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The Integrated Nutrition Project is an ongoing comprehensive elementary school-based program focused on increasing consumption of whole grains, fruits, and vegetables in children and establishing nutrition education in the schools through local partnerships. This paper reports on years three and four outcomes. It was hypothesized that blending Social Cognitive Theory with the educational philosophies of Piaget and Dewey would enhance behavior change. The primary intervention consisted of (1) 24 weekly hands-on activities taught by a resource teacher and (2) six parent-taught lunchroom “mini-lessons.” Classroom activities were designed to reinforce concepts in math, science, literacy, and social studies. The quasi-experimental design used classrooms in matched schools; 20 and 17 classes were in treatment and comparison conditions, respectively, in year four. Surveys, interviews, and lunchroom plate waste were used to assess children; teachers were interviewed. Students in treatment classrooms achieved significantly greater gains in knowledge and self-efficacy regarding food preparation and fruit and vegetable consumption and consumed 0.4 more National Cancer Institute equivalent servings of fruits and vegetables in the lunchroom. Teachers responded favorably to the resource teacher model and the hands-on approach. The project's outcomes were attributed to the intervention's theory-based behavior change focus and the use of a resource teacher who ensured consistent delivery of the intervention. Program implications include the need to explore variations of the resource teacher model and the potential for implementation on a larger scale.

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.

Background Fetal and neonatal mortality rates in low-income countries are at least 10-fold greater than in high-income countries. These differences have been related to poor access to and poor quality of obstetric and neonatal care. Methods This trial tested the hypothesis that teams of health care providers, administrators and local residents can address the problem of limited access to quality obstetric and neonatal care and lead to a reduction in perinatal mortality in intervention compared to control locations. In seven geographic areas in five low-income and one middle-income country, most with high perinatal mortality rates and substantial numbers of home deliveries, we performed a cluster randomized non-masked trial of a package of interventions that included community mobilization focusing on birth planning and hospital transport, community birth attendant training in problem recognition, and facility staff training in the management of obstetric and neonatal emergencies. The primary outcome was perinatal mortality at ≥28 weeks gestation or birth weight ≥1000 g. Results Despite extensive effort in all sites in each of the three intervention areas, no differences emerged in the primary or any secondary outcome between the intervention and control clusters. In both groups, the mean perinatal mortality was 40.1/1,000 births (P = 0.9996). Neither were there differences between the two groups in outcomes in the last six months of the project, in the year following intervention cessation, nor in the clusters that best implemented the intervention. Conclusions This cluster randomized comprehensive, large-scale, multi-sector intervention did not result in detectable impact on the proposed outcomes. While this does not negate the importance of these interventions, we expect that achieving improvement in pregnancy outcomes in these settings will require substantially more obstetric and neonatal care infrastructure than was available at the sites during this trial, and without them provider training and community mobilization will not be sufficient. Our results highlight the critical importance of evaluating outcomes in randomized trials, as interventions that should be effective may not be. Trial registration ClinicalTrials.gov NCT01073488

Interference with Zn absorption is one proposed explanation for adverse effect of Fe supplements in Fe-replete subjects in malaria endemic areas. We determined the effect of Fe on Zn absorption and...

To compare iron status in breastfed infants randomized to groups receiving complementary feeding regimens that provided iron from fortified infant cereals or meats, and to examine the development of the enteric microbiota in these groups.Forty-five exclusively breastfed 5-month-old infants were randomized to 1 of 3 feeding groups (FGs)-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-day diet records. Iron status was assessed at the end of the study by measurements of hemoglobin, serum ferritin, and soluble transferrin receptor levels. In a subsample of 14 infants, enteric microbiota were profiled in monthly stool samples (5-9 months) by 16S ribosomal RNA gene pyrosequencing.Infants in the 2 cereal FGs had 2- to 3-fold greater daily iron intakes versus the meat FG (P.0001). More than one-quarter (27%) of the infants had a low serum ferritin level, and 36% were mildly anemic, with no significant differences by FG; more infants in the meat FG had a high soluble transferrin receptor value (P = .03). Sequence analysis identified differences by time and FG in the abundances of several bacterial groups, including significantly more abundant butyrate-producing Clostridium group XIVa in the meat FG (P = .01) CONCLUSION: 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, then reconsideration of strategies to both meet infants' iron requirements and optimize the developing microbiome may be warranted.

