Background/Objectives: Dietary diversity is associated with overall quality and nutrient adequacy of the diet in low-income countries. We determined the association between dietary diversity and ...stunting among children aged 6–59 months in rural Bangladesh. Subjects/Methods: In total, 165 111 under-fives who participated in the National Surveillance Project in 2003–2005 were included in the analysis. Dietary diversity score (DDS) was constructed through the summation of the number of days each of the nine food groups was consumed in the previous week. The association between stunting and DDS was determined adjusting for confounders using logistic regression models. All analyses were performed separately for children aged 6–11, 12–23 and 24–59 months. Results: One-half of the children were stunted. In multivariate analyses, compared with low DDS, high dietary diversity was associated with a 15, 26 and 31% reduced odds of being stunted among children aged 6–11, 12–23 and 24–59 months, respectively, after adjusting for all potential confounders (odds ratio (OR)=0.85, 95% confidence interval (CI): 0.76–0.94; OR=0.74, 95% CI: 0.69–0.79; OR=0.69, 95% CI: 0.66–0.73). In all groups, children who were still breastfed were more likely to have limited diversity (OR=1.88, 95% CI: 1.32–2.67; OR=1.71, 95% CI: 1.52–1.92; OR=1.15, 95% CI: 1.11–1.19). Those having diarrhea in the past week and coming from families with low socioeconomic status were more likely to have decreased diversity (P<0.05). Conclusions: Reduced dietary diversity is a strong predictor of stunting in rural Bangladesh. The inclusion of a variety of food groups into complementary foods may be essential to improve child nutritional status.
Two biochemical indicators are currently recommended for determining whether vitamin A deficiency (VAD) is a public health problem: serum retinol and serum retinol-binding protein (RBP). After ...consideration of 40 data sets and the original rationale for previously proposed cut-offs, a cut-off for serum retinol concentration was proposed at <0.70 μmol/L (20 μg/dL) in ≥15% of the sampled population. This cut-off should be applied to a representative group of preschool age children (6–71 mo). Because measurement of low serum retinol concentrations requires high precision, analysis should be done by HPLC. For serum RBP, a cut-off cannot be reliably specified, because available data are too few and too variable. However, because serum RBP concentration correlates well with serum retinol concentration, it can be used to determine whether VAD is a public health problem in those populations for which the relationship between serum concentrations of retinol and RBP have been established. More efforts to establish a reliable cut-off for RBP is warranted, because analysis, in particular radial immunodiffusion (RID), is relatively simple and inexpensive. Whereas HPLC and RID analyses must be done in a laboratory, methods are being developed for assessing serum retinol and RBP under more remote conditions. J. Nutr. 132: 2895S–2901S, 2002.
BACKGROUND: In-home fortification of complementary foods with micronutrient powders containing low amounts of iron may be potentially safer than powders containing high amounts of iron. However, low ...iron doses have little nutritional effect, unless iron absorption is high. OBJECTIVE: The objective was to maximize iron absorption from a low-iron micronutrient powder for in-home fortification by testing combinations of iron as NaFeEDTA, ascorbic acid, and a microbial phytase active at gut pH. In addition, a recently proposed enhancer of iron absorption, L-α-glycerophosphocholine (GPC), was tested. DESIGN: In 6 separate iron-absorption studies using a crossover design, women (n = 101) consumed whole-maize porridge fortified with 3 mg stable isotope-labeled FeSO₄ or NaFeEDTA with different combinations of enhancers added to the meals at the time of consumption. Incorporation of iron isotopes into erythrocytes 14 d later was measured. RESULTS: The addition of phytase when iron was present as either NaFeEDTA or FeSO₄, with or without ascorbic acid, significantly increased iron absorption. The combined addition of phytase, ascorbic acid, and NaFeEDTA resulted in an absorption of 7.4%, compared with an absorption of 1.5% from FeSO₄ without enhancers in the same meal (P < 0.001). The addition of ascorbic acid did not significantly increase iron absorption from NaFeEDTA, and the addition of calcium did not significantly inhibit iron absorption from NaFeEDTA in the presence of ascorbic acid. The addition of L-α-glycerophosphocholine did not significantly increase iron absorption. CONCLUSION: Optimization of the micronutrient powder increased iron absorption from a highly inhibitory meal almost equal to5-fold. This approach may allow for effective, untargeted in-home fortification of complementary foods with low amounts of highly bioavailable iron.
