Welcome to the Interactive Programme of MNF 2023

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Background&Aims

Folate (vitamin B9) is an essential co-factor for one-carbon metabolism. Controversial evidence has emerged regarding the association between folate and cognitive performance. The aim of the study was to investigate the association between baseline dietary folate intake and cognitive decline in a population exposed to mandatory fortification during a median follow-up of 8 years.

Methods

Multicenter, prospective cohort study involving 15,105 public servants aged 35 to 74 years old, both sexes, from The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Baseline dietary intake was assessed by a Food Frequency Questionnaire (FFQ). Six cognitive tests were performed in the three waves to assess memory, executive function and global cognition. Linear mixed-effects models were used to assess the association between dietary folate intake at baseline and changes in cognition over time.

Results

Data from 11,276 participants were analyzed. The mean (SD) age was 51.7 (9) years, 50% were women, 63% were overweight/obese, and 56% had graduated from college or more. Overall dietary folate intake was not associated with cognitive decline; neither vitamin B12 intake was a modifier of this association. General dietary supplements and specifically multivitamins use did not affect these findings. Natural food folate group was associated with a slower rate of global cognitive decline (β (95% CI): 0.001(0.000;0.002), P = 0.015). There was no association between fortified food group and cognition scores.

Conclusion

Overall dietary folate intake was not associated with cognitive function in this Brazilian population. However, folate naturally occurring in food sources may slow global cognitive decline.

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Historically, agriculture and food systems were designed to produce food in abundance to prevent hunger and micronutrient deficiencies by ensuring nutritious agricultural products were plentiful, affordable, and accessible. As the purpose of the food system expands from avoiding deficiencies to include chronic disease reduction, the range of optimal nutrient intakes demonstrates greater population heterogeneity as the biological pathways underpinning deficiency avoidance and chronic disease reduction can be distinct. This presentation will focus on results from experimental mouse models and in vitro model systems that provide insights into the mechanisms that account for differences in folate requirements for chronic disease reduction, including neural tube defects and peripheral neuropathies. The results are discussed in light of the tension between precision nutrition and population nutrition

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Objectives: Young children are at high risk of anemia due to often overlapping risks of micronutrient deficiency, infections, and inflammation. The objective of this analysis was to gain insight into the metabolic effects of these conditions in a sample of 6-9 month old infants.

Methods: Baseline plasma samples from 400 randomly selected participants enrolled in a randomized controlled trial of eggs for complementary feeding were analyzed. Presence of anemia (hemoglobin < 11.0 g/dL), iron deficiency (ferritin < 12.0ug/L or soluble transferrin receptor > 8.3mg/L), inflammation (c-reactive protein >5 or α-1-acid glycoprotein > 1), and malaria (positive plasmodium test results) were used to categorize participants in separate analyses. Plasma metabolites were identified by Metabolon Inc using authenticated standards and compared across iron deficiency and morbidity groups using Wilcoxon rank-sum tests.

Results: Out of 837 metabolites analyzed, 63 were associated with anemia, 21 with iron deficiency, 511 with inflammation, and 315 with malaria. Six metabolites were common between iron deficiency and anemia, and 49 metabolites were common between anemia and malaria. Three metabolites were distinct to anemia, five to iron deficiency, 236 to inflammation, and 51 to malaria.

Conclusions: Anemia, iron deficiency, inflammation, and malaria affect the metabolome of young children. Some metabolites were associated with multiple conditions, but there were also metabolites that were unique to each condition. These results identify metabolites that may be useful to target for future exploration of biomarkers for iron deficiency and anemia and to understand the metabolic effects of these conditions on child health.

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Objective: The overall study used the principles and frameworks of implementation research in developing a model for WIFAS intervention. We identified barriers and facilitators of the implementation of WIFAS program. We adapted the implementation strategy (operational guideline) based on our findings of implementation bottlenecks and facilitators. Finally, we documented lessons and evaluated effectiveness using WIFAS coverage and adherence indicators.