OBJECTIVE: To describe the staffing and availability of medical equipment and medications and the performance of procedures at health facilities providing maternal and neonatal care at African, Asian, and Latin American sites participating in a multicenter trial to improve emergency obstetric/neonatal care in communities with high maternal and perinatal mortality. STUDY DESIGN: In 2009, prior to intervention, we surveyed 136 hospitals and 228 clinics in 7 sites in Africa, Asia, and Latin America regarding staffing, availability of equipment/medications, and procedures including cesarean section. RESULTS: The coverage of physicians and nurses/midwives was poor in Africa and Latin America. In Africa, only 20% of hospitals had full-time physicians. Only 70% of hospitals in Africa and Asia had performed cesarean sections in the last 6 months. Oxygen was unavailable in 40% of African hospitals and 17% of Asian hospitals. Blood was unavailable in 80% of African and Asian hospitals. CONCLUSIONS: Assuming that adequate facility services are necessary to improve pregnancy outcomes, it is not surprising that maternal and perinatal mortality rates in the areas surveyed are high. The data presented emphasize that to reduce mortality in these areas, resources that result in improved staffing and sufficient equipment, supplies, and medication, along with training, are required. Fil: Manasyan, Albert. Centre for Infectious Disease Zambia; Zambia. University of Alabama at Birmingahm; Estados Unidos Fil: Saleem, Sarah. Aga Khan University; Pakistán Fil: Koso Thomas, Marion. Eunice Kennedy Shriver National Institute of Child Health and Human Development; Estados Unidos Fil: Althabe, Fernando. Instituto de Efectividad Clínica y Política de Salud. Departamento de Investigación en Salud Madre e Infantil. Buenos Aires; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Pasha, Omrana. Aga Khan University; Pakistán Fil: Chomba, Elwyn. Centre for Infectious Disease Zambia; Zambia. University of Alabama at Birmingahm; Estados Unidos. University of Zambia; Zambia Fil: Goudar, Shivaprasad S.. KLE; India Fil: Patel, Archana. Indira Gandhi Government Medical College; India Fil: Esamai, Fabian. Moi University; Kenia Fil: Garces, Ana. Francisco Marroquin University; Guatemala Fil: Kodkany, Bhala. KLE; India Fil: Belizan, Jose. Instituto de Efectividad Clínica y Política de Salud. Departamento de Investigación en Salud Madre e Infantil. Buenos Aires; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: McClure, Elizabeth M.. Research Triangle Institute; Estados Unidos Fil: Derman, Richard J.. Christiana Health Care; Estados Unidos Fil: Hibberd, Patricia. Indiana University; Estados Unidos Fil: Liechty, Edward A.. Massachusetts General Hospital for Children; Estados Unidos Fil: Hambidge, K. Michael. State University of Colorado Boulder; Estados Unidos Fil: Carlo, Waldemar A.. Centre for Infectious Disease Zambia; Zambia Fil: Buekens, Pierre. Tulane School of Public Health and Tropical Medicine; Estados Unidos Fil: Moore, janet. Research Triangle Institute; Estados Unidos Fil: Wright, Linda L.. Eunice Kennedy Shriver National Institute of Child Health and Human Development; Estados Unidos Fil: Goldenberg, Robert L.. Columbia University; Estados Unidos

The refinement of techniques that can accurately measure small changes in zinc stable isotope ratios in biological samples provides new opportunities for advancing our understanding of human zinc metabolism. The feasibility of utilizing more than one zinc stable isotope label simultaneously is invaluable for more complex kinetic studies. These techniques are especially valuable for investigations of the regulation of Zn homeostasis in infants and in women during the reproductive cycle in whom problems with zinc nutriture may be relatively frequent and of concern for preand postnatal growth and development. Initially, these techniques have been applied to studying the role of the intestine in the maintenance of zinc homeostasis and have served to emphasize the importance of the modulation of fecal excretion of endogenous zinc. Application of stable isotope techniques to explore zinc metabolism beyond the intestinal tract is still limited but has considerable potential for advancing our understanding of zinc metabolism in health and disease.

