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1.  Newborn length predicts early infant linear growth retardation and disproportionately high weight gain in a low-income population1-2 
Early human development  2013;89(12):10.1016/j.earlhumdev.2013.09.008.
Background
Stunting is prevalent by the age of 6 mo in the indigenous population of the Western Highlands of Guatemala.
Aim
The objective of this study was to determine the time course and predictors of linear growth failure and weight-for-age in early infancy.
Study Design and Subjects
One hundred and forty eight term newborns had measurements of length and weight in their homes, repeated at 3 and 6 mo. Maternal measurements were also obtained.
Results
Mean ± SD length-for-age Z-score (LAZ) declined from newborn -1.0 (1.01) to -2.20 (1.05) and -2.26 (1.01) at 3 and 6 mo respectively. Stunting rates for newborn, 3 and 6 mo were 47%, 53% and 56% respectively. A multiple regression model (R2 = 0.64) demonstrated that the major predictor of LAZ at 3 mo was newborn LAZ with the other predictors being newborn weight-for-age Z-score (WAZ), gender and maternal education*maternal age interaction. Because WAZ remained essentially constant and LAZ declined during the same period, weight-for-length Z-score (WLZ) increased from -0.44 to +1.28 from birth to 3 mo. The more severe the linear growth failure, the greater WAZ was in proportion to the LAZ.
Conclusion
The primary conclusion is that impaired fetal linear growth is the major predictor of early infant linear growth failure indicating that prevention needs to start with maternal interventions.
doi:10.1016/j.earlhumdev.2013.09.008
PMCID: PMC3859373  PMID: 24083893
2.  Zinc Absorption from Micronutrient Powder Is Low but Is not Affected by Iron in Kenyan Infants 
Nutrients  2014;6(12):5636-5651.
Interference with zinc absorption is a proposed explanation for adverse effects of supplemental iron in iron-replete children in malaria endemic settings. We examined the effects of iron in micronutrient powder (MNP) on zinc absorption after three months of home fortification with MNP in maize-based diets in rural Kenyan infants. In a double blind design, six-month-old, non-anemic infants were randomized to MNP containing 5 mg zinc, with or without 12.5 mg of iron (MNP + Fe and MNP − Fe, respectively); a control (C) group received placebo powder. After three months, duplicate diet collections and zinc stable isotopes were used to measure intake from MNP + non-breast milk foods and fractional absorption of zinc (FAZ) by dual isotope ratio method; total absorbed zinc (TAZ, mg/day) was calculated from intake × FAZ. Mean (SEM) TAZ was not different between MNP + Fe (n = 10) and MNP − Fe (n = 9) groups: 0.85 (0.22) and 0.72 (0.19), respectively, but both were higher than C (n = 9): 0.24 (0.03) (p = 0.04). Iron in MNP did not significantly alter zinc absorption, but despite intakes over double estimated dietary requirement, both MNP groups’ mean TAZ barely approximated the physiologic requirement for age. Impaired zinc absorption may dictate need for higher zinc doses in vulnerable populations.
doi:10.3390/nu6125636
PMCID: PMC4276989  PMID: 25493942
zinc absorption; micronutrient powders; iron supplementation; malaria; Kenya
3.  Effects of Different Complementary Feeding Regimens on Iron Status and Enteric Microbiota in Breastfed Infants 
The Journal of pediatrics  2013;163(2):416-423.e4.
Objectives
To compare iron status in breastfed infants randomized to complementary feeding regimens that provided iron from fortified infant cereals or meats, and examined the development of the enteric microbiota among groups.
Study design
Forty-five exclusively breastfed 5 month old infants were randomized to commercially available pureed meats, iron- and zinc-fortified infant cereals, or iron-only fortified infant cereals as the first and primary complementary food through 9–10 months of age. Dietary iron was determined by monthly 3-d diet records. Iron status was assessed at end of the study by hemoglobin (Hb), serum ferritin (SF), and soluble transferrin receptor (STfR) measurements. In a subsample 14 infants, enteric microbiota were profiled in monthly stool samples (5–9 mo) by 16S rRNA gene pyrosequencing.