Results: We used home room teachers and selected a fixed day to deliver the supplement. We selected a day that was not a market and fasting day and with good rate of attendance. We used three different modalities to deliver the service i.e. observed; take home and girl to girl approach. Take home delivery modality was used during school break, semester break and fasting seasons.

We identified and enrolled 16, 323 adolescent girls. Among these, 87.9% consumed at least one IFA tablet. The adherence levels of adolescent girl’s significantly improved over the supplementation period. The WIFAS adherence level reached to 93.7% at the sixth month of supplementation period.

Key challenges are mainly related absenteeism resulting non-adherence, unavailability of safe water in the school and mobility of adolescent girls. Refusal to take supplement and defaulting from program by girls due to bullying by boys was also documented.

Conclusions: We demonstrated a high coverage and adherence of WIFA supplementation among adolescent girls. We identified key program barriers and developed mitigation strategies for improved coverage and documented lessons to be used for scale up.

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Surprisingly few reports are available to predict bioavailability of minerals from foods using models containing load, absorption enhancers, and absorption inhibitors in foods. Attempts at developing bioavailability algorithms have been reported for iron and zinc. For iron, these algorithms have included physiological status of the host to adjust iron requirements rather than a means to predict iron bioavailability from various foods. Recently, an algorithm for predicting calcium absorption from foods using calcium, oxalate, and phytate loads has been developed. Algorithms to predict bioavailability of minerals can be used to assess mineral deficiencies for individuals, groups, and geographical regions and for policy and strategies to reduce gaps in nutrient needs relative to requirements. The International Life Sciences Institute US & Canada seeks partners and advisors to develop micronutrient bioavailability algorithms and their applications for individuals and populations. This presentation will discuss benefits and challenges to developing micronutrient bioavailability algorithms.

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A key aspect of improving micronutrient resilience is ensuring that those who are displaced by conflict and crises have access to micronutrient-dense foods, such as animal-source foods. An intervention in Mozambique aimed to do this by providing chickens and training on chicken-rearing practices to people in an internally displaced persons (IDPs) camp in Nampula Province. To understand the feasibility of this intervention and inform future similar approaches, we performed 15 in-depth individual interviews and a cross-sectional survey of 123 beneficiaries to understand the IDPs' prior experience with chicken rearing, views on eggs and chicken as food, and intervention experiences. Eggs and chickens were seen as desirable, healthy foods, including for young children, and most respondents did not give cultural taboos importance. However, chickens were mostly kept to reproduce and eventually sell, and eggs were mostly kept to hatch, not eat; those who mentioned eating eggs and chickens did so only occasionally. Many described chickens as an emergency savings device that gave them financial stability in difficult times: something they could sell when they needed money and did not have other options. Most respondents had fewer chickens than they had been given a few months earlier; the vast majority reported the chickens had died. Due to fears of theft, many kept chickens in their homes, potentially predisposing household members to environmental enteropathy. To improve nutrition impact in the future, similar approaches would need to address this potential unintended consequence as well as to encourage egg and chicken consumption.

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Micronutrient deficiency which is commonly found amongst pregnant and lactating mothers (LM) in developing countries has significant deleterious impact on both the mother and child. Very limited studies have explored effect of multiple micronutrient supplementation (MMS) on human milk(HM) selenium profile. This study assessed the effect of MMS on HM selenium levels and nutritional status of their infants.

This quasi-experimental study involved 66 mother– child pair who were assigned to intervention group (IG) and control group (CG) using simple random sampling. The IG received MMS containing 65µg selenium while the CG received placebo. HM samples were collected at ≤ 5 days, 6 weeks and 10 weeks. Child anthropometrics were collected; and selenium in HM was analysed. Selenium intake was assessed using a multi-pass 24-hour dietary recall method. Data were analysed using descriptive statistics, bivariate analysis and correlation at α_0.05.