Objective: High prevalences of vitamin A deficiency and anaemia among adolescents warrant interventions. This study evaluated the effectiveness of school-based supplementation to reduce anaemia and ...improve vitamin A status. Design: School-based, grade-randomized, intervention. Subjects and setting: In all, 1757 girls and 1859 boys, aged 12-15 y, in 24 Junior High Schools. Interventions: Weekly supplementation for 14 weeks with 60 mg iron and 250 microgram folate (Fe group; n=978), 10 000 IU vitamin A (VA group; n=970) or both (VAFe group; n=1042) to subjects in 15 schools, compared to subjects in nine other schools not receiving supplements (control; n=626). Results: The baseline anaemia prevalence (Hb <120 g/l) in girls was 20% (prepubertal) and 26% (pubertal), and in boys 24% (pre-pubertal) and 11% (pubertal). Serum retinol concentrations were low (<1.05 micromol/l) in 41% of boys and 45% of girls. The interventions did not increase haemoglobin concentrations. Serum retinol concentration of boys, but not girls, in the VA group increased (0.33 vs 0.07 micromol/l in controls; P<0.01). The risk factors for low serum retinol concentration were lower baseline serum retinol concentration (OR 0.02-0.03) with, for girls, nightblindness at baseline (OR 5.88), and for boys, not receiving vitamin A (OR control: 1.00; VA: 0.37; Fe: 0.77; VAFe: 0.34) and maternal illiteracy (OR mother never attended school 1.00, mother received any formal education 0.17-0.33). Conclusions: Supplementation with vitamin A increased serum retinol concentration of boys. Iron supplementation did not change Hb. This appeared to be due to poor compliance, and partly related to side effects.
Summary
There is little evidence to support the general assumption that dietary carotenoids can improve vitamin A status. We investigated in Bogor District, West Java, Indonesia, the effect of an ...additional daily portion of dark-green leafy vegetables on vitamin A and iron status in women with low haemoglobin concentrations (<130 g/L) who were breastfeeding a child of 3-17 months.
Every day for 12 weeks one group (n=57) received stirfried vegetables, a second (n=62) received a wafer enriched with β-carotene, iron, vitamin C, and folic acid, and a third (n=56) received a non-enriched wafer to control for additional energy intake. The vegetable supplement and the enriched wafer contained 3·5 mg β-carotene, 5·2 mg and 4·8 mg iron, and 7·8 g and 4·4 g fat, respectively. Assignment to vegetable or wafer groups was by village. Wafers were distributed double-masked. In the enriched-wafer group there were increases in serum retinol (mean increase 0·32 95% Cl 0·23-0·40 μmol/L), breastmilk retinol (0·59 0·35-0·84 μmol/L), and serum β-carotene (0·73 0·59-0·88 μmol/L). These changes differed significantly from those in the other two groups, in which the only significant changes were small increases in breastmilk retinol in the control-wafer group (0·16 0·02-0·30 μmol/L) and in serum β-carotene in the vegetable group (0·03 0-0·06 μmol/L). Changes in iron status were similar in all three groups.
An additional daily portion of dark-green leafy vegetables did not improve vitamin A status, whereas a similar amount of β-carotene from a simpler matrix produced a strong improvement. These results suggest that the approach to combating vitamin A deficiency by increases in the consumption of provitamin A carotenoids from vegetables should be re-examined.
The objectives of this study were to quantify the effectiveness of dietary retinol sources, orange fruit, and dark-green, leafy vegetables in improving vitamin A status, and to test whether orange ...fruit is a better source of vitamin A and carotenoids than are leafy vegetables. Anemic schoolchildren aged 7-11 y (n = 238) in West Java, Indonesia, were randomly allocated to 1 of 4 groups to consume 2 complete meals/d, 6 d/wk, for 9 wk: 1) 556 retinol equivalents (RE)/d from retinol-rich food (n = 48); 2) 509 RE/d from fruit (n = 49); 3) 684 RE/d from dark-green, leafy vegetables and carrots (n = 45); and 4) 44 RE/d from low-retinol, low-carotene food (n = 46). Mean changes in serum retinol concentrations of the retinol-rich, fruit, vegetable, and low-retinol, low-carotene groups were 0.23 (95% CI: 0.18, 0.28), 0.12 (0.06, 0.18), 0.07 (0.03,0.11), and 0.00 (-0.06, 0.05) micromol/L, respectively. Mean changes in serum beta-carotene concentrations in the vegetable and fruit groups were 0.14 (0.12, 0.17) and 0.52 (0.43, 0.60) micromol/L, respectively. Until now, it has been assumed that 6 microg dietary beta-carotene is equivalent to 1 RE. On the basis of this study, however, the equivalent of 1 RE would be 12 microg beta-carotene (95% CI: 6 microg, 29 microg) for fruit and 26 microg beta-carotene (95% CI: 13 microg, 76 microg) for leafy vegetables and carrots. Thus, the apparent mean vitamin A activity of carotenoids in fruit and in leafy vegetables and carrots was 50% (95% CI: 21%, 100%) and 23% (95% CI: 8%, 46%) of that assumed, respectively. This has important implications for choosing strategies for controlling vitamin A deficiency. Research should be directed toward ways of improving bioavailability and bioconversion of dietary carotenoids, focusing on factors such as intestinal parasites, absorption inhibitors, and food matrixes.
To determine the most effective method for analysing haemoglobin concentrations in large surveys in remote areas, and to compare two methods (indirect cyanmethaemoglobin and HemoCue) with the ...conventional method (direct cyanmethaemoglobin).
