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Women of reproductive age (WRA) are at increased risk for anemia and iron deficiency. However, there is limited population-level data in India, which could help inform evidence-based recommendations and policy.To conduct a population-based biomarker survey of anemia, iron deficiency, and inflammation in WRA in Southern India.Participants were WRA (15-40 y) who were not pregnant or lactating. Blood samples (n = 979) were collected and analyzed for hemoglobin (Hb), serum ferritin (SF), soluble transferrin receptor (sTfR), C-reactive protein (CRP), and alpha-1 acid glycoprotein (AGP). Anemia and severe anemia were defined as Hb 12.0 and 8.0 g/dL. Serum ferritin was adjusted for inflammation using BRINDA methods. Iron deficiency was defined as SF 15.0 μg/L, iron insufficiency was defined as SF 20.0 and 25.0 μg/L, and iron deficiency anemia was defined as Hb 12.0 g/dL and SF 15.0 μg/L. Inflammation was defined as CRP5.0 mg/L or AGP1.0 g/L. Restricted cubic spline regression models were also used to determine if alternative SF thresholds should be used t to classify iron deficiency.A total of 41.5% of WRA had anemia, and 3.0% had severe anemia. Findings from spline analyses suggested a SF cut-off of15.0 μg/L, consistent with conventional cut-offs for iron deficiency. 46.3% of WRA had SF 15.0 μg/L (BRINDA-adjusted: 61.5%), 55.0% had SF 20.0 μg/L (72.7%), 61.8% had SF 25.0 μg/L (81.0%), and 30.0% had IDA (34.5%). 17.3% of WRA had CRP5.0 mg/L and 22.2% had AGP1.0 g/L. The prevalence of ID (rural vs. urban: 49.1% vs. 34.9%; p = 0.0004), iron insufficiency (57.8% vs. 43.8%; p = 0.0005), and IDA (31.8% vs. 22.4%; p = 0.01) were significantly higher in rural areas, although CRP levels were lower and there were no differences in elevated CRP or AGP.The burden of anemia and iron deficiency in this population was substantial, and increased after adjusting for inflammation, suggesting potential to benefit from screening and interventions.NCT04048330.

Anemia is an important public health problem, and accurate estimates may inform policy and programs. Although hemoglobin assessment of venous blood via automated hematology analyzers (AHA) is recommended, most population-based surveys are based on analysis of capillary blood via portable hemoglobinometers to estimate anemia prevalence.To evaluate screening methods for hemoglobin and anemia assessment using paired venous samples.Participants were women of reproductive age (15-40y) who were not pregnant or lactating. Paired venous whole blood samples (n = 896) were analyzed for hemoglobin (Hb) via portable hemoglobinometer (HemoCue 301) and Coulter Counter AHA. Anemia and severe anemia were defined as Hb12.0 and8.0 g/dL, respectively. Bland-Altman methods were used to assess level of agreement for Hb results (mean difference, standard deviation of differences, limits of agreement). Diagnostic accuracy parameters (sensitivity, specificity, positive predictive value, negative predictive value, accuracy) were calculated to evaluate HemoCue performance compared to the AHA reference, overall and by sociodemographic, nutritional, and metabolic characteristics.The estimated anemia prevalence was significantly lower via HemoCue vs. AHA (36.3% vs. 41.6%; p-value0.0001). The HemoCue had 84.4% accuracy for anemia screening and 98.8% for severe anemia, compared to the AHA reference. The HemoCue had 74.8% sensitivity and 91.2% specificity, compared to AHA. HemoCue sensitivity was higher in WRA with iron deficiency (SF15.0 μg/L 81.6% vs. SF ≥15.0 μg/L: 41.3%), and lower in WRA with metabolic risk factors, including overweight (BMI≥25.0 kg/m2; 63.9% vs. 78.8%), or elevated CRP (CRP1.0 mg/L: 67.2% vs. ≤1.0 mg/L: 82.9%), trunk fat (TF35%: 62.7% vs. ≤35%: 80.1), or whole-body fat (WBF35%: 63.9% vs. ≤35%: 80.3%).Findings suggest that women with anemia may be incorrectly identified as not anemic via portable hemoglobinometer, and the anemia prevalence may be underestimated at the population level. Registration number: NCT04048330.

