Efficacy of Amaranth Grain Flour or Multi-micronutrient Fortified Maize Porridge on Iron of Kenyan Pre-school Children: A Randomized, Controlled Intervention.

Objectives: Adding iron-rich foods or multi-micronutrients powder (MNP) could be options to control iron deficiency anaemia (IDA) in children. Data evaluating the impact of fortification with iron-rich foods such as amaranth grain and MNP containing low doses of highly bio-available iron to control IDA is limited. We assessed the efficacy of maize porridge enriched with amaranth grain or MNP to reduce IDA in Kenyan pre-school children. Methods: In a 16-week intervention trial, children (n=279; 12-59 months) were randomly assigned to: unrefined maize porridge (control; 4.1 mg of iron/meal); unrefined maize (30%) and amaranth grain (70%) porridge (amaranth group; 23 mg of iron/meal); or unrefined maize porridge with MNP (MNP group; 6.6 mg iron/meal; 2.5 mg iron as NaFeEDTA). Primary outcomes were anaemia and iron status with treatment effects estimated relative to control. Results: At baseline, 38% were anaemic and 30% iron deficient. Consumption of MNP reduced prevalence of anaemia [-46% (95% CI= -67,-12)], ID [-70% (95% CI=-89,-16)], IDA [-75% (95% CI= -92,-20)] and soluble transferrin receptor [-10% (95% CI=-16,-4)] concentration while significantly increasing haemoglobin [2.7 g/L (95% CI= 0.4, 5.1)] and plasma ferritin [40% (95% CI=10, 95)] concentration. There was no significant change in haemoglobin or iron status in the amaranth group. Conclusions: Consumption of maize porridge fortified with low dose highly bio-available iron MNP can reduce the prevalence of IDA in pre-school children. In contrast, fortification with amaranth grain even when shown to have high iron concentration without reduction of phytic acid may not show significant improvement in iron status.

Effects of High and Low Dose Iron-Containing Micronutrient Powders for In-Home Fortification of Complementary Foods on the Gut Microbiome and Gut Inflammation in Kenyan Infants.

Objectives: Primary outcome was change in composition of gut microbiome, after 3 weeks and 4 months. Secondary outcomes were changes in faecal calprotectin, treated diarrhoea, anaemia, iron status and systemic inflammation. Methods: We performed two randomized controlled trials in 6-month-old Kenyan infants consuming home-fortified maize porridge daily for four months. 1) infants received an MNP containing 2.5 mg iron as NaFeEDTA (+2.5 mgFeMNP) or the identical MNP without iron (-2.5 mgFeMNP). 2) a different MNP containing 12.5 mg iron as ferrous fumarate (+12.5 mgFeMNP) or the identical MNP without iron (-12.5 mgFeMNP). Results: We enrolled 117 infants, and 101 infants completed the studies between March 2010 and September 2012. Baseline prevalence of anaemia and systemic inflammation were 67.3% and 29.7%, respectively. At baseline, 63% of the total microbial 16S rRNA could be assigned to Bifidobacteriaceae; using qPCR, Salmonella was detected in 22.8% of infants, B. cereus in 38.6%, S. aureus in 71.3%, C. difficile in 53.5%, and C. perfringens in 86.1%. Body iron stores increased in the +12.5 mgFeMNP (p=0.001), but not in the +2.5 mgFeMNP. Using pyrosequencing, +FeMNPs increased enterobacteria, especially Escherichia/Shigella (p=0.048), the enterobacteria/ bifidobacteria ratio (p=0.020), and Clostridium (p=0.03) compared to -FeMNPs; +FeMNPs also increased faecal calprotectin (p=0.002). Most of these effects were confirmed using qPCR, and many were statistically stronger in ±12.5 mgFeMNP study than in ±2.5 mgFeMNP study. During the trial, 27.3% of infants in the +12.5 mgFeMNP group required treatment for diarrhoea vs. 8.3% in the -12.5 mgFeMNP group (p=0.092). Conclusions: In rural Africa where infectious disease burden is high, provision of iron-containing MNPs to infants increases gut inflammation and modifies the gut microbiome toward a potentially more pathogenic profile.

Dietary Diversity is a Good Indicator of Micronutrient Intake among Kenyan Women, Moderated by Season.

Objectives: Determining that dietary diversity can be used as indicator of micronutrient adequacy irrespective of season, we examined seasonal variations in dietary diversity, nutrient adequacy, and their association among Kenyan women (reproductive age). Methods: Repeated non-consecutive 24hr-recalls data collected during pre-harvest (period 1, Oct 2007, n=73), post-harvest (period 2, April 2008, n=203) and pre-harvest (period 3, Oct 2008, n=192) seasons. We constructed dietary diversity scores (DDS) based on 13 food groups, minimum intake of 15 g and calculated mean probability of adequacy (MPA) for 11 micronutrients. Correlations / regression analysis tested association between DDS and MPA and effects of season. Sensitivity/specificity analysis detected cut-off values of DDS indicating low nutrient adequacy. Results: DDS ranged from 4.5±1.2 period 1 to 3.2±1.3 period 3, indicating low diverse diet, based on starchy staples, without consumption of organ meat and fish. MPA ranged from 0.36±0.07 period 1 to 0.11±0.08 period 3. DDS and MPA were significantly associated in all seasons, the strength of association varied slightly per season, being stronger in the post/pre-harvest periods 2 and 3. DDS cut-off of 4 (MPA≤40%) periods 1 and 2, and DDS cut-off of 3 (MPA≤20%) period 3, maximized sensitivity/specificity detecting low adequacy. Conclusions: DDS can be used as a simple indicator for micronutrient adequacy, but strength of association and cut-off level of DDS indicating inadequacy is moderated by season.

Effect of Provitamin A-biofortified Cassava on Vitamin A Status of Kenyan Children: A Randomised Controlled Trial.

Objectives: To measure the effect of daily consumption of provitamin A-biofortified cassava on vitamin A status in children aged 5-13 years. Methods: Mild-to-moderate vitamin A deficient children (n=342) were randomly allocated to groups receiving: 1) 375 g of white cassava and placebo supplement; 2) 375 g of white cassava and a supplement of β-carotene (1,054 μg); 3) 375 g of biofortified cassava and placebo supplement. Children received the intervention 6 days/week for 18.5 weeks. Field staff and participants were blinded to supplementation. Cooked cassava was mashed with salt and 4 g of oil per portion. Biofortified cassava supplied 208 μg RAE, which is ~50% of the age-specific estimated average requirement for vitamin A for children. The primary endpoint was serum retinol concentration and secondary endpoint was serum β-carotene concentration, both at end of intervention; in the analysis, we adjusted for sex and serum concentrations at baseline of retinol, C-reactive protein and α1-acid-glycoprotein. Results: Complete data were collected for 337 children. Compliance to cassava feeding was similar between treatment groups. Preliminary results showed that consumption of biofortified cassava and β-carotene supplementation resulted in a similar increase in retinol concentrations (for both interventions, mean: 0.81 μmol/L versus 0.77 μmol/L; difference, 95% CI: 0.04 μmol/L, 0.00─0.07 μmol/L) but in a different increase in serum β-carotene concentration (for β-carotene supplement group, mean: 0.25 μmol/L (95% CI: 0.17─0.33), for biofortified cassava group, mean: 0.81 μmol/L (95% CI: 0.73-0.88)) Conclusions: Provitamin A-biofortified cassava improves the vitamin A status of primary school children in Kenya.