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Effectiveness of zinc fortified drinking water on zinc intake, status and morbidity of rural Kenyan pre-school children
Kujinga-Chopera, P. - \ 2016
University. Promotor(en): Michael Zimmermann, co-promotor(en): Inge Brouwer; D. Moretti. - Wageningen : Wageningen University - ISBN 9789462577572 - 127 p.
preschool children - drinking water - zinc - fortification - kenya - diarrhoea - nutrient deficiencies - morbidity - childhood diseases - diet - diet studies - peuters en kleuters - drinkwater - zink - fortificatie - diarree - voedingsstoffentekorten - morbiditeit - kinderziekten - dieet - dieetstudies
The iodized salt programme in Bangalore, India provides adequate iodine intakes in pregnant women and more-than-adequate iodine intakes in their children
Jaiswal, N. ; Boonstra, A. ; Sharma, S.K. ; Srinivasan, K. ; Zimmerman, M.B. - \ 2015
Public Health Nutrition 18 (2015)3. - ISSN 1368-9800 - p. 403 - 413.
school-aged children - urinary iodine - dietary iodine - deficiency - iodization - fortification - excretion - bread - nutrition - rajasthan
Objective To compare the iodine status of pregnant women and their children who were sharing all meals in Bangalore, India. Design A cross-sectional study evaluating demographic characteristics, household salt iodine concentration and salt usage patterns, urinary iodine concentrations (UIC) in women and children, and maternal thyroid volume (ultrasound). Setting Antenatal clinic of an urban tertiary-care hospital, which serves a low-income population. Subjects Healthy pregnant women in all trimesters, aged 18–35 years, who had healthy children aged 3–15 years. Results Median (range) iodine concentrations of household powdered and crystal salt were 55·9 (17·2–65·9) ppm and 18·9 (2·2–68·2) ppm, respectively. The contribution of iodine-containing supplements and multi-micronutrient powders to iodine intake in the families was negligible. Adequately iodized salt, together with small amounts of iodine in local foods, were providing adequate iodine during pregnancy: (i) the overall median (range) UIC in women was 172 (5–1024) µg/l; (ii) the median UIC was >150 µg/l in all trimesters; and (iii) thyroid size was not significantly different across trimesters. At the same time, the median (range) UIC in children was 220 (10–782) µg/l, indicating more-than-adequate iodine intake at this age. Median UIC was significantly higher in children than in their mothers (P=0·008). Conclusions In this selected urban population of southern India, the iodized salt programme provides adequate iodine to women throughout pregnancy, at the expense of higher iodine intake in their children. Thus we suggest that the current cut-off for median UIC in children indicating more-than-adequate intake, recommended by the WHO/UNICEF/International Council for the Control of Iodine Deficiency Disorders may, need to be reconsidered.
Yellow cassava: efficacy of provitamin A rich cassava on improvement of vitamin A status in Kenyan schoolchildren
Talsma, E.F. - \ 2014
University. Promotor(en): Michael Zimmermann; Frans Kok, co-promotor(en): Inge Brouwer; Alida Melse-Boonstra. - Wageningen : Wageningen University - ISBN 9789461738554 - 143
cassave - provitaminen - retinol - vitamine a tekort - voedingstoestand - schoolkinderen - kenya - fortificatie - cassava - provitamins - vitamin a deficiency - nutritional state - school children - fortification
Background: Biofortified yellow cassava has great potential to alleviate vitamin A deficiency in sub-Saharan Africa and can be used as a complementary approach to other interventions. However, direct evidence whether yellow cassava can significantly contribute to the vitamin A intake and status of populations is required. The overall aim of this thesis is to provide proof of principle whether biofortified yellow cassava can improve the vitamin A status of schoolchildren in Kenya.
Methods: The research was conducted in Kibwezi district, Eastern Kenya. First the effect of daily consumption of yellow cassava was assessed in 342 primary school children in Kenya in a randomized controlled feeding trial with serum retinol concentration as primary outcome. Furthermore we investigated the sensory and cultural acceptability of yellow cassava in a cross-sectional study (n=140) in three primary schools for children as well as their caretakers. Next we studied the diagnostic performance of several proxy markers to assess vitamin A deficiency in comparison with serum retinol concentration as a field based method to assess vitamin A deficiency (n=375). And last we used the dietary intake data of children in the randomized controlled trial to model the potential contribution of yellow cassava to the nutrient adequacy of micronutrient intake using linear programming.
Results: The randomized controlled feeding trial collected complete data for 337 children with a compliance of 100%. Primary analyses (per protocol) showed that serum retinol concentrations in the yellow cassava group, increased with 0.04 μmol/L (95%CI: 0.00‒0.07 μmol/L) compared to the white cassava group and secondary analyses showed that serum β-carotene concentration increased with 524% (448%‒608%). No evidence of effect modification by initial vitamin A status, zinc status, or polymorphisms in the β-carotene monooxygenase gene was found. In the acceptability study 72% of caretakers and children were able to detect a significant difference in taste between white and yellow cassava and indicated to prefer yellow cassava because of its soft texture, sweet taste and attractive color. Serum concentrations of retinol binding protein, transthyretin and C-reactive protein combined showed excellent diagnostic performance in estimating vitamin A deficiency in primary school children, with an area under the curve of 0.98. Adding yellow cassava to the diet as a school lunch improved the nutrient adequacy of the diet of schoolchildren, however, even with the addition of nutrient dense foods such as fish and oil, nutrient adequacy could not be ensured for fat, riboflavin, niacin, folate and vitamin A.
