria risk. High-risk areas were mainly found in the north-central and western area, while relatively low-risk areas were located in the north at the country border, in the northeast, in the south-east around Abidjan, and in the central-west between two high prevalence areas. The malaria risk map at high spatial resolution gives an important overview of the geographical distribution of the disease in Cote d’Ivoire. It is a useful tool for the national malaria control programme and can be utilized for spatial targeting of control interventions and rational resource allocation.


Micronutrient Deficits Are Still Public Health Issues among Women and Young Children in Vietnam


April 2012, PLoS ONE

As no national data existed on the prevalence of micronutrient deficiencies, a survey was conducted in 2010 to assess the micronutrient status of randomly selected women of reproductive age (n=1526) and children aged 6–75 months (n=586). In women, according to international thresholds, prevalence of zinc deficiency (ZnD, 67.2±2.6%) and vitamin B12 deficiency (11.7±1.7%) represented public health problems, whereas prevalence of anemia (11.6±1.0%) and iron deficiency (ID, 13.7±1.1%) were considered low, and folate (3%) and vitamin A (VAD, 2%) deficiencies were considered negligible. However, many women had marginal folate (25.1%) and vitamin A status (13.6%). Moreover, overweight (BMI≥23 kg/m2 for Asian population) or underweight occurred in 20% of women respectively highlighting the double burden of malnutrition. In children, a similar pattern was observed for ZnD (51.9±3.5%), anemia (9.1±1.4%) and ID (12.9±1.5%) whereas prevalence of marginal vitamin A status was also high (47.3±2.2%). There was a significant effect of age on anemia and ID prevalence, with the youngest age group (6–17 mo) having the highest risk for anemia, ID, ZnD and marginal vitamin A status as compared to other groups. Though the prevalence of anemia and ID in Vietnam has been markedly reduced over the last decade, a large part of the population is still at risk for other deficiencies such as zinc, vitamin A, folate and vitamin B12 especially the youngest children aged 6–17 mo.


Quantification of vitamin A in palm oil using a fast and simple portable device: method validation and comparison to high-pressure liquid chromatography.


September 2011, International Journal for Vitamin and Mineral Research

Vitamin A deficiency continues to be a global public health problem. Fortification of oil with vitamin A is considered a cost-effective, feasible strategy to prevent this problem but quality control poses a challenge to program implementation. To overcome this, we have validated a newly developed device that quantitatively measures the content of retinyl palmitate in refined palm oil, is simple to use, and yields immediate results.Linearity of analysis ranged from 2.5 – 30 mg retinol equivalents (RE)/ kg of palm oil, with 2.5 mg RE/kg being the determination limit; inter- and intra-assay precision ranged from 1.4 – 7.1 %. Comparison with a high-performance liquid chromatography method showed high agreement between the methods (R(2) = 0.92; Limits of Agreement: -1.24 mg to 2.53 mg RE/kg), and further comparisons illustrate that the new device is useful in low-resource settings. This device offers a field- and user-friendly solution to quantifying the vitamin A content in refined palm oil.