Maize meal fortification is associated with improved vitamin A and iron status in adolescents and reduced childhood anaemia in a food aid-dependent refugee population

Abstract Objective To assess changes in the Fe and vitamin A status of the population of Nangweshi refugee camp associated with the introduction of maize meal fortification. Design Pre- and post-intervention study using a longitudinal cohort. Setting Nangweshi refugee camp, Zambia. Subjects Two hundred and twelve adolescents (10-19 years), 157 children (6-59 months) and 118 women (20-49 years) were selected at random by household survey in July 2003 and followed up after 12 months. Results Maize grain was milled and fortified in two custom-designed mills installed at a central location in the camp and a daily ration of 400 g per person was distributed twice monthly to households as part of the routine food aid ration. During the intervention period mean Hb increased in children (0·87 g/dl; P < 0·001) and adolescents (0·24 g/dl; P = 0·043) but did not increase in women. Anaemia decreased in children by 23·4 % (P < 0·001) but there was no significant change in adolescents or women. Serum transferrin receptor (log10-transformed) decreased by −0·082 μg/ml (P = 0·036) indicating an improvement in the Fe status of adolescents but there was no significant decrease in the prevalence of deficiency (−8·5 %; P = 0·079). In adolescents, serum retinol increased by 0·16 μmol/l (P < 0·001) and vitamin A deficiency decreased by 26·1 % (P < 0·001). Conclusions The introduction of fortified maize meal led to a decrease in anaemia in children and a decrease in vitamin A deficiency in adolescents. Centralised, camp-level milling and fortification of maize meal is a feasible and pertinent intervention in food aid operation

Micronutrient fortification to improve growth and health of maternally HIV-unexposed and exposed Zambian infants: a randomised controlled trial

Background: The period of complementary feeding, starting around 6 months of age, is a time of high risk for growth faltering and morbidity. Low micronutrient density of locally available foods is a common problem in low income countries. Children of HIV-infected women are especially vulnerable. Although antiretroviral prophylaxis can reduce breast milk HIV transmission in early infancy, there are no clear feeding guidelines for after 6 months. There is a need for acceptable, feasible, affordable, sustainable and safe (AFASS by WHO terminology) foods for both HIV-exposed and unexposed children after 6 months of age. Methods and Findings: We conducted in Lusaka, Zambia, a randomised double-blind trial of two locally made infant foods: porridges made of flour composed of maize, beans, bambaranuts and groundnuts. One flour contained a basal and the other a rich level of micronutrient fortification. Infants (n = 743) aged 6 months were randomised to receive either regime for 12 months. The primary outcome was stunting (length-for-age Z < -2) at age 18 months. No significant differences were seen between trial arms overall in proportion stunted at 18 months (adjusted odds ratio 0.87; 95% CI 0.50, 1.53; P = 0.63), mean length-for-age Z score, or rate of hospital referral or death. Among children of HIV-infected mothers who breastfed <6 months (53% of HIV-infected mothers), the richly-fortified porridge increased length-for-age and reduced stunting (adjusted odds ratio 0.17; 95% CI 0.04, 0.84; P = 0.03). Rich fortification improved iron status at 18 months as measured by hemoglobin, ferritin and serum transferrin receptors. Conclusions: In the whole study population, the rich micronutrient fortification did not reduce stunting or hospital referral but did improve iron status and reduce anemia. Importantly, in the infants of HIV-infected mothers who stopped breastfeeding before 6 months, the rich fortification improved linear growth. Provision of such fortified foods may benefit health of these high risk infants

A micronutrient-fortified food enhances iron and selenium status of Zambian infants but has limited efficacy on zinc.