Conclusions: Consumption of yellow cassava is acceptable and improves the serum retinol concentrations of primary school children in Kenya. The combination of three proxy markers is a promising approach to measure vitamin A deficiency in a low resource setting. Yellow cassava contributes to a better nutrient adequacy but should be accompanied by additional dietary guidelines and interventions to fill the remaining nutrient gaps.
Enhancing pterin and para-aminobenzoate content is not sufficient to successfully biofortify potato tubers and Arabidopsis thaliana plants with folate
Blancquaert, D. ; Storozhenko, S. ; Daele, W. ; Stove, C. ; Visser, R.G.F. ; Lambert, W. ; Straeten, D. van der - \ 2013
Journal of Experimental Botany 64 (2013)12. - ISSN 0022-0957 - p. 3899 - 3909.
time quantitative pcr - folic-acid - tomato fruit - gene - expression - transformation - homocysteine - promoter - disease - fortification
Folates are important cofactors in one-carbon metabolism in all living organisms. Since only plants and micro- organisms are capable of biosynthesizing folates, humans depend entirely on their diet as a folate source. Given the low folate content of several staple crop products, folate deficiency affects regions all over the world. Folate biofortification of staple crops through enhancement of pterin and para-aminobenzoate levels, precursors of the folate biosynthesis pathway, was reported to be successful in tomato and rice. This study shows that the same strategy is not sufficient to enhance folate content in potato tubers and Arabidopsis thaliana plants and concludes that other steps in folate biosynthesis and/or metabolism need to be engineered to result in substantial folate accumulation. The findings provide a plausible explanation why, more than half a decade after the proof of concept in rice and tomato, successful folate biofortification of other food crops through enhancement of para-aminobenzoate and pterin content has not been reported thus far. A better understanding of the folate pathway is required in order to determine an engineering strategy that can be generalized to most staple crops.
Efficacy of iron fortified cowpea flour in improving iron status of schoolchildren in malaria endemic rural Ghana
Abizari, A.R. - \ 2013
University. Promotor(en): Michael Zimmermann, co-promotor(en): Inge Brouwer; M. Armar-Klemesu. - S.l. : s.n. - ISBN 9789461735263 - 191
vignameel - fortificatie - ijzer - ijzergebrekanemie - voedingstoestand - schoolkinderen - ghana - schoolmaaltijden - edta - biologische beschikbaarheid - voedingsprogramma - malaria - voedselsoevereiniteit - cowpea meal - fortification - iron - iron deficiency anaemia - nutritional state - school children - school meals - bioavailability - nutrition programmes - food sovereignty
Children in sub-Saharan Africa are more likely to have survived the critical first 1000 days of life carrying along unresolved micronutrient deficiencies into the school-age. Iron-deficiency is the most prevalent micronutrient problem affecting school-age children in sub-Saharan Africa and yet the most difficult to resolve. It is necessary to ensure an adequate iron intake through the diet of school-age children and school-based feeding intervention may be a way to improve iron intake of schoolchildren. Such a feeding intervention would be more sustainable if it relies on locally produced food(s) with the potential to support food sovereignty. In this context, this thesis investigated whether foods based on cowpeas, an indigenous legume crop originating from Africa, can be used in a school feeding setting to improve iron status of school-age children in Ghana.
The investigations in this thesis comprised cross-sectional dietary and iron status assessment of schoolchildren (n=383), cowpea acceptability among schoolchildren (n=120 mother-child pairs), chemical analysis of cowpea landraces (n=14), an in vivo iron bioavailability among young women (n=16) and a randomized cowpea intervention trial (n=241) conducted mainly in Tolon-Kumbungu district of Ghana.
The results indicated that iron-deficiency and iron-deficiency anaemia affect 8 and 7 out of every 10 schoolchildren respectively. It also showed that the probability of adequate dietary iron intake is 0.32 but much larger (~0.90) if schoolchildren benefitted from a school feeding programme. Mothers/caregivers intended to give cowpeas to their schoolchildren 2–3 times per week. The positive attitudes of mothers towards cowpea predicted their intention to give them to their schoolchildren but they were worried about the cost, long cooking time and the discomfort their children may suffer after consuming cowpeas. The chemical analysis showed that cowpeas contain appreciable amounts of iron (4.9–8.2 mg/ 100 gd.w) and zinc (2.7–4.1 mg/100 gd.w) but also high amounts of inhibitory phytate (477–1110 mg/100 gd.w) and polyphenol (327–1055 mg/100 gd.w). Polyphenol concentration in particular was higher (P<0.05) in coloured compared to white landraces. Iron bioavailability from red and white cowpeas were 1.4 and 1.7%, respectively, in NaFeEDTA-fortified meals and 0.89 and 1.2%, respectively, in FeSO4-fortified meals. Compared with FeSO4, fortification with NaFeEDTA increased the amount of iron absorbed from white and red cowpea meals by 0.05 and 0.08 mg (P < 0.05) respectively. Irrespective of the fortificant used, there was no significant difference in the amount of iron absorbed from the 2 varieties of cowpea. Finally the results from the intervention trial showed that fortification of whole cowpea flour with NaFeEDTA resulted in improvement of haemoglobin (P<0.05), serum ferritin (P<0.001) and body iron stores (P<0.001), and reduction in transferrin receptor concentration (P<0.001). Fortification also resulted in 30% and 47% reduction in the prevalence of iron-deficiency (ID) and iron-deficiency anaemia (IDA) (P<0.05), respectively.
Overall, this thesis has shown that in a malarious region with high iron-deficiency like (northern) Ghana, iron status of schoolchildren can be improved through the consumption of cowpeas within a school feeding programme. The improvement in iron status is however unlikely to result from the usual/conventional consumption of cowpeas but through fortification of whole cowpea flour with a highly bioavailable iron compound. This thesis has also shown that the most suitable iron compound for such whole cowpea flour fortification is NaFeEDTA irrespective of whether the cowpea has high or low concentration of polyphenols.