Samples of venous and capillary blood from 121 mothers in Indonesia were compared using all three methods.
When the indirect cyanmethaemoglobin method was used the prevalence of anaemia was 31-38%. When the direct cyanmethaemoglobin or HemoCue method was used the prevalence was 14-18%. Indirect measurement of cyanmethaemoglobin had the highest coefficient of variation and the largest standard deviation of the difference between the first and second assessment of the same blood sample (10-12 g/l indirect measurement vs 4 g/l direct measurement). In comparison with direct cyanmethaemoglobin measurement of venous blood, HemoCue had the highest sensitivity (82.4%) and specificity (94.2%) when used for venous blood.
Where field conditions and local resources allow it, haemoglobin concentration should be assessed with the direct cyanmethaemoglobin method, the gold standard. However, the HemoCue method can be used for surveys involving different laboratories or which are conducted in relatively remote areas. In very hot and humid climates, HemoCue microcuvettes should be discarded if not used within a few days of opening the container containing the cuvettes.
An estimated 100-140 million children worldwide suffer vitamin A deficiency disorders (VADD). Strategies for combating VADD are best used in combination because they serve particular target groups ...and none has full coverage. Homestead food production (HFP) can contribute to combating vitamin A deficiency directly, by increasing intake of vitamin A-rich foods, and indirectly through improving health and increasing income. By the late 1990s, conversion factors for estimating vitamin A obtained from plant foods were revised from 6:1 to 12:1 (microgram beta-carotene:retinol activity equivalent) by the U.S. Institute of Medicine, and by West and colleagues to 21:1 for a mixed diet (12:1 for fruits and 26:1 for vegetables). Thus, plant foods contribute less to vitamin A intake than do other sources. HFP's contribution can be maximized by increasing the amount of vitamin A-rich food consumed, including animal source foods, choosing foods with higher vitamin A content, and improving bioavailability by adding fat, destroying the matrix of vegetables, and deworming. Since the early 1990s, HFP programs have also included nutrition education and were then generally successful in increasing vitamin A intake. However, impact on vitamin A status was not often accessed. Two examples of evaluating impact using a plausibility approach are described. It is concluded that HFP can make a valuable contribution to combating VADD, especially where dietary diversity is low and when animal husbandry and nutrition education are included. Impact can be further maximized by using program infrastructure to introduce micronutrient-rich cultivars and improved breeds, and by adding other interventions, such as deworming and micronutrient supplementation.
To evaluate the evidence that carotene-rich fruits and vegetables can overcome vitamin A deficiency.
Results of studies on the relationship between dietary carotenoids and vitamin A deficiency were ...evaluated critically.
Increased intake of fruits and vegetables has been shown to be related to improved vitamin A status in many cross-sectional, case-control and community-based studies, but this does not prove causality of the relationship. Many experimental studies indicating a positive effect of fruits and vegetables can be criticized for their poor experimental design while recent experimental studies have found no effect of vegetables on vitamin A status. Thus, it is too early to draw firm conclusions about the role of carotene-rich fruits and vegetables in overcoming vitamin A deficiency. Bioavailability of dietary carotenoids and their conversion to retinol are influenced by the following factors: Species of carotene; molecular Linkage; Amount of carotene in a meal; Matrix in which the carotenoid is incorporated; Absorption modifiers; Nutrient status of the host; Genetic factors; Host-related factors and Interactions (SLAMANGHI). Studies are required to quantify the impact of these factors, especially of the matrix, host-related factors and absorption modifiers.
The effectiveness of carotene-rich foods in improving vitamin A status and ways of improving carotene bioavailability need further investigation.
Objective:To determine whether paternal smoking is associated with an increased risk of child malnutrition among families in rural Indonesia.Methods:The relation between paternal smoking and child ...malnutrition was examined in a population-based sample of 438 336 households in the Indonesia Nutrition and Health Surveillance System, 2000–2003. Main outcome measures were child underweight (weight-for-age Z score <−2) and stunting (height-for-age Z score <−2) and severe underweight and severe stunting, defined by respective Z scores <−3, for children aged 0–59 months of age.Results:The prevalence of paternal smoking was 73.7%. The prevalence of underweight and stunting was 29.4% and 31.4%, and of severe underweight and severe stunting was 5.2%, and 9.1%, respectively. After adjusting for child gender, child age, maternal age, maternal education, weekly per capita household expenditure and province, paternal smoking was associated with an increased risk of underweight (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01 to 1.05, p = 0.001) and stunting (OR 1.11, 95% CI 1.09 to 1.13, p<0.001) and severe underweight (OR 1.06, 95% CI 1.01 to 1.10) p = 0.020) and severe stunting (OR 1.12, 95% CI 1.08 to 1.16, p<0.001).Conclusions:Paternal smoking is associated with an increased risk of child malnutrition in families living in rural Indonesia.
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