The assessment of human zinc nutritional status has proven to be difficult and challenging task over the course of many years. Dietary and medical history and physical examination may all provide important clues. Of the many laboratory assays for measurement of tissue zinc concentration and functional indices of zinc status, plasma zinc, despite many limitations, remains the assay of choice. Utilization of stable isotope techniques to evaluate zinc homeostasis include measurement of absorption of exogenous zinc, excretion of endogenous zinc and estimation of the combined size of the pools of zinc that are readily available on a whole organism level. Such measurements are starting to yield useful new insights into zinc status. While this approach appears to offer the potential for significant progress on a research basis, it does not provide techniques that are readily applied on a large scale or under ‘field’ conditions. Carefully designed, randomized, placebo controlled supplementation trials are almost invariably required to delineate the clinical and metabolic effects of correcting putative deficiency states. In the case of zinc, these can serve the additional role of confirming the underlying zinc deficiency state.

To investigate whether a fundamental lesion in energy metabolism is a feature of cystic fibrosis, we measured total energy expenditure using the doubly labeled water technique in 19 infants with presymptomatic cystic fibrosis (0.8 to 6.6 months of age) identified through newborn screening. Total energy expenditure data collected in a cohort of healthy infants by the same method were used for comparison. Energy balance studies were additionally performed in 10 of the infants with cystic fibrosis. Total energy expenditure levels in infants with cystic fibrosis, expressed as either kilocalories per day or kilocalories per kilogram of fat free mass per day, did not differ from control levels. When expressed on the basis of body weight (in kilocalories per kilogram per day), expenditure levels in infants with cystic fibrosis were greater (p0.05) than control levels. No differences in expenditure were observed between those infants who were homozygous (n = 10) for the delta F508 mutation and the heterozygous infants (n = 7), regardless of how expenditure was expressed. Assessment of energy balance indicated that infants with cystic fibrosis grow at a normal rate for metabolizable energy intakes similar to those reported for healthy infants. We conclude that there are no differences in energy expenditure between infants with presymptomatic cystic fibrosis and healthy infants, once differences in body composition are taken into account. This finding indicates that the primary cystic fibrosis defect is not an energy-requiring one.

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.

Background: Improved complementary feeding is cited as a critical factor for reducing stunting. Consumption of meats has been advocated, but its efficacy in low-resource settings has not been tested. Objective: The objective was to test the hypothesis that daily intake of 30 to 45 g meat from 6 to 18 mo of age would result in greater linear growth velocity and improved micronutrient status in comparison with an equicaloric multimicronutrient-fortified cereal. Design: This was a cluster randomized efficacy trial conducted in the Democratic Republic of Congo, Zambia, Guatemala, and Pakistan. Individual daily portions of study foods and education messages to enhance complementary feeding were delivered to participants. Blood tests were obtained at trial completion. Results: A total of 532 (86.1%) and 530 (85.8%) participants from the meat and cereal arms, respectively, completed the study. Linear growth velocity did not differ between treatment groups: 1.00 (95% CI: 0.99, 1.02) and 1.02 (95% CI: 1.00, 1.04) cm/mo for the meat and cereal groups, respectively (P = 0.39). From baseline to 18 mo, stunting [length-for-age z score (LAZ)

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 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.

Objective To implement a vital statistics registry system to register pregnant women and document birth outcomes in the Global Network for Women's and Children's Health Research sites in Asia, Africa, and Latin America. Methods The Global Network sites began a prospective population-based pregnancy registry to identify all pregnant women and record pregnancy outcomes up to 42 days post-delivery in more than 100 defined low-resource geographic areas (clusters). Pregnant women were registered during pregnancy, with 42-day maternal and neonatal follow-up recorded—including care received during the pregnancy and postpartum periods. Recorded outcomes included stillbirth, neonatal mortality, and maternal mortality rates. Results In 2010, 72 848 pregnant women were enrolled and 6-week follow-up was obtained for 97.8%. Across sites, 40.7%, 24.8%, and 34.5% of births occurred in a hospital, health center, and home setting, respectively. The mean neonatal mortality rate was 23 per 1000 live births, ranging from 8.2 to 48.5 per 1000 live births. The mean stillbirth rate ranged from 13.7 to 54.4 per 1000 births. Conclusion The registry is an ongoing study to assess the impact of interventions and trends regarding pregnancy outcomes and measures of care to inform public health. ClinicalTrial.gov Trial Registration: NCT01073475