Effects of iron and n-3 fatty acid supplementation, alone and in combination, on cognition in school children: a randomized, double-blind, placebo-controlled intervention in South Africa
Baumgartner, J. ; Smuts, C.M. ; Malan, L. ; Kvalsvig, J. ; Stuijvenberg, M.E. van; Hurrell, R.F. ; Zimmermann, M.B. - \ 2012
American Journal of Clinical Nutrition 96 (2012)6. - ISSN 0002-9165 - p. 1327 - 1338.
monoamine metabolism - combined deficiency - male rats - brain - schoolchildren - performance - memory - fortification - nutrition - cells
Background: Little is known about the combined effects of iron and n-3 (omega-3) fatty acid (FA) supplementation on cognitive performance. The provision of either DHA/EPA or iron alone in rats with combined iron and n-3 FA deficiency has been reported to exacerbate cognitive deficits associated with deficiency. Objective: We investigated the effects of iron and DHA/EPA supplementation, alone and in combination, in children with poor iron and n-3 FA status. Design: In a 2-by-2 factorial trial, children with iron deficiency (ID) (n = 321; aged 6-11 y) were allocated to receive 1) iron (50 mg) plus DHA/EPA (420/80 mg), 2) iron plus placebo, 3) placebo plus a mixture of DHA and EPA (DHA/EPA), or 4) placebo plus placebo as oral supplements (4/wk) for 8.5 mo. Cognition was assessed at baseline and endpoint by using the Hopkins Verbal Learning Test (HVLT) and subscales of the Kaufman Assessment Battery for Children. Results: Both iron and DHA/EPA significantly increased weight-for-age z scores. Iron increased the number of words recalled at HVLT recall 2 (intervention effect: 0.90; 95% CI: 0.18, 1.62), and in anemic children, iron increased scores in the Atlantis Delayed test (1.51; 95% CI: 0.03, 2.99) and HVLT recall 2 (2.02; 95% CI: 0.55, 3.49). DHA/EPA showed no benefit in any of the cognitive tests but decreased Atlantis test scores (-2.48; 95% CI: -3.99, -0.96) in children who were anemic at baseline and decreased Atlantis delayed scores (-0.9: 95% CI: -1.45, -0.36) in girls with ID, whereas boys tended to perform better. Conclusions: In children with poor iron and n-3 FA status, iron supplementation improved verbal and nonverbal learning and memory, particularly in children with anemia. In contrast, DHA/EPA supplementation had no benefits on cognition and impaired working memory in anemic children and long-term memory and retrieval in girls with ID. The trial was registered at clinicaltrials.gov as NCT01092377. Am J Clin Nutr 2012;96:1327-38.
Zinc Biofortification of Rice in China: A stimulation of zinc intake with different dietary patterns
Qin, Y. ; Boonstra, A. ; Yuan, B. ; Pan, X. ; Dai, Yue - \ 2012
Nutrients 4 (2012)6. - ISSN 2072-6643 - p. 517 - 528.
randomized controlled-trials - jiangsu province - children - calcium - women - fortification - health - risk - supplementation - population
A cross-sectional survey of 2819 adults aged 20 years and above was undertaken in 2002 in Jiangsu Province. Zinc intake was assessed using a consecutive 3-day 24-h dietary recall method. Insufficient and excess intake was determined according to the Chinese Dietary Recommended Intakes. Four distinct dietary patterns were identified namely “traditional”, “macho”, “sweet tooth”, and “healthy”. Intake of zinc from biofortified rice was simulated at an intermediate zinc concentration (2.7 mg/100 g) and a high zinc concentration (3.8 mg/100 g) in rice. Average total zinc intake was 12.0 ± 3.7 mg/day, and insufficiency of zinc intake was present in 15.4%. Simulated zinc intake from biofortified rice with intermediate and high zinc concentration decreased the prevalence of low zinc intake to 6.5% and 4.4%, respectively. The effect was most pronounced in the “traditional” pattern, with only 0.7% of insufficiency of zinc intake remaining in the highest quartile of the pattern. Zinc intake was inversely associated with the “sweet tooth” pattern. Zinc biofortifed rice improves dietary zinc intake and lowers risk for insufficient zinc intake, especially for subjects with a more “traditional” food pattern, but less for subjects with a “sweet tooth” food pattern.
Whole cowpea meal fortified with NaFeEDTA reduces iron deficiency among Ghanaian school children in a malaria endemic area
Abizari, A.R. ; Moretti, D. ; Schuth, S. ; Zimmerman, M.B. ; Armar-Klemesu, M. ; Brouwer, I.D. - \ 2012
The Journal of Nutrition 142 (2012)10. - ISSN 0022-3166 - p. 1836 - 1842.