BACKGROUND: Women of reproductive age are at an increased risk of anemia and micronutrient deficiencies. Evidence supports the role of periconceptional nutrition in the development of neural tube defects (NTDs) and other pregnancy complications. Vitamin B(12) deficiency is a risk factor for NTDs and may modify folate biomarkers that predict NTD risk at the population level. There is an interest in mandatory fortification with vitamin B(12) and folic acid for anemia and birth defect prevention. However, there are limited population-representative data needed to inform policy and guidelines. OBJECTIVES: This randomized trial will be conducted to evaluate the efficacy of quadruple-fortified salt (QFS; iron, iodine, folic acid, vitamin B(12)) in 1,000 households in Southern India. METHODS: Women 18 to 49 y who are not pregnant or lactating and reside within the catchment area of our community-based research site in Southern India will be screened and invited to participate in the trial. After informed consent, women and their households will be randomized to receive one of the following 4 interventions: 1) double-fortified salt (DFS; iron, iodine), 2) DFS + folic acid (iron, iodine, folic acid), 3) DFS + vitamin B(12) (iron, iodine, vitamin B(12)), or 4) DFS + folic acid and vitamin B(12) (QFS; iron, iodine, folic acid, vitamin B(12)) for 12 mo. Structured interviews will be conducted by trained nurse enumerators to collect sociodemographic, anthropometric, dietary, health, and reproductive history data. Biological samples will be collected at baseline, midpoint, and endpoint. Whole blood will be analyzed for hemoglobin using Coulter Counter. Total vitamin B(12) will be measured by chemiluminescence; red blood cell folate and serum folate will be evaluated using the World Health Organization-recommended microbiologic assay. CONCLUSIONS: The results of this randomized trial will help to evaluate the efficacy of QFS to prevent anemia and micronutrient deficiencies. Clinical trial registration numbers: NCT03853304 and Clinical Trial Registry of India REF/2019/03/024479. REGISTRATION NUMBER: NCT03853304 and REF/2019/03/024479.

This analysis was conducted to evaluate the evidence of the efficacy of iron biofortification interventions on iron status and functional outcomes. Iron deficiency is a major public health problem worldwide, with a disproportionate impact on women and young children, particularly those living in resource-limited settings. Biofortification, or the enhancing of micronutrient content in staple crops, is a promising and sustainable agriculture-based approach to improve nutritional status. Previous randomised efficacy trials and meta-analyses have demonstrated that iron-biofortification interventions improved iron biomarkers; however, no systematic reviews to date have examined the efficacy of biofortification interventions on health outcomes. We conducted a systematic review of the efficacy of iron-biofortified staple crops on iron status and functional outcomes: cognitive function (e.g. attention, memory) and physical performance. Five studies from three randomised efficacy trials (i.e. rice, pearl millet, beans) conducted in the Philippines, India and Rwanda were identified for inclusion in this review. Iron status (Hb, serum ferritin, soluble transferrin receptor, total body iron, α-1-acid glycoprotein) was measured at baseline and endline in each trial; two studies reported cognitive outcomes, and no studies reported other functional outcomes. Meta-analyses were conducted using DerSimonian and Laird random-effects methods. Iron-biofortified crop interventions significantly improved cognitive performance in attention and memory domains, compared with conventional crops. There were no significant effects on categorical outcomes such as iron deficiency or anaemia. Further studies are needed to determine the efficacy of iron-biofortified staple crops on human health, including additional functional outcomes and other high-risk populations.

OBJECTIVES: To estimate the serum folate insufficiency threshold (sf-IT) corresponding to the red blood cell (RBC) folate insufficiency threshold for optimal neural tube defect (NTD) prevention. METHODS: Participants were 977 women of reproductive age (WRA; 15–40y; not pregnant or lactating) from a population-based biomarker survey in Southern India. Venous blood samples were collected at enrollment. Plasma, serum, and red blood cells were centrifuged, processed, and stored < -80°C until batch analysis. Total vitamin B12 concentrations were measured via chemiluminescence; RBC and serum folate concentrations were measured using the World Health Organization-recommended microbiological assay. Vitamin B12 deficiency was defined as total vitamin B12

Background Women of reproductive age (WRA) are a high-risk population for anemia and micronutrient deficiencies. However, there are few representative population-level data from India, which could help inform evidence-based recommendations and policy. Objective To conduct a population-based biomarker survey of anemia and vitamin B-12 and folate status in WRA as part of a periconceptional surveillance program in southern India. Methods Participants were WRA (15–40 y) who were not pregnant or lactating. Whole blood (n = 979) was analyzed for hemoglobin via a Coulter counter (Coulter HMX). Plasma, serum, and RBCs were processed and stored at −80°C or less until batch analysis. Vitamin B-12 concentrations were measured via chemiluminescence; RBC and serum folate concentrations were evaluated via microbiological assay. Anemia and severe anemia were defined as hemoglobin