The weight of the LM were 70.84±10.58kg and 66.32±10.45kg at baseline and endline. At baseline, 6 and 10 weeks, HM selenium concentration reduced in both IG (223.2±16.5µg/l, 141.3±5.9µg/l, 129.8±5.0µg/l) and CG (214.29±14.4 µg/l, 141.2±6.3 µg/l, 129.1±6.3 µg/l), respectively. Mean selenium intake of LM was 64.3±45.47µg/day which is low compared to the dietary reference intake of 70µg/day. MMS was not associated with changes in HM selenium of the LM. There was no association between changes in stunting, wasting and underweight of the infants of the LM in both groups.

Further research should be done to examine the effects of supplementing LM with higher dose of selenium in MMS vs single selenium supplementation.

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Thyroglobulin (Tg) has been considered a measure of population iodine status but there is no global guidance. Median Tg levels for iodine sufficiency were previously reported by the World Health Organization (WHO) but removed due to lack of evidence. This analysis examines Tg and spot urinary iodine concentration (UIC) data from Guatemala’s 2017–2018 Epidemiological Health and Nutritional Surveillance System. The analysis aims to identify Tg concentrations that correspond to published thresholds for population iodine status among women ages 15–49 years.

We analyzed data from 813 Guatemalan women with both UIC and Tg measurements. Correlations both at individual and population levels were examined for both indicators. We used bootstrap sampling with replacement and combinatorics to generate population cluster k-medians of UIC (mUIC) and Tg (mTg) concentrations that correspond to WHO definitions for UIC.

Mean age was 30.0 ± 8.9 years and mTg was 10.3 ng/mL (9.9, 10.7). Overall, mUIC was 150.8 µg/L (141.6, 163.9) (pregnant women [165.5 µg/L, n=95] and non-pregnant women [148.7 µg/L, n=1656]). Correlations between spot UIC and Tg were not significant at the individual-level, but correlations based on population k-medians were significant, but weak, that demonstrated U-shaped relationship according to WHO categories.

The significant and graded mUIC-mTg correlations suggests that Tg concentrations predictive of UIC categories are obtainable for Guatemalan women ages 15–49 years.

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Background: Anemia in pregnancy is a major public health problem in India. Despite IFA supplementation through national programmes, prevalence of anemia has remained unaltered. Reasons could be poor compliance to IFA or co-existing deficiencies of other micronutrients. Hence, we evaluated the effectiveness of oral multiple micronutrient supplement (MMS) in pregnancy on anemia and other micronutrient statuses.

Methods: We conducted a triple-blinded RCT in rural Haryana, India. Non-anemic pregnant women (n=200) were randomized to receive either oral MMS (30mg iron) or IFA (60mg iron) throughout pregnancy starting from second trimester. Trial was registered with Clinical Trials Registry – India (CTRI/2020/11/028999).

Results: MMS had greater effect on anemia, with difference of differences in hemoglobin 0.80 (95% CI: 0.44 – 1.16) g/dl (p<0.0001). There were significant differences between the groups in changes in serum ferritin, vitamin-B12 and folate favouring MMS. But, the proportion of participants with anemia increased from baseline to endline in both the groups. Compliance was comparable in the two groups, with 72.3% and 64.8% receiving MMS and IFA respectively having good compliance (p=0.271). Prevalence of adverse-events was slightly lower with MMS compared to IFA, though not significant (32.98% vs 46.15%; p=0.067).

Conclusions: MMS is non-inferior to IFA for anemia prophylaxis in pregnancy, and is at the verge of superiority. Vitamin-B12 and folate deficiencies improved with MMS supplementation. But neither supplement was able to meet the pregnancy demands, seen by the increase in anemia prevalence in both the groups. Compliance to supplementation and adverse-events profile were not significantly different between the groups.

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Objective:

Honduras established large-scale food fortification (LSFF) programs since the 1960s but lacks up-to-date data on standards compliance. We surveyed Honduran markets to determine the micronutrient content of fortified foods.

Methods:

We collected regionally representative samples of sugar, salt, wheat and maize flours, milk, and bouillon cubes/consommé powders in 14 municipalities in six regions. In each municipality we purchased samples from the busiest stores, considering all types of foods and brands. The Institute of Nutrition of Central America and Panama completed the micronutrient determinations.