soluble transferrin receptor - phytic acid - ferric pyrophosphate - phaseolus-vulgaris - controlled-trial - northern ghana - young-women - anemia - fortification - bioavailability
Cowpeas, like other legumes, contain high amounts of native iron but are rich in phytic acid (PA) and polyphenols (PP) that inhibit iron absorption. NaFeEDTA may overcome the combined inhibitory effect of PA and PP. Our objective was to test the efficacy of NaFeEDTA-fortified cowpea meal in improving iron status of school children in a malaria endemic area. We conducted a double-blind, controlled trial with 5- to 12-y-old school children from 2 rural communities in northern Ghana (n = 241). Eligible children were randomly assigned to 2 treatment groups to receive either cowpea meal fortified with 10 mg Fe/meal as NaFeEDTA, or an identical but nonfortified cowpea meal. Meals were provided 3 d/wk for a period of ~7 mo under strict supervision. Mass deworming and malaria antigenemia screening and treatment were carried out at baseline and 3.5 mo into the trial. Consumption of cowpea flour fortified with NaFeEDTA resulted in improvement of hemoglobin (P <0.05), serum ferritin (P <0.001), and body iron stores (P <0.001) and reduction of transferrin receptor (P <0.001) compared with nonfortified flour. Fortification resulted in a 30 and 47% reduction in the prevalence of iron deficiency (ID) and iron deficiency anemia (IDA) (P <0.05), respectively. The results indicate that fortification of cowpea flour with NaFeEDTA overcomes the combined inhibitory effect of PA and PP and, when used for targeted school-based fortification of cowpea flour, is effective in reducing the prevalence of ID and IDA among school children in malaria endemic rural northern Ghana.
Phytic Acid-to-Iron Molar Ratio Rather than Polyphenol Concentration Determines Iron Bioavailability in Whole-Cowpea Meal among Young Women
Abizari, A.R. ; Moretti, D. ; Zimmerman, M.B. ; Armar-Klemesu, M. ; Brouwer, I.D. - \ 2012
The Journal of Nutrition 142 (2012)11. - ISSN 0022-3166 - p. 1950 - 1955.
sodium-bicarbonate - phaseolus-vulgaris - absorption - isotope - food - fortification - phytate - humans - beans - availability
Limited data exist on iron absorption from NaFeEDTA and FeSO(4) in legume-based flours. The current study compared iron absorption from NaFeEDTA and FeSO(4) as fortificants within and between red and white varieties of cowpea with different concentrations of polyphenols (PP) but similar phytic acid (PA)-to-iron molar ratios. We performed a paired crossover study in young women (n = 16). Red-cowpea (high-PP) and white-cowpea (low-PP) test meals (Tubani) were each fortified with ((57)Fe)-labeled NaFeEDTA or ((58)Fe)-labeled FeSO(4) and were randomly administered. Iron absorption was measured as erythrocyte incorporation of stable iron isotopes. Per serving, the mean (±SD) PP concentrations of the white- and red-cowpea-based meals were 74 ± 3.6 and 158 ± 1.8 mg, respectively, and the molar ratio of PA to iron was 3.0 and 3.3. Iron bioavailabilities from red and white cowpeas were 1.4 and 1.7%, respectively, in NaFeEDTA-fortified meals and 0.89 and 1.2%, respectively, in FeSO(4)-fortified meals. Compared with FeSO(4), fortification with NaFeEDTA increased the amount of iron absorbed from either of the cowpea meals by 0.05 to 0.08 mg (P <0.05). Irrespective of the fortificant used, there was no significant difference in the amount of iron absorbed from the 2 varieties of cowpea. The results suggest that NaFeEDTA is more bioavailable in legume-based flours compared with FeSO(4). In cowpea-based flours, the major determinant of low iron absorption may be the high molar ratio of PA to iron and not variations in PP concentration
Control of iron deficiency in the first 1000 days in life: prevention of impaired child development
Chang, S. - \ 2012
University. Promotor(en): Frans Kok, co-promotor(en): Inge Brouwer; J. Chen; -- Guansheng Ma. - S.l. : s.n. - ISBN 9789461733825 - 125
ijzergebrekanemie - peuters en kleuters - zuigelingen - kindervoedering - aanvullende voedingsprogramma's - bijvoeding - voedselsupplementen - fortificatie - china - kinderontwikkeling - cognitieve ontwikkeling - iron deficiency anaemia - preschool children - infants - child feeding - supplemental feeding programs - supplementary feeding - food supplements - fortification - child development - cognitive development
Evidence indicates that the first 1000 days of life (the period from the woman’s pregnancy continuing into the child’s second year) is the most critical period. This is where nutritional deficiencies have a significant and often irreversible adverse impact on child survival and growth affecting their ability to learn in school and productivity in later life. Sufficient iron supply and intake during pregnancy and in children under two years of age are an important component for nutrition interventions during these critical 1000 days. A causal relationship between iron deficiency and poorer brain function has not been demonstrated yet. In addition, there is ample evidence that the high frequency of iron deficiency anemia (IDA) in the developing world has substantial health and economic costs. It is therefore of public health significance to explore effective and optimal approaches for iron supplementation and iron fortification among high risk populations (i.e., pregnant women, infants and young children).
This thesis addresses some of the above outstanding areas, aiming at i) exploring the long-term effect of IDA in pregnancy and IDA in children under 2 years on cognitive and psychomotor function and social emotional behaviour, ii) understanding the impact of prenatal multiple micronutrient supplementation on health outcomes of newborns, and iii) investigating iron absorption from a complementary food fortified with a mixture of FeSO4 and NaFeEDTA.
The human brain is vulnerable during critical periods of development, including the last trimester of fetal life and the first 2 years of childhood - a period of rapid brain growth termed the “brain growth spurt”. We found that iron deficiency anemia in the third trimester of pregnancy is associated with impaired mental development of the child before 24 months of age. The children whose mothers had iron deficiency anemia showed a significantly lower Mental Development Index (MDI) at 12, 18 and 24 months of age. The adjusted mean difference was 5.8 (95% Confidence interval [CI] 1.1 to 10.5), 5.1 (95% CI 1.2 to 9.0) and 5.3 (95% CI 0.9 to 9.7) respectively. Further analysis showed MDI in the prenatal IDA and non-prenatal IDA groups were similar with supplementation of iron-folic acid (60 mg iron), but significantly lower in the prenatal IDA group with supplementation of folic acid or multiple micronutrients. Prenatal iron supplementation with sufficient iron protects child development even when women’s IDA was not properly corrected during pregnancy (chapter 2).