To evaluate the impact of birth attendant training using the World Health Organization Essential Newborn Care (ENC) course among traditional birth attendants, with a particular emphasis on the effect of acquisition of skills on perinatal outcomes.Population-based, prospective, interventional pre-post design study.11 rural clusters in Chimaltenango, Guatemala.Health care providers.This study analyzed the effect of training and implementation of the ENC health care provider training course between September 2005 and December 2006.The primary outcome measure was the rate of death from all causes in the first seven days after birth in fetuses/infants ≥1500g. Secondary outcome measures were overall rate of stillbirth, rate of perinatal death, which included stillbirths plus neonatal deaths in the first seven days in fetuses/infants ≥1500g.Perinatal mortality decreased from 39.5/1000 pre-ENC to 26.4 post-ENC (RR 0.72; 95%CI 0.54-0.97). This reduction was attributable almost entirely to a decrease in the stillbirth rate of 21.4/1000 pre-Essential Newborn Care to 7.9/1000 post-ENC (RR 0.40; 95%CI 0.25-0.64). Seven-day neonatal mortality did not decrease (18.3/1000 to 18.6/1000; RR 1.05; 95%CI 0.70-1.57).Essential Newborn Care training reduced stillbirths in a population-based controlled study with deliveries conducted almost exclusively by traditional birth attendants. Scale-up of this intervention in other settings might help assess reproducibility and sustainability.

Reliable estimates of zinc requirements have assumed greater priority as the global public health importance of preventing zinc deficiency has gained increasing recognition. On a global public health basis, our first most evident goal is reliable estimates of average population requirements. Despite expectations of rapid advances towards simpler and more sophisticated strategies, estimations of zinc requirements continue to depend on a factorial approach. Since the Dietary Reference Intakes (DRIs) were published, there have been important advances in techniques for the factorial approach but also confusion resulting from the subsequent publication of conflicting 'international' estimates. The reasons for these differences have now been fully elucidated, removing an obstruction to continuing progress and refinements of our knowledge base. A key advance has been the development and validation of a model that can be simply applied to determine the inhibitory effects of phytate on zinc absorption. Better understanding of maternal and young child zinc requirements continues to present a challenge of special importance.

The objectives of this study were to examine the growth pattern of healthy infants who were fed human milk exclusively for > or = 5 months and its relationship to intakes of milk, energy, and zinc. Monthly anthropometric measurements were obtained on 71 infants through 7 months of age and on 43 through 9 months. Milk zinc concentrations were determined and milk intake was measured by 3-day test weighing. Mean (+/- SD) calculated energy intake from human milk was 106 +/- 20, 79 +/- 11, 70 +/- 10, and 57 +/- 12 kcal/kg per day at 2 weeks and 3, 5, and 7 months of age, respectively; intake from milk plus solids was 70 +/- 13 kcal/kg at 7 months. Zinc intakes from human milk were 2.3 +/- 0.68, 1.0 +/- 0.43, 0.81 +/- 0.42, and 0.52 +/- 0.31 mg/day at these points. The maximum mean weight-for-age percentile for both sexes was 62 at 2 months; the mean percentile declined to 33 by 7 months and to 25 by 9 months of age. Mean length-for-age percentile declined from 43 at 2 weeks of age to 28 and 26 by 7 and 9 months of age, respectively. Energy intake at 2 weeks of age was positively associated with the weight increment from 2 weeks to 7 months of age (p = 0.003) and with a change in weight-for-age z scores from 2 weeks to 3 months of age (p = 0.028). Mean energy intakes of healthy breast-fed infants are lower through the first 7 months of life than current recommendations. Zinc intakes of breast-fed infants are likely to be adequate, on average, through 5 months of breast-feeding but subsequently are marginal without the introduction of weaning foods. Revision of standards for growth based on observations in breast-fed infants may be appropriate, but the possibility of growth-limiting nutrient deficiencies should also be investigated.

The rationale for promoting the availability of local, affordable, non-fortified food sources of bioavailable iron in developing countries is considered in this review. Intake of iron from the regular consumption of meat from the age of 6 months is evaluated with respect to physiological requirements. Two major randomized controlled trials evaluating meat as a first and regular complementary food are described in this article. These trials are presently in progress in poor communities in Guatemala, Pakistan, Zambia, Democratic Republic of the Congo, and China.