Micronutrient-fortified, cereal-based infant foods are recommended for reducing multiple micronutrient deficiencies in low-income countries, but their nutritional quality is not always optimal. In a double-blind randomized trial, we compared the efficacy of a locally produced porridge based on maize, beans, bambaranuts, and groundnuts fortified with 19 (rich) or 9 (basal) micronutrients. Infants aged 6 mo from Lusaka, Zambia were randomized to receive the richly fortified (n = 373) or basal (n = 370) porridge daily for 12 mo along with routine vitamin A supplements. Baseline and final micronutrient status and inflammation (based on α-1-glycoprotein) were assessed using nonfasting blood samples. Baseline prevalence of anemia (39%) and zinc deficiency (51%) were a public health concern. There were overall treatment effects on hemoglobin (Hb) (P = 0.001), serum transferrin receptor (P 11.0 mg/L), and iron deficiency were 0.37 (95% CI = 0.25, 0.55), 0.18 (0.09, 0.35), and 0.30 (0.18, 0.50) times those in the basal group, respectively. The rich level of fortification had no overall treatment effect on serum zinc (1.09; 0.66, 1.80) but improved serum zinc in children with lower Hb concentrations at baseline (P = 0.024). A locally produced cereal- and legume-based infant food richly fortified with micronutrients reduced anemia and improved iron and selenium status but may require reformulation to improve the biochemical zinc status of urban Zambian infants

Micronutrient supplementation has limited effects on intestinal infectious disease and mortality in a Zambian population of mixed HIV status: a cluster randomized trial.

BACKGROUND: Diarrheal disease remains a major contributor to morbidity and mortality in Africa, but host defense against intestinal infection is poorly understood and may depend on nutritional status. OBJECTIVE: To test the hypothesis that defense against intestinal infection depends on micronutrient status, we undertook a randomized controlled trial of multiple micronutrient supplementation in a population where there is borderline micronutrient deficiency. DESIGN: All consenting adults (> or =18 y) living in a carefully defined sector of Misisi, Lusaka, Zambia, were included in a cluster-randomized (by household), double-blind, placebo-controlled trial with a midpoint crossover. There were no exclusion criteria. Participants were given a daily tablet containing 15 micronutrients at just above the recommended nutrient intake or placebo. The primary endpoint was the incidence of diarrhea; secondary endpoints were severe episodes of diarrhea, respiratory infection, nutritional status, CD4 count, and mortality. RESULTS: Five hundred participants were recruited and followed up for 3.3 y (10,846 person-months). The primary endpoint, incidence of diarrhea (1.4 episodes/y per person), did not differ with treatment allocation. However, severe episodes of diarrhea were reduced in the supplementation group (odds ratio: 0.50; 95% CI: 0.26, 0.92; P = 0.017). Mortality was reduced in HIV-positive participants from 12 with placebo to 4 with supplementation (P = 0.029 by log-rank test), but this was not due to changes in CD4 count or nutritional status. CONCLUSION: Micronutrient supplementation with this formulation resulted in only modest reductions in severe diarrhea and reduced mortality in HIV-positive participants. The trial was registered as ISRCTN31173864

Accelerator Mass Spectrometry Can Be Used to Assess Vitamin A Metabolism Quantitatively in Boys in a Community Setting123

A survey indicated that high-dose vitamin A (HD-VA) supplements had no apparent effect on vitamin A (VA) status, assessed by serum retinol concentrations, of Zambian children lt 5 y of age. To explore possible reasons for the lack of response, we quantified absorption, retention, and urinary elimination of either a single HD-VA supplement (209.8 μmol; 60 mg) or a smaller dose of stable isotope (SI)-labeled VA (17.5 μmol; 5 mg), which was used to estimate VA pool size, in 3- to 4-y-old Zambian boys (n = 4 for each VA dose). A tracer dose of [14C2]-labeled VA (0.925 kBq; 25 nCi) was coadministered with the HD-VA supplement or SI-labeled VA, and 24-h stool and urine samples were collected for 3 and 7 consecutive days, respectively, and 24-h urine samples at 4 later time points. Accelerator MS was used to quantify 14C in stool and urine. Estimates of absorption, retention, and the urinary elimination rate (UER) were 83.8 ± 7.1%, 76.3 ± 6.7%, and 1.9 ± 0.6%/d, respectively, for the HD-VA supplement and 76.5 ± 9.5%, 71.1 ± 9.4%, and 1.8 ± 1.2%/d, respectively, for the SI-labeled VA. Mean estimates of absorption, retention, and the UER did not differ by size of the VA dose administered. Estimated absorption and retention were negatively associated with reported fever (r = minus 0.83; P = 0.011). The HD-VA supplement and SI-labeled VA were adequately absorbed, retained, and utilized in apparently healthy Zambian preschool-age boys; absorption and retention may be affected by recent fever