In a second study, we compared social emotional affect and behavior of three groups of non-anemic 4-year-old children: children with IDA in infancy whose anemia was not corrected before 24 months (chronic IDA, n=27); children with IDA in infancy whose anemia was corrected before 24 months (corrected IDA, n=70), and children who were non-IDA in infancy and at 24 months (n=64). Children’s social referencing, wariness, frustration tolerance behavior and affect were observed in a laboratory setting. The whole procedure was videotaped. Child affective and behavioral display was coded using a time-sampling (5-second segments) coding scheme. Preschool aged children whohad chronic IDA in the first 2 years of life showed affected social emotional behavior. In contrast, children whose anemia was corrected before 24 months were comparable to children who were non-iron deficient and anemic throughout the first 2 years of life in terms of behavior and affect (chapter 3).
Overall, our results indicate that adverse effects can be reduced and/or prevented with iron supplementation during critical periods of brain development.WHO recommends universal distribution of iron-folic acid supplements to pregnant women in developing countries to prevent and treat iron deficiency anemia. However, pregnant women are often deficient in several other nutrients concurrently, all of which can negatively affect their own health as well as their infants’ health, growth and development across the life course. Multiple micronutrient supplements containing iron and other micronutrients should be more efficient to help to reduce anemia, because other nutrients often lacking in the diets of pregnant women in poor populations, including vitamin A, riboflavin and vitamin B6 and B12, are also needed for hemoglobin synthesis. Improving maternal status of multiple micronutrients could also benefit pregnancy outcome, infant micronutrient stores at birth and breast milk content of micronutrients.
In a randomized double blind controlled trial described in chapter 4, we examined the impact of prenatal supplementation with multiple micronutrients or iron-folic acid compared to folic acid alone on birth weight, duration of gestation and maternal hemoglobin concentration in the third trimester. In total 5828 pregnant women were involved. The results suggest multiple micronutrients are as effective as iron folic acid in increasing maternal hemoglobin concentration, birth weight and mean duration of gestation. Our study also shows good adherence can be achieved with multiple micronutrients during pregnancy.
Using 2000 and 2005 Food and Nutrition Surveillance data, we found that complementary feeding practices are suboptimal in both rural and poor rural areas in China, although significant improvements in practices have been made from year 2000 to year 2005. The percentage of consuming meat/eggs more than 4 times a week among 6-9 months children was only 30%, for other age groups only around 50% or less. The high energy and nutrient requirements relative to body size, the capacity to only consume small amounts of foods indicate that nutrient-dense foods must be provided from 6 months until the second and third year of life. Inclusion of animal products can meet the energy and nutrients gap in some cases, but this increases costs and may not be feasible for the lowest-income groups. Furthermore, the amount of animal products that can feasibly be included are generally not sufficient for iron, calcium and sometimes zinc. Thus strategies to optimize nutrient intake from locally available foods may need to be combined with other approaches such as complementary food fortification in order to fully address the problems of micronutrient malnutrition (chapter 6).
In-home fortification of complementary food is an effective approach to provide additional iron and other nutrients to infants and young children in developing countries. To determine whether iron absorption is enhanced with a mixture of FeSO4 and NaFeEDTA, we conducted an iron absorption study with a crossover design in two groups with children aged 24 to 31 months. A complementary food consisting of millet porridge with cabbage, tofu, and pork-filled wheat flour dumplings was fortified with 2 mg iron as either FeSO4 or NaFeEDTA (study 1) or 4 mg iron as FeSO4 or a mixture of 2 mg each of FeSO4 and NaFeEDTA (study 2). Iron absorption was determined based on erythrocyte incorporation of stable iron isotopes. In study 1, the geometric mean iron absorption(±SD) was 8.0% (3.1, 20.8) and 9.2% (3.1, 27.0) from food fortified with FeSO4 and NaFeEDTA, respectively. In study 2, iron absorption was significantly higher from food fortified with 4 mg iron as 1:1 mixture of FeSO4/NaFeEDTA than from food fortified with FeSO4 only; the geometric mean iron absorption was 6.4% (3.0, 13.5) and 4.1% (1.9, 8.9), respectively. We concluded that the equal mixture of FeSO4 and NaFeEDTA significantly enhanced iron absorption and can be a strategy to ensure adequate iron absorption from phytate-containing complementary foods (Chapter 5).
The studies in this thesis provide further evidence on the association between IDA during the first critical 1000 days of live and the long-term impact on child development. Our research results and the meta-analysis of 12 randomized controlled trials (including our trial in China) suggest that the daily provision of multiple micronutrients is an optimal approach for pregnant women in developing countries including China in terms of the health outcome of newborns. The benefits of giving at least 30 mg iron daily to pregnant women shown in our study as well as by others can provide guidance to policy makers on the development of a prenatal nutrient supplementation standard in China. Moreover, enhanced iron absorption from a mixture of FeSO4 and NaFeEDTA as a fortificant supports China’s current practice on the use of NaFeEDTA for in-home fortification of complementary food.Considering our study findings and research by others, the following research is proposed for the near future. 1) Continuing research into the causal relationship of iron deficiency and child behaviour; 2) Developing of better measurement tools to assess child development; 3) Exploring the causality of anemia in the region.