Results
Infants in cereal groups had 2–3 fold greater daily iron intakes vs the meat group (P < 0.0001). 27% of participants had low SF, and 36% were mildly anemic, without significant differences by feeding group; more infants in meat group had high STfR (p=0.03). Sequence analysis identified differences by time and feeding group in the abundances of several bacterial groups, including significantly more abundant butyrate producing Clostridium Group XIVa in the meat group (P=0.01)
Conclusions
A high percentage of healthy infants who were breastfed-only were iron deficient, and complementary feeding, including iron exposure, influenced the development of the enteric microbiota. If these findings are confirmed, reconsideration of strategies to both meet infants’ iron requirements and optimize the developing microbiome may be warranted.
doi:10.1016/j.jpeds.2013.01.024
PMCID: PMC3674183  PMID: 23452586
iron; complementary feeding; breastfeeding; phylogeny; microbiome
4.  Preconception maternal nutrition: a multi-site randomized controlled trial 
Background
Research directed to optimizing maternal nutrition commencing prior to conception remains very limited, despite suggestive evidence of its importance in addition to ensuring an optimal nutrition environment in the periconceptional period and throughout the first trimester of pregnancy.
Methods/Study design
This is an individually randomized controlled trial of the impact on birth length (primary outcome) of the time at which a maternal nutrition intervention is commenced: Arm 1: ≥ 3 mo preconception vs. Arm 2: 12-14 wk gestation vs. Arm 3: none.
192 (derived from 480) randomized mothers and living offspring in each arm in each of four research sites (Guatemala, India, Pakistan, Democratic Republic of the Congo). The intervention is a daily 20 g lipid-based (118 kcal) multi-micronutient (MMN) supplement. Women randomized to receive this intervention with body mass index (BMI) <20 or whose gestational weight gain is low will receive an additional 300 kcal/d as a balanced energy-protein supplement. Researchers will visit homes biweekly to deliver intervention and monitor compliance, pregnancy status and morbidity; ensure prenatal and delivery care; and promote breast feeding. The primary outcome is birth length. Secondary outcomes include: fetal length at 12 and 34 wk; incidence of low birth weight (LBW); neonatal/infant anthropometry 0-6 mo of age; infectious disease morbidity; maternal, fetal, newborn, and infant epigenetics; maternal and infant nutritional status; maternal and infant microbiome; gut inflammatory biomarkers and bioactive and nutritive compounds in breast milk. The primary analysis will compare birth Length-for-Age Z-score (LAZ) among trial arms (independently for each site, estimated effect size: 0.35). Additional statistical analyses will examine the secondary outcomes and a pooled analysis of data from all sites.
Discussion
Positive results of this trial will support a paradigm shift in attention to nutrition of all females of child-bearing age.
Trial registration
ClinicalTrials.gov NCT01883193.
doi:10.1186/1471-2393-14-111
PMCID: PMC4000057  PMID: 24650219
Preconception; Maternal; Nutrition; Birth length; Epigenetics; Microbiome
5.  Bioavailability of zinc oxide added to corn tortilla is similar to that of zinc sulfate and is not affected by simultaneous addition of iron 
Food and nutrition bulletin  2012;33(4):261-266.
Background
Corn tortilla is the staple food of Mexico and its fortification with zinc, iron, and other micronutrients is intended to reduce micronutrient deficiencies. However, no studies have been performed to determine the relative amount of zinc absorbed from the fortified product and whether zinc absorption is affected by the simultaneous addition of iron.
Objective
To compare zinc absorption from corn tortilla fortified with zinc oxide versus zinc sulfate and to determine the effect of simultaneous addition of two doses of iron on zinc bioavailability.
Methods
A randomized, double-blind, crossover design was carried out in two phases. In the first phase, 10 adult women received corn tortillas with either 20 mg/kg of zinc oxide added, 20 mg/kg of zinc sulfate added, or no zinc added. In the second phase, 10 adult women received corn tortilla with 20 mg/kg of zinc oxide added and either with no iron added or with iron added at one of two different levels. Zinc absorption was measured by the stable isotope method.