To determine population-based stillbirth rates and to determine whether the timing and maturity of the stillbirths suggest a high proportion of potentially preventable deaths.Prospective observational study.Communities in six low-income countries (Democratic Republic of Congo, Kenya, Zambia, Guatemala, India, and Pakistan) and one site in a mid-income country (Argentina).Pregnant women residing in the study communities.Over a five-year period, in selected catchment areas, using multiple methodologies, trained study staff obtained pregnancy outcomes on each delivery in their area.Pregnancy outcome, stillbirth characteristics.Outcomes of 195,400 deliveries were included. Stillbirth rates ranged from 32 per 1,000 in Pakistan to 8 per 1,000 births in Argentina. Three-fourths (76%) of stillbirth offspring were not macerated, 63% were ≥ 37 weeks and 48% weighed 2,500 g or more. Across all sites, women with no education, of high and low parity, of older age, and without access to antenatal care were at significantly greater risk for stillbirth (p0.001). Compared to those delivered by a physician, women delivered by nurses and traditional birth attendants had a lower risk of stillbirth.In these low-middle income countries, most stillbirth offspring were not macerated, were reported as ≥ 37 weeks' gestation, and almost half weighed at least 2,500 g. With access to better medical care, especially in the intrapartum period, many of these stillbirths could likely be prevented.

Researchers tested male and female infants from rural Ethiopia to investigate relations among hemoglobin, anthropometry, and attention. They utilized a longitudinal design to examine differences in attention performance from 6 (M = 24.9 weeks, n = 89) to 9 months of age (M = 40.6 weeks, n = 85), differences hypothesized to be related to changes in iron status and growth delays. Stunting (length-for-age z-scores < −2.0) and attention performance [t(30) = −2.42, p = .022] worsened over time. Growth and hemoglobin predicted attention at 9 months [R2 = .15, p < .05], but not at 6. The use of the attention task at 9 months was supported. The study contributes to the knowledge base of hemoglobin, growth, and attention.

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

Background: Micronutrient deficiencies are common in patients undergoing gastric bypass. The effect of this type of surgery on zinc absorption and zinc status is not well known. Objective: The objective was to evaluate the effects of Roux-en-Y gastric bypass (RYGBP) on zinc status and zinc absorption at different stages after surgery. We hypothesized that zinc status would be significantly impaired after surgery and that this impairment would be less severe in subjects receiving increased supplemental zinc. We also hypothesized that zinc absorption would be lower after surgery. Design: Anthropometric and body-composition variables and dietary and biochemical indexes of zinc status and zinc absorption were determined in 67 severe and morbidly obese women [mean (6SD) age: 36.9 6 9.8 y; BMI (in kg/m 2 ): 45.2 6 4.7] who underwent RYGBP. The subjects were randomly assigned to 1 of 2 vitamin-mineral supplementation groups. Measurements were made before and 6, 12, and 18 mo after surgery. Fifty-six subjects completed the 18-mo follow-up. Results: Mean plasma zinc, erythrocyte membrane alkaline phosphatase activity, and the size of the rapidly exchangeable zinc pool decreased after RYGBP. Percentage zinc absorption decreased significantly from 32.3% to 13.6% at 6 mo after RYGBP and to 21% at 18 mo after surgery. No effect of supplement type was observed. Conclusions: Zinc status is impaired after RYGBP, despite the finding that dietary plus supplemental zinc doubled recommended zinc intakes in healthy persons. Zinc absorption capacity is significantly reduced soon after RYGBP, with no major changes until 18 mo after surgery. Am J Clin Nutr 2011;94:1004‐11.

Iodine deficiency is one of the most common micronutrient deficiencies worldwide and is a major cause of preventable mental retardation. The purpose of this study was to assess the iodine status and cognitive function of women of childbearing age and their five-year-old children.A cross-sectional study was conducted in a rural village in southern Ethiopia. A convenience sample of one hundred women and their five year-old children participated in the study. Goiter grade, urinary iodine excretion, Raven's CPM and cognitive tests from the Kaufman ABC-II, were administered to the women and their children.The use of iodized salt was only 2%. The mean iodine content of water in and around the study area was 4.46 microg/l. Occurrence of goiter was 85% in the women and 33% in children. Urinary iodine excretion for all participants was49 microg/L, the top of the range for moderate iodine deficiency. The median urinary iodine excretion (UIE) was 1 microg/L for both mothers and children. For children, measures of short term memory (Sequential index) were correlated with the visual processing (Simultaneous index) (r = 0.49, p0.0001). Goiter and urinary iodine excretion were correlated to Sequential index (r = 0.39, p = 0.0011 and r = 0.2, p = 0.05) respectively, but not to the Simultaneous index for children. Sequential (r = 0.21, p = 0.03) and Simultaneous (r = 0.29, p = 0.004) indices of mothers and children were correlated.The high prevalence of goiter and the low urinary iodine excretion demonstrate serious long- and short-term iodine deficiency in the study area. Relations between measures of iodine status and short term memory in children raise concern about potential functional effects of iodine deficiency.