Zinc intake and dietary pattern in Jiangsu Province, China: consequences of nutrition transition
Qin, Y. - \ 2012
University. Promotor(en): Frans Kok; Michael Zimmermann, co-promotor(en): Alida Melse-Boonstra; J.K. Zhao. - S.l. : s.n. - ISBN 9789461733740 - 133
zink - voedingstoestand - fortificatie - dieet - hypertensie - obesitas - china - zinc - nutritional state - fortification - diet - hypertension - obesity
Background: Jiangsu Province is an economically booming area in East China, where soil zinc concentrations are low. Nutrition transition to a dietary pattern with more animal source foods may have improved zinc intake in this area. However, such a transition may also have increased the burden of non-communicable diseases (NCDs), such as hypertension and obesity. Investigation of dietary patterns in relation to undernutrition and overnutrition could help to better address both problems.
Objectives: The first aim of this thesis was to assess zinc status in Jiangsu Province using dietary zinc intake, serum zinc and stunting as indicators, as well to investigate the potential of biofortified rice to improve zinc intake. The second aim was to investigate the association between dietary patterns and high blood pressure, taking obesity into account.
Methods:Data from the 2002 National Nutrition and Health Survey in Jiangsu Province were used to assess zinc intake in the population aged 4-89 years (n=3,867). Primary school children (n=2,268) were selected from three counties in the Province with relatively low soil zinc for assessment of stunting. Serum zinc was measured among children in the county where stunting was highest (n=297). Thirteen women were recruited in the same county for three test rounds with rice meals (zinc biofortified rice, zinc extruded fortified rice and control rice). Fractional zinc absorption (FAZ) was measured with the use of the double isotope tracer ratio method. Effect of biofortified rice with zinc, at a level of 2.7 and 3.8 mg/100g, on zinc intake was simulated in adults (n=2.819). For adults, four distinct dietary patterns were identified, named “traditional”, “Macho”, “sweet tooth” and “healthy” pattern. Associations were assessed between the four dietary patterns and blood pressure in adults (n=2,518) by using Poisson regression analysis.
Results:The overall prevalence of insufficient intake of zinc was 22.9%, with a higher prevalence in children (64.6%) and adolescents (64.9%), and in those with low socio-economic status (27.3%). Around 4% of the primary school children were stunted, and the prevalence of zinc deficiency measured by serum and hair zinc was 0.7%, and 15.2%, respectively. Biofortified 70Zn enriched rice with an intrinsic label was found to have higher fractional zinc absorption (FAZ) than extrinsically labeled fortified extruded rice. However, FAZ could not be accurately quantified because we could not determine the exact amount of isotope infused to subjects due to adhesion of zinc to the vial. When simulating zinc intake by replacing normal rice with zinc biofortified rice with either 2.7 and 3.8 mg/100g of zinc, the prevalence of insufficient zinc intake decreased from 15.4% to 6.5% and 4.4%, respectively. The “traditional” dietary pattern in Jiangsu Province was most strongly associated with high blood pressure (P for trend = 0.005). This pattern is characterized primarily by consumption of rice and fresh vegetable; secondary of pork and fish; and lastly of root vegetable and wheat flour, but also by high salt intake. Subjects with overweight and obesity were more likely to have high blood pressure than those with normal weight.
Conclusion: Children and adolescents had low dietary zinc intake, in Jiangsu Province, where the soil is also deficient in zinc. However, these findings did not match with the low prevalence of stunting and zinc deficiency based on serum zinc concentrations in primary school children from three rural areas of the Province. Zinc appears to be better absorbed from biofortified rice than from control rice or from extruded fortified rice, which needs further investigation. Simulated zinc intake from biofortified rice with zinc at a level of 2.7 mg/kg has the potential to significantly improve zinc intake, especially in the “traditional” dietary pattern. However, this pattern is also related to high blood pressure, which may be due to high salt intake. High blood pressure is also positively and independently related to obesity. Nutrition education is required to improve knowledge and awareness of healthy diets in Jiangsu Province.
Efficacy of amaranth grain (Amaranthus cruentus) on anaemia and iron deficiency in Kenyan pre-school children
Macharia-Mutie, C.W. - \ 2012
University. Promotor(en): Frans Kok, co-promotor(en): Inge Brouwer; A.M. Mwangi. - [S.l. : s.n. - ISBN 9789461732910 - 167
amaranthus cruentus - anemie - ijzergebrekanemie - peuters en kleuters - kenya - fortificatie - anaemia - iron deficiency anaemia - preschool children - fortification
Fonio (Digitaria exilis) as a staple food in Mali : an approach to upgrade nutritional value
Fanou-Fogny, N.M.L. - \ 2012
University. Promotor(en): Frans Kok, co-promotor(en): Inge Brouwer; R.A.M. Dossa. - S.l. : s.n. - ISBN 9789461732927 - 188
digitaria exilis - mali - ijzer - fortificatie - ijzerabsorptie - voedingstoestand - sporenelementtekorten - voedingswaarde - vrouwen - iron - fortification - iron absorption - nutritional state - trace element deficiencies - nutritive value - women
Conclusions and recommendations
Estimation of micronutrient intake distributions: development of methods to support food and nutrition policy making
Verkaik-Kloosterman, J. - \ 2011
University. Promotor(en): Pieter van 't Veer, co-promotor(en): M.C. Ocké. - [S.l.] : S.n. - ISBN 9789085859451 - 192
sporenelementen - vitaminen - voedingsstoffenopname (mens en dier) - dieet - beleid inzake voedsel - volksgezondheid - fortificatie - voedselsupplementen - trace elements - vitamins - nutrient intake - diet - food policy - public health - fortification - food supplements
Methods & Results
Three main methodological improvements have been made. First, the combination of a deterministic approach with probabilistic approaches to be able to take into account uncertainty and variability were needed. This method was applied to estimate habitual iodine and salt intake distributions. From DNFCSs no detailed information was available on the discretionary use of (iodized) salt and no up to date information was available on the use of iodized salt in industrially processed foods. Estimates of the proportion of the population discretionarily using (iodized) salt and the proportion of industrially processed foods applying iodized salt were obtained from other data sources. The model accurately estimates habitual iodine and salt intake distributions when compared with studies measuring urinary iodine and sodium excretion. Additionally a framework was developed to simulate the habitual intake distribution for potential scenarios of future fortification strategies. Within this framework, deterministic and probabilistic approaches were combined when uncertainty or variability had to be taken into account. This framework was illustrated by the estimation of habitual folate-equivalent intake for different scenarios of mandatory or voluntary fortification with folic acid. Further this framework was applied to estimate the habitual iodine intake for several potential changes in the Dutch iodine policy and also for several scenarios of salt reduction strategies.