OBJECTIVES: To examine the burden of anemia and micronutrient deficiencies among young children living in urban slums of Mumbai, India. METHODS: Participants were children 10–18 months of age (n = 278) residing in urban slums in Mumbai who were screened as part of a randomized feeding trial of biofortified pearl millet. Venous blood was collected by a pediatric phlebotomist and hemoglobin (Hb) concentrations were assessed via Coulter counter. Samples were processed and stored 5.0 mg/L. Iron deficiency anemia was defined as Hb 5.0 mg/L. The prevalence of vitamin B(12) deficiency was 17.0%, 41.8% of children had vitamin B(12) insufficiency, and 19.9% had folate deficiency. Among anemic children, 84.5% had ≥1 micronutrient deficiency and 22.7% had ≥ 2 micronutrient deficiencies. Iron deficiency (RR: 2.15; 95% CI: 1.55, 2.99; P

OBJECTIVES: To conduct a biomarker survey to examine the anemia burden and vitamin B(12) and folate status in women of reproductive age as part of an ongoing periconceptional surveillance program in Southern India. METHODS: Participants were women of reproductive age (15–40 y) who were not pregnant or lactating and resided in households within the 50 km(2) catchment area of our community-based research site in Southern India. Venous blood samples were collected at enrollment (n = 813), and whole blood samples were analyzed for hemoglobin using an automated Coulter counter. Plasma, serum, and red blood cells (RBC) were separated by centrifugation, processed, and stored

OBJECTIVES: To examine biomarkers of heavy metal exposure in women of reproductive age as part of an ongoing periconceptional surveillance program in Southern India. METHODS: Participants were women of reproductive age (15–40 y) who were not pregnant or lactating and resided in households within the 50 km(2) catchment area of our community-based research site. Venous blood samples were collected in metal-free blue top K2EDTA vacutainers, and urine samples were collected in acid-washed containers. Plasma and red blood cells were separated by centrifugation, processed, and stored 5.8 µg/L. A total of 31.1% of participants had detectable chromium plasma concentrations (median (IQR): 2.5 (1.0, 15.0) µg/L), with 15.7% of samples >2.1 µg/L. Concentrations of two or more heavy metals detected in plasma were found in 41.4% of participants: 7.1% lead and mercury, 18.6% lead and chromium, 10.0% mercury and chromium, and 5.7% with all three detected in plasma. No participants in this pilot sub-sample had plasma concentrations of arsenic or cadmium above the detection limit for this method (≥1.0 µg/L). CONCLUSIONS: Findings from this pilot study provide preliminary evidence of heavy metal exposure – including lead, mercury, and chromium – in women of reproductive age in this setting. Because of potential interactions between exposure to heavy metals and folate status that may impact the risk of birth defects, biomarker surveillance of heavy metals remains a critical component of this program. FUNDING SOURCES: Centers for Disease Control and Prevention. AF was supported by the National Institutes of Health #5 T32 HD087137

OBJECTIVES: To examine the burden of metabolic outcomes and associations of vitamin B(12) status with metabolic health in women of reproductive age (WRA), as part of a population-based biomarker survey in Chittoor, India. METHODS: Participants (980 WRA; 15–40y nonpregnant or lactating) were assessed for glycated hemoglobin (HbA1c; nephelometry) and serum vitamin B(12) concentrations (chemiluminescence). Anthropometric measurements and systolic (SBP) and diastolic (DBP) blood pressures were collected in triplicate. Bioelectrical impedance analysis was used to evaluate whole body (WF%) and trunk (TF%) fat among women ≤ 18y. We defined elevated HbA1c as ≤ 6.5% and ≤ 5.7-< 6.5%, and hypertension as stage 1 (SBP 130–139 or DBP 80–89 mmHg) and stage 2 (SBP ≤ 140 or DBP ≤ 90 mmHg). Vitamin B(12) was natural logarithmically transformed prior to analyses; vitamin B(12) deficiency was defined as