Background Zinc fortification is recommended as an appropriate strategy to enhance population zinc status, but guidelines are needed on the appropriate types and levels of zinc fortification of cereal flours for mass fortification programs. Objective To review available information on the scientific rationale, efficacy, and effectiveness of zinc fortification programs, and to develop guidelines on appropriate levels of fortification of cereal flours, based on simulations of the amount of zinc absorbed under different dietary conditions and information on possible adverse effects. Methods Systematic review of scientific literature and application of an existing prediction equation to estimate zinc absorption. Results Previously completed research demonstrates that zinc intake and absorption are increased when zinc-fortified foods are consumed, but little information is, as yet, available on the biologic impact of large-scale fortification programs. Studies suggest that there are no disadvantages of the recommended ranges of zinc fortification with regard to the sensory properties of zinc-fortified foods, and most research indicates that there are no adverse effects of zinc fortification on the utilization of other minerals. Conclusions Zinc fortification of cereal flour is a safe and appropriate strategy for enhancing the zinc status of population subgroups who consume adequate amounts of fortified cereal flour, although additional information is needed to confirm the efficacy and effectiveness of large-scale zinc fortification programs to control zinc deficiency. The appropriate level of fortification depends on the population subgroup, their usual amount of flour intake, the degree of milling and fermentation that is practiced, and the usual intakes of zinc and phytate from other food sources. Fortification recommendations are presented for different dietary scenarios.

After age 6 mo, the combination of breast-feeding and unfortified plant-based complementary feeding provides inadequate zinc (Zn). Additionally, high phytate intakes compromise the bioavailability of zinc. Our principal objective in this randomized controlled, doubly masked trial was to determine the effect of substituting low-phytate maize, a daily 5-mg zinc supplement, or both, in infants between ages 6-12 mo on impaired linear growth velocity, a common feature of zinc deficiency. In the Western Highlands of Guatemala, 412 infants were randomized to receive low-phytate or control maize. Within each maize group, infants were further randomized to receive a zinc supplement or placebo. Length, weight, and head circumference were measured at 6, 9, and 12 mo of age. There were no significant differences between the 2 maize groups or between the Zn supplement and placebo groups and no treatment interaction was observed for length-for-age (LAZ), weight-for-length (WLZ) or head circumference Z-scores. Overall mean (+/- SD) Z-scores at 6 mo for combined treatment groups were: LAZ, -2.1 +/- 1.1; WLZ, 0.7 +/- 1.0; and head circumference Z-score, -0.7.0 +/- 1.0. At 12 mo, these had declined further to: LAZ, -2.5 +/- 1.1; WLZ, -0.0 +/- 0.9; and head circumference Z-score, -0.9 +/- 1.1; 83.3% were stunted and 2% were wasted. Low linear growth in older Guatemalan infants was not improved with either low-phytate maize or a daily 5-mg zinc supplement. Low contribution of maize to the complementary food of the infants negated any potential advantage of feeding low-phytate maize.