A second methodological improvement was the development of a new statistical model to estimate habitual total micronutrient intake aggregated from food and dietary supplements. Within this 3-part model, habitual intake is estimated separately for a) intake from food for non-users of dietary supplements, b) intake from food for users of dietary supplements, and c) intake from dietary supplements for users only. Habitual total intake for the whole population was obtained by combination of the three separate habitual intake distributions (‘first shrink then add’). This 3-part model was illustrated by vitamin D intake for young children. With a more simple ‘first add then shrink’ approach the estimation of habitual total vitamin D intake distribution may give inconsistent results for the distribution of intake from foods and dietary supplements combined as compared to the intake from food only. In addition, this more simple approach may not be able to cope with multi modal distributions. With the newly developed model this inconsistency problem was solved and the multi-modal shape of the distribution as observed in the ‘raw’ data was preserved.
Third, a model calculating the maximum safe fortification level per 100 kcal of a food was developed for the Dutch situation. By considering the tolerable upper intake level and reasonable high micronutrient intakes from food and dietary supplements, the ‘free space’ for voluntary fortification was calculated. This amount was divided over the amount of energy intake that can and may be fortified. The model was applied to derive safe maximum fortification levels for vitamin A, D, and folic acid. Based on these results the risk manager decided to legally allow voluntary fortification with vitamin D and folic acid up to a maximum level of 4.5 and 100 μg/100 kcal respectively.
Multivitamin supplement use and risk of invasive breast cancer
Meulepas, J.M. ; Newcomb, P.A. ; Burnett-Hartman, A.N. ; Hampton, J.M. ; Trentham-Dietz, A. - \ 2010
Public Health Nutrition 13 (2010)10. - ISSN 1368-9800 - p. 1540 - 1545.
multimineral supplements - nutrient intake - national-health - united-states - folate intake - vitamin - fortification - determinants - population - prostate
Objective: Multivitamin supplements are used by nearly half of middle-aged women in the USA. Despite this high prevalence of multivitamin use, little is known about the effects of multivitamins on health outcomes, including cancer risk. Our main objective was to determine the association between multivitamin use and the risk of breast cancer in women. Design: We conducted a population-based case-control study among 2968 incident breast cancer cases (aged 20-69 years), diagnosed between 2004 and 2007, and 2982 control women from Wisconsin, USA. All participants completed a structured telephone interview which ascertained supplement use prior to diagnosis, demographics and risk factor information. Odds ratios and 95% confidence intervals were calculated using multivariable logistic regression. Results: Compared with never users of multivitamins, the OR for breast cancer was 1.02 (95% CI 0.87, 1.19) for current users and 0.99 (95% CI 0.74, 1.33) for former users. Further, neither duration of use (for >= 10 years: OR = 1.13, 95% CI 0.93, 1.38, P for trend 0.25) nor frequency (> 7 times/week: OR = 1.00, 95% CI 0.77, 1.28, P for trend 0.97) was related to risk in current users. Stratification by menopausal status, family history of breast cancer, age, alcohol, tumour staging and postmenopausal hormone use did not significantly modify the association between multivitamin use and breast cancer. Conclusions: The current study found no association between multivitamin supplement use and breast cancer risk in women.
Micronutrients, omega-3 fatty acids and cognitive performance in Indian schoolchildren
Eilander, J.H.C. - \ 2009
University. Promotor(en): Frans Kok, co-promotor(en): S.J.M. Osendarp; S. Muthayya. - [S.l. : S.n. - ISBN 9789085854708 - 175
sporenelementen - meervoudig onverzadigde vetzuren - cognitieve ontwikkeling - mentale vaardigheid - minerale supplementen - fortificatie - ondervoeding - schoolkinderen - india - omega-3 vetzuren - kenvermogen - trace elements - polyenoic fatty acids - cognitive development - mental ability - mineral supplements - fortification - undernutrition - school children - omega-3 fatty acids - cognition
Dietary folate intake: is there a need for folic acid fortification in the Netherlands?