Results:

Although most salt samples were fortified, only 21% met current national standards (67–100 ppm iodine), but this standard exceeds global recommendations. Ninety-two percent of bouillon cube samples, mostly imported, contained well-iodized salt. Although all sugar samples contained vitamin A, 63% met fortification standards. All wheat flour samples were fortified and 87% met iron fortification standards. Although fortification of maize flour is voluntary, 28% of samples were fortified. Similarly, 86% of ultra-high temperature milk and 67% of powdered milk were fortified.

Conclusions:

Sugar and wheat flour fortification is working acceptably well despite lack of constant inspection. Bouillon cubes used well-iodized salt. Industry-processed milk is fortified voluntarily. Maize fortification has potential to benefit the population given high use of industrially processed flour (greater than 70%). Although most salt contains iodine, compliance with the current standard is low. Despite the success of LSFF in Honduras, attention to enforcement, a review of the salt standard, and consideration of compulsory fortification of maize and dairy products is needed.

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Introduction: The combined sandwich-ELISA (s-ELISA; VitMin Lab, Germany) and the Quansys Q-Plex™ Human Micronutrient Array (7-Plex) are multiplex serum assays that are used to assess population micronutrient status in low-income countries. We aimed to compare the agreement of five analytes, α-1-acid glycoprotein (AGP), C-reactive protein (CRP), ferritin, retinol binding protein 4 (RBP4), and soluble transferrin receptor (sTfR) as measured by the 7-Plex and the s-ELISA. Methods: Pregnant women (n=249) were recruited at primary healthcare clinics in Johannesburg and serum samples were collected between March 2016 and December 2017. Agreement between continuous measurements was assessed by Bland-Altman plots and concordance measures. Agreement in classifications of deficiency or inflammation was assessed by Cohen’s kappa. Results: Strong correlations (r>0.80) were observed between the 7-Plex and s-ELISA for CRP and ferritin. The 7-Plex assay gave consistently higher measurements than the s-ELISA except for CRP. Except for CRP (Lin’s ρ=0.92), there was poor agreement between the two assays, with Lin’s ρ <0.90. Discrepancies of test results difference between methods increased as the serum concentrations rose. Cohen’s kappa for all the five analytes was <0.81 and ranged from slight agreement (vitamin A deficiency) to substantial (inflammation, iron deficiency) agreement. Conclusion: The 7-Plex 1.0 is a research and or surveillance tool with potential for use in low-resource laboratories but cannot be used interchangeably with the s-ELISA. Further optimising and validation is required to establish its interchangeability with other validated methods.

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Vitamin B2 & B6 are essential in fat, protein, and carbohydrate metabolism. Both with B12 have prominent role in one-C-metabolism. B2 & B6 deficiency are common in developing countries due to adaptation to a vegetarian culture. Cobalamin in milk is HO-B12 unlike CN- B12 or CH3-B12 in the pills. Studies confirm equal uptake of CN-B12 & HO-B12 but distribute differently in the human body where, HO-B12 is expressed in the liver more efficiently than CN-B12. However, there is paucity in study regarding changes in Vit B2 & Vit B6 levels after dairy products intake. These findings raise questions; What are the changes in B2 & B6 after milk/pill supplementation? Which milk is better to improve B12 status? We aimed to see the effect of four-weeks supplementation on B2, B6 & B12 concentration in lactovegetarians.

An intervention study was designed to supplement and observe the effect of daily intake of 2 oral doses of cow milk (200 mL, n-23), buffalo milk (200 mL, n-22) and CN-B12 (0.78 ug, n-22) for 4 weeks on vitamin status of vitamin B12 deficient adults. Blood was collected at baseline and 4 weeks post supplementation for measuring plasma B2, B6, B12, holotranscobalamin and homocysteine on Architect.

Daily intake of milk/tablet improved the B12 status of all the subjects. Plasma B2 and B6 concentrations were decreased in milk supplemented groups, more in buffalo milk group. The reduction was associated with base line B12 status. Milk supplement appeared to stimulate the metabolic utility of B2 and B6 vitamins.