Results
The mean (± SEM) fractional zinc absorption from unfortified tortilla, tortilla fortified with zinc oxide, and tortilla fortified with zinc sulfate did not differ among treatments: 0.35 ± 0.07, 0.36 ± 0.05, and 0.37 ± 0.07, respectively. The three treatment groups with 0, 30, and 60 mg/kg of added iron had similar fractional zinc absorption (0.32 ± 0.04, 0.33 ± 0.02, and 0.32 ± 0.05, respectively) and similar amounts of zinc absorbed (4.8 ± 0.7, 4.5 ± 0.3, and 4.8 ± 0.7 mg/day, respectively).
Conclusions
Since zinc oxide is more stable and less expensive and was absorbed equally as well as zinc sulfate, we suggest its use for corn tortilla fortification. Simultaneous addition of zinc and iron to corn tortilla does not modify zinc bioavailability at iron doses of 30 and 60 mg/kg of corn flour.
PMCID: PMC3909684  PMID: 23424892
Corn tortillas; food fortification; stable isotopes; zinc absorption; zinc oxide
6.  EVALUATION OF MEAT AS A FIRST COMPLEMENTARY FOOD FOR BREASTFED INFANTS: IMPACT ON IRON INTAKE & GROWTH 
Nutrition reviews  2011;69(0 1):10.1111/j.1753-4887.2011.00434.x.
The rationale is considered for promoting the availability of local, affordable, non-fortified food sources of bioavailable iron in developing countries. Intakes of iron from the regular consumption of meat from the age of six months are evaluated with respect to physiological requirements. The paper includes a description of two major randomized controlled trials of meat as a first and regular complementary food that are currently in progress. These trials involve poor communities in Guatemala, Pakistan, Zambia, Democratic Republic of the Congo and China.
doi:10.1111/j.1753-4887.2011.00434.x
PMCID: PMC3875190  PMID: 22043884
iron; meat; complementary feeding
7.  Biofortification of Pearl Millet with Iron and Zinc in a Randomized Controlled Trial Increases Absorption of These Minerals above Physiologic Requirements in Young Children123 
The Journal of Nutrition  2013;143(9):1489-1493.
Millet is unusually drought resistant and consequently there is a progressive increase in the use of these grains as a human food staple, especially in large areas of India and sub-Saharan Africa. The purpose of this study was to determine the absorption of iron and zinc from pearl millet biofortified with 2 micronutrients that are typically deficient in nonfortified, plant-based diets globally. The study was undertaken in 40 children aged 2 y in Karnataka, India (n = 21 test/19 controls). Three test meals providing ∼84 ± 17 g dry pearl millet flour were fed on a single day for zinc and 2 d for iron between 0900 and 1600 h. The quantities of zinc and iron absorbed were measured with established stable isotope extrinsic labeling techniques and analyses of duplicate diets. The mean (± SD) quantities of iron absorbed from test and control groups were 0.67 ± 0.48 and 0.23 ± 0.15 mg/d, respectively (P < 0.001). The quantities of zinc absorbed were 0.95 ± 0.47 and 0.67 ± 0.24 mg/d, respectively (P = 0.03). These data did not include absorption of the modest quantities of iron and zinc contained in snacks eaten before and after the 3 test meals. In conclusion, quantities of both iron and zinc absorbed when iron and zinc biofortified pearl millet is fed to children aged 2 y as the major food staple is more than adequate to meet the physiological requirements for these micronutrients.
doi:10.3945/jn.113.176677
PMCID: PMC3743277  PMID: 23843474
8.  Infant Stunting Is Associated With Short Maternal Stature 
The objectives were to determine the range of maternal height associated with growth velocity of older infants and the magnitude of this association in an indigent population. Maternal height and infant length-for-age z scores (LAZ) were positively correlated at both 6 (n=412, r=0.324) and 12 (n=388, r=0.335) months (P<0.0001) and for maternal heights from 131 to 164 cm. Maternal height is independently associated with infant LAZ and stunting (LAZ <−2) at both 6 and 12 months (P<0.001) and with linear growth velocity from 6 to 12 months (P=0.0023).
doi:10.1097/MPG.0b013e3182331748
PMCID: PMC3607506  PMID: 21866055
infant growth; maternal height; stunting
9.  Fecal calprotectin levels are higher in rural than in urban Chinese infants and negatively associated with growth 
BMC Pediatrics  2012;12:129.