Winkels, R.M. - \ 2008
University. Promotor(en): M.B. Katan, co-promotor(en): P. Verhoef; Ingeborg Brouwer. - S.l. : S.n. - ISBN 9789085852001 - 133
foliumzuur - foliumzuurtekort - fortificatie - dieet - voedingsstoffenopname (mens en dier) - vitamine b12 - biologische beschikbaarheid - dieetrichtlijnen - nederland - geslacht (gender) - folic acid - folic acid deficiency - fortification - diet - nutrient intake - vitamin b12 - bioavailability - dietary guidelines - netherlands - gender
Synthesis, characterization, and bioavailability in rats of ferric phosphate nanoparticles
Rohner, F. ; Ernst, F.O. ; Arnold, M. ; Hilbe, M. ; Biebinger, R. ; Ehrensperger, F. ; Pratsinis, S.E. ; Langhans, W. ; Hurrell, R.F. ; Zimmermann, M.B. - \ 2007
The Journal of Nutrition 137 (2007)3. - ISSN 0022-3166 - p. 614 - 619.
flame spray-pyrolysis - particle-size - iron bioavailability - delivery-system - pyrophosphate - nanotechnology - fortification - absorption - toxicity - powders
Particle size is a determinant of iron (Fe) absorption from poorly soluble Fe compounds. Decreasing the particle size of metallic Fe and ferric pyrophosphate added to foods increases Fe absorption. The aim of this study was to develop and characterize nanoparticles of FePO4 and determine their bioavailability and potential toxicity in rats. Amorphous FePO4 nanopowders with spherical structure were synthesized by flame spray pyrolysis (FSP). The nanopowders were characterized and compared with commercially available FePO4 and FeSO4, including measurements of specific surface area (SSA), structure by transmission electron microscopy, in vitro solubility at pH 1 and 2, and relative bioavailability value (RBV) to FeSO4 in rats using the hemoglobin repletion method. In the latter, the potential toxicity after Fe repletion was assessed by histological examination and measurement of thiobarbituric acid reactive substances (TBARS). The commercial FePO4 and the 2 FePO4 produced by FSP (mean particle sizes, 30.5 and 10.7 nm) had the following characteristics: SSA: 32.6, 68.6, 194.7 m2/g; in vitro solubility after 30 min at pH 1: 73, 79, and 85% of FeSO4; and RBV: 61, 70, and 96%, respectively. In the histological examinations and TBARS analysis, there were no indications of toxicity. In conclusion, nanoparticles of FePO4 have a solubility and RBV not significantly different from FeSO4. Reducing poorly soluble Fe compounds to nanoscale may increase their value for human nutrition.
Efficacy and safety of fortification with iron of maize flour in African children
Andang'o, P.E.A. - \ 2007
University. Promotor(en): Frans Kok, co-promotor(en): Hans Verhoef; S.J.M. Osendarp. - [S.l.] : S.n. - ISBN 9789085048121 - 149
ijzer - fortificatie - maïsbloem - nadelige gevolgen - mineraaltekorten - kinderen - afrika - iron - fortification - corn flour - adverse effects - mineral deficiencies - children - africa
Food fortification is an effective strategy for reaching populations with micronutrient deficiencies. Fortification with iron presents a major challenge because of the presence of phytates and other iron absorption inhibitors in diets of poor people. Addition of iron does not necessarily mean that it is absorbed. Because of its low cost and its relative stability in food vehicles, electrolytic iron has been the fortificant of choice in many national programmes, despite its low bioavailability compared to fortificants such as ferrous salts. NaFeEDTA may be a more effective iron fortificant in high-phytate foods. Concerns about its cost and safety, however, have delayed its application in fortification programmes. This thesis is based on a 5-month randomised placebo-controlled trial conducted among school children (n = 516) aged 3-8 years in Kenya in May-November 2005. It aimed to measure the benefits of fortification with NaFeEDTA or electrolytic iron, and to assess the safety of using NaFeEDTA as an iron fortificant. The specific objectives were to assess a) the efficacy of fortifying whole maize flour with NaFeEDTA (28 mg iron/kg flour or 56 mg/kg) or electrolytic iron (56 mg/kg); b) the effect of the intervention on cognitive and motor function; c) response to the intervention of individuals with α+-thalassaemia genotype relative to their counterparts with a normal genotype; d) and the effect of NaFeEDTA on the status of zinc, calcium, copper, magnesium and manganese. Fortification with NaFeEDTA at high levels (56 mg iron per kg flour), or low levels (28 mg/kg) reduced the prevalence of iron deficiency anaemia by 89% (95% CI 49% to 97%) and 48% (-20% to 77%), respectively. High-dose fortification with NaFeEDTA led to larger gains in iron status than low-dose level, and was more efficacious in children with iron deficiency at baseline. By contrast, electrolytic iron did not improve iron status. There was no evidence that the iron intervention improved either cognitive or motor function of these children; or that children with the α+-thalassaemia genotype responded differently to the iron intervention than their peers with a normal genotype. There was also no evidence that NaFeEDTA adversely affected the status of the nutritionally important mineral elements assessed. The thesis concludes that in high-phytate flours, NaFeEDTA is more suitable than electrolytic iron for supplementation of iron in the diet. Governments should act and implement national programmes to fortify industrially processed flour, whereby NaFeEDTA should be considered the preferred fortificant in high-phytate food vehicles.
Iron and zinc deficiencies in China: existing problems and possible solutions
Guansheng Ma, - \ 2007
University. Promotor(en): Frans Kok; Evert Jacobsen. - [S.l.] : S.n. - ISBN 9789085045601 - 160
ijzergebrekanemie - gebreksziekten - zink - ijzer - voedingsstoffenbeschikbaarheid - fytinezuur - fytaten - fortificatie - maatregel op voedingsgebied - cost effective analysis - iron deficiency anaemia - deficiency diseases - zinc - iron - nutrient availability - phytic acid - phytates - fortification - nutritional intervention - cost effectiveness analysis
Micronutrient deficiencies affect the health and development of the population of China as well as its socia] and economic development. Iron and zinc deficiencies are quite prevalent, while insufficient intake and poor bioavailability are the major causes. Phytate is be!ieved to bc a potent inhibitor. Feasible, cost-effective and sustainable intervention programs to combat iron and zinc deficiencies need to be identified and developed.