OBJECTIVES: To conduct a biomarker survey to examine the burden of anemia, iron deficiency, and inflammation in women of reproductive age in Southern India. METHODS: Participants were women of reproductive age (15–40 y; n = 980) who were not pregnant or lactating and resided in households within the 50 km,(2) catchment area of our periconceptional surveillance program in Southern India. Venous blood samples were collected at enrollment by a trained laboratory technician at our research facility. Whole blood samples were analyzed for hemoglobin (Hb) using an automated Coulter counter. Plasma, serum, and red blood cells were separated by centrifugation, processed, and stored 5.0 mg/L, AGP > 1.0 g/L). RESULTS: A total of 41.1% of women were anemic and 2.9% had severe anemia. In the biomarker analyses, 53.8% of women were iron deficient (67.2% after BRINDA adjustment) and 29.1% had iron deficiency anemia (31.2% after BRINDA adjustment). A total of 14.7% of women had elevated CRP levels (>5.0 mg/L) and 24.4% had elevated AGP (>1.0 g/L) concentrations. CONCLUSIONS: The substantial burden of anemia and iron deficiency in this study population suggest an opportunity for prevention of anemia and micronutrient deficiencies. Findings from this biomarker survey will inform the development of a randomized efficacy trial for the prevention of anemia and birth defects in Southern India. FUNDING SOURCES: This study was supported by the Centers for Disease Control and Prevention (CDC), and the University of South Carolina's Disability Research and Dissemination Center through its cooperative agreement with the Centers for Disease Control and Prevention. AF was supported by the National Institutes of Health.

OBJECTIVES: To characterize the reproductive history and pregnancy outcomes in women of reproductive age as part of an ongoing periconceptional surveillance program in Southern India. METHODS: Participants were women of reproductive age (15-40 y) who were not pregnant or lactating and resided in households within the 50 km(2) catchment area of our community-based research site in Southern India (n = 813). After obtaining informed consent/assent, reproductive and obstetric histories were captured by a trained OB/GYN nurse via an electronic interviewer-administered questionnaire with the study participants. RESULTS: In this population, most participants reported being married (76.1%) and having some formal education (83.7%), with a median age of 30 (interquartile range [IQR] 24, 36) years. The average age of menarche reported was 13.0 (IQR 12.0, 14.0) years, and the median age at first pregnancy was 19.0 (IQR 17.0, 21.0) years. A total of 76.6% of women reported at least one previous pregnancy; 7.9% were primiparous and 65.7% were multiparous, with a median of 2.0 (IQR 2.0, 2.0) children currently living per woman. Approximately 80% of women reported taking any iron (80.4%) or folic acid (77.9%) supplements at any point during pregnancy. To date, women reported a total of 1,614 previous pregnancies with 1,318 live births (n = 1,308 singleton live births, n = 5 sets of twins), 169 spontaneous abortions, 94 induced abortions, and 42 stillbirths. Fifteen pregnancies were reported to have been affected by birth defects (n = 1 cleft lip, n = 2 cleft palate with cleft lip, n = 2 talipes equinovarus/clubfoot, n = 3 spina bifida, n = 3 encephalocele, n = 1 anencephaly, and n = 3 other birth defects). A total of 48 women reported a biological relative with a birth defect diagnosed at birth. CONCLUSIONS: A substantial burden of birth defects was reported in this population (7 neural tube defects in 1,614 pregnancies). Findings from this survey will inform the establishment of an ongoing birth defects surveillance system and a randomized efficacy trial for prevention of anemia and birth defects in Southern India. FUNDING SOURCES: Centers for Disease Control and Prevention. AF was supported by the National Institutes of Health #5 T32 HD087137

Vitamin B12 deficiency has been associated with increased risk of adverse pregnancy outcomes. Few prospective studies have investigated the burden or determinants of vitamin B12 deficiency early in life, particularly among pregnant adolescents and their children. The objectives of this study were to determine the prevalence of vitamin B12 deficiency and to examine associations between maternal and neonatal vitamin B12 status in a cohort study of healthy pregnant adolescents. Serum vitamin B12 and folate concentrations were measured in adolescents at mid-gestation (n = 124, 26.4 &plusmn, 3.5 weeks) and delivery (n = 131, 40.0 &plusmn, 1.3 weeks), and in neonates at birth using cord blood. Linear regression was used to examine associations between maternal and neonatal vitamin B12 status. Although the prevalence of vitamin B12 deficiency (&lt, 148.0 pmol/L, 1.6%) in adolescents was low during pregnancy, 22.6% of adolescents were vitamin B12 insufficient (&lt, 221.0 pmol/L, 22.6%) at mid-gestation. Maternal vitamin B12 concentrations significantly decreased from mid-gestation to delivery (p &lt, 0.0001), and 53.4% had insufficient vitamin B12 status at delivery. Maternal vitamin B12 concentrations (p &lt, 0.001) and vitamin B12 deficiency (p = 0.002) at delivery were significantly associated with infant vitamin B12 concentrations in multivariate analyses, adjusting for gestational age, maternal age, parity, smoking status, relationship status, prenatal supplement use, pre-pregnancy body mass index, race, and intake of vitamin B12 and folate. Maternal vitamin B12 concentrations significantly decreased during pregnancy and predicted neonatal vitamin B12 status in a cohort of healthy pregnant adolescents.