Background
Fecal calprotectin (FC) is an established simple biomarker of gut inflammation. To examine a possible relationship between linear growth and gut inflammation, we compared fecal calprotectin levels in 6 month old infants from poor rural vs affluent urban families.
Methods
The project was a cross-sectional comparison of FC from rural and urban populations in China. The relationship between length-for-age Z-score (LAZ) and FC concentrations were also compared. Single fecal samples were assayed for FC using EK-CAL ELISA kits.
Results
The age of subjects for both locations was 6.1 ± 0.2 mo; all were apparently healthy. The mean ± SD of the LAZ for the rural and urban infants were −0.6 ± 0.9 and 0.4 ± 0.9, respectively. FC had a non-normal distribution. The median FC of 420.9 and 140.1 μg/g for rural and urban infants, respectively, were significantly different (P < 0.0001). For the rural group, linear regression analysis showed that an increase in FC of 100 μg/g was associated with a decrease of 0.06 in LAZ.
Conclusion
FC levels were significantly elevated in the rural infants and high concentrations accounted for approximately one-third of the low LAZ scores of these infants.
doi:10.1186/1471-2431-12-129
PMCID: PMC3504525  PMID: 22917269
Fecal calprotectin; Infants; Children; Gut inflammation; Growth
10.  Complementary feeding: a Global Network cluster randomized controlled trial 
BMC Pediatrics  2011;11:4.
Background
Inadequate and inappropriate complementary feeding are major factors contributing to excess morbidity and mortality in young children in low resource settings. Animal source foods in particular are cited as essential to achieve micronutrient requirements. The efficacy of the recommendation for regular meat consumption, however, has not been systematically evaluated.
Methods/Design
A cluster randomized efficacy trial was designed to test the hypothesis that 12 months of daily intake of beef added as a complementary food would result in greater linear growth velocity than a micronutrient fortified equi-caloric rice-soy cereal supplement. The study is being conducted in 4 sites of the Global Network for Women's and Children's Health Research located in Guatemala, Pakistan, Democratic Republic of the Congo (DRC) and Zambia in communities with toddler stunting rates of at least 20%. Five clusters per country were randomized to each of the food arms, with 30 infants in each cluster. The daily meat or cereal supplement was delivered to the home by community coordinators, starting when the infants were 6 months of age and continuing through 18 months. All participating mothers received nutrition education messages to enhance complementary feeding practices delivered by study coordinators and through posters at the local health center. Outcome measures, obtained at 6, 9, 12, and 18 months by a separate assessment team, included anthropometry; dietary variety and diversity scores; biomarkers of iron, zinc and Vitamin B12 status (18 months); neurocognitive development (12 and 18 months); and incidence of infectious morbidity throughout the trial. The trial was supervised by a trial steering committee, and an independent data monitoring committee provided oversight for the safety and conduct of the trial.
Discussion
Findings from this trial will test the efficacy of daily intake of meat commencing at age 6 months and, if beneficial, will provide a strong rationale for global efforts to enhance local supplies of meat as a complementary food for young children.
Trial registration
NCT01084109
doi:10.1186/1471-2431-11-4
PMCID: PMC3032692  PMID: 21232139
11.  Zinc, Gravida, Infection, and Iron, but Not Vitamin B-12 or Folate Status, Predict Hemoglobin during Pregnancy in Southern Ethiopia1,2 
The Journal of nutrition  2008;138(3):581-586.
The etiology of anemia during pregnancy in rural Southern Ethiopia is uncertain. Intakes of animal-source foods are low and infections and bacterial overgrowth probably coexist. We therefore measured the dietary intakes of a convenience sample of Sidama women in late pregnancy who consumed either maize (n = 68) or fermented enset (Enset ventricosum) (n = 31) as their major energy source. Blood samples were analyzed for a complete blood count, vitamin B-12 and folate status, plasma ferritin, retinol, zinc, albumin, and C-reactive protein (CRP). The role of infection and gravida was also examined. Dietary intakes were calculated from 1-d weighed records. No cellular animal products were consumed. Of the women, 29% had anemia, 13% had iron deficiency anemia, 33% had depleted iron stores, and 74 and 27% had low plasma zinc and retinol, respectively. Only 2% had low plasma folate (<6.8 nmol/L) and 23% had low plasma vitamin B-12 (<150 pmol/L), even though 62% had elevated plasma methylmalonic acid (MMA) (> 271 nmol/L). None had elevated plasma cystathionine or total homocysteine (tHcys). Women with enset-based diets had higher (P = 0.052) plasma vitamin B-12 concentration and lower (P < 0.05) cell volume, plasma cystathionine, and retinol than women consuming maize-based diets, but mean hemoglobin, plasma ferritin, MMA, tHcys, and folate did not differ. Plasma zinc, followed by CRP (≤5 mg/L), gravida (≤4), and plasma ferritin (≥12 μmg/L) status were major positive predictors of hemoglobin. Despite some early functional vitamin B-12 deficiency, there was no macrocytic anemia. Consumption of fermented enset may have increased vitamin B-12 levels in diet and plasma.
PMCID: PMC2440679  PMID: 18287370
12.  Calcium Absorption from Tortilla Meals Prepared from Low-phytate Maize. 
Background:
Calcium fortification of maize has been achieved for millenia in Central America by the process of nixtamalization. Bioavailability of calcium is, however, compromised by phytate, present in large quantities in maize kernels and only modestly reduced by nixtamalization.
Objective:
The objective of this study was to compare calcium absorption from tortilla meals prepared from low-phytate maize with that from maize with typical phytate content.
Design:
Five healthy adult women were fed two test meals of approximately 140g tortillas in lieu of breakfast at one month intervals. On one occasion the tortillas were prepared from maize with approximately 60% phytate reduction (lpa1-1) and on the other occasion from the matching isohybrid wild-type maize. 44Ca (0.3mg/kg body weight) was administered in water as an extrinsic label commencing midway through the test meal and 42Ca (0.06 mg/kg body weight) was administered intravenously immediately after the test meal. Isotope ratios of 42Ca/43Ca and 44Ca/43Ca were measured by inductively-coupled plasma mass spectrometry in urine collected as an eight-hr pool from 16-24 hrs after administration of the intravenous tracer and prepared by the oxalate precipitation method. Fractional absorption of calcium was determined by a dual isotope ratio technique.
Results:
Mean fractional absorption from tortillas prepared from the low-phytate maize was 0.50 ± 0.03 compared with a mean of 0.35 ± 0.07 from the control maize (p = 0.01).
Conclusion:
The increase in quantity of calcium absorbed could be of practical importance for calcium nutriture when intake of dairy products is limited.
PMCID: PMC1592687  PMID: 16002804
maize; phytate; low-phytate maize alleles; tortillas; calcium absorption
13.  Zinc absorption during late pregnancy in rural southern Ethiopia2 
Background
Little is yet known about zinc absorption in late pregnancy, and no information on absorption from the total diet is available.
Objective
The objective was to measure the fractional absorption of zinc (FAZ) and to estimate the total quantity of absorbed zinc (TAZ) each day during the third trimester of pregnancy in poor rural southern Ethiopian women.
Design
The participants (n =17) were a convenience sample from a larger study population. The third stage of pregnancy was estimated from fundal height by the Bushulo Health Center prenatal outreach program. FAZ was determined with a dual-isotope tracer ratio technique that uses measurements of urine enrichment with zinc stable isotopes administered intravenously and orally, as an extrinsic label, with all meals in 1 d. Total dietary zinc (TDZ) was calculated from weighed diet records and Ethiopian food-composition tables supported by zinc and phytate analyses of major food items for individual meals. Plasma zinc and exchangeable zinc pool size were also estimated.
Results
Mean (±SD) FAZ was 0.35 ± 0.11, TDZ was 6.0 ± 3.2 mg/d, TAZ was 2.1 ± 1.0 mg/d, phytate intake was 1033 ± 843 mg/d, plasma zinc was 44.1 ± 6.0 μg/dL, and the exchangeable zinc pool size was 142 ± 39 mg. The molar ratio of phytate to zinc was 17:1.
Conclusions
Women from a poor rural population who were dependent on a moderately high-phytate diet had low TDZ and low plasma zinc concentrations in the third trimester of pregnancy. TAZ was modestly higher than that predicted but did not meet physiologic requirements.
PMCID: PMC1987331  PMID: 17093163
Zinc; absorption; phytate; pregnancy; Ethiopia

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