Background: Extrinsic labeling techniques are typically used to measure fractional absorption of zinc (FAZextrinsic) but none have been adequately evaluated. Objective: To compare determination of the quantity of zinc absorbed (TAZextrinisic) using measurements of FAZextrinsic with results of simultaneous determinations of dietary zinc absorbed (TAZmetabolic) that are not dependent on labeling ingested food with an extrinsic tracer (modified metabolic balance technique). Design: 70Zn was administered orally with all meals for 6 consecutive days to 21 healthy, free-living adult women consuming a constant diet. 68Zn and 67Zn were administered intravenously. FAZextrinsic was measured using a dual isotope tracer ratio technique and multiplied by dietary zinc to give TAZextrinsic. TAZmetabolic was determined by addition of net absorption of zinc and endogenous fecal zinc, the latter determined by an isotope dilution technique. Results: TAZextrinsic and TAZnetabolic were 3.0 ± 1.1 mg/day and 3.1 ± 1.1 mg/day respectively, paired t-test p = 0.492. The correlation coefficient for TAZextrinsic and TAZmetabolic was 0.91, and for FAZextrinsic and FAZmetabolic was 0.95. A Bland Altman analysis indicated a bias of 0.07, and the limits of agreement of -0.86 to 1.01 for TAZextrinsic and TAZmetabolic. Conclusion: These results from two independent methods provide reasonable validation of our extrinsic labeling technique for a wide range of composite diets.

This article provides a review of how the challenge of bioavailability was approached in establishing the Dietary Reference Intakes, with a special focus on folic acid, vitamin B-12, beta-carotene, iron, selenium, and zinc, the targeted micronutrients for this workshop. In a future perspective, the necessity of having a clear working definition of bioavailability is emphasized. The bioavailability of micronutrients should be considered, with advantage, under subheadings determined by the broad factors that affect bioavailability. Special emphasis is given to giving greater and specific attention to factors involved in the maintenance of homeostasis. These factors, it is argued, are best considered separately from even a broad definition of bioavailability and have the potential to provide new insights into some micronutrient requirements.

Zinc has earned recognition recently as a micronutrient of outstanding and diverse biological, clinical, and global public health importance. Regulation of absorption by zinc transporters in the enterocyte, together with saturation kinetics of the absorption process into and across the enterocyte, are the principal means by which whole-body zinc homeostasis is maintained. Several physiologic factors, most notably the quantity of zinc ingested, determine the quantity of zinc absorbed and the efficiency of absorption. Other factors are age and the time over which zinc is ingested. Zinc from supplements has not been shown to be absorbed differently from that taken with meals that lack inhibitors of zinc absorption. The principal dietary factor known to impair zinc bioavailability is inositol hexa- (and penta-) phosphate or phytate. Modeling of zinc absorption as a function of dietary zinc and phytate accounts for80% of the variability in the quantity of zinc absorbed. Fitting the model to new data has resulted in continual improvement in parameter estimates, which currently indicate a maximal absorption in adults of approximately 6 mg Zn/d and that the average estimated dietary requirement doubles with 1000 mg dietary phytate/d. Intestinal excretion of endogenous zinc is regulated in response to recent absorption and to zinc status. The quantitative relation of intestinal excretion of endogenous zinc to zinc absorption is currently considered to be of major importance in the determination of zinc requirements. The effects of phytate on intestinal losses of endogenous zinc merit further investigation but are probably not of the same magnitude as its inhibitory effects on absorption of exogenous zinc.

Malnutrition is a major factor in the etiology, management and prognosis of persistent diarrhea in young children. Apart from inadequate energy intake, deficiencies of several specific nutrients have been implicated. Zinc is a micronutrient that appears to be of special interest, at least in some communities. Zinc deficiency has been documented in otherwise normal children. The risk of deficiency, however, is enhanced by diarrhea which is associated with variable but sometimes gross increases in zinc losses in the feces. These losses could contribute to a vicious circle, as there is now evidence that mild as well as severe zinc deficiency states can contribute to the duration and severity of diarrheal disease. During rehabilitation, impaired zinc nutriture could be responsible for slow growth, especially if the rehabilitation diet is high in phytate, a recognized inhibitor of zinc absorption. Research should be directed to a better understanding of zinc metabolism and homeostasis during diarrhea disease, to the consequences of zinc deficiency and to the benefits to be derived from zinc supplementation programs.

Background: Iron deficiency and iron deficiency anemia are common in patients who undergo gastric bypass. The magnitude of change in iron absorption is not well known. Objective: The objective was to evaluate the effects of Roux-en-Y gastric bypass (RYGBP) on iron status and iron absorption at different stages after surgery. We hypothesized that iron absorption would be markedly impaired immediately after surgery and would not improve after such a procedure. Design: Anthropometric, body-composition, dietary, hematologic, and iron-absorption measures were determined in 67 severe and morbidly obese women [mean age: 36.9 6 9.8 y; weight: 115.1 6 15.6 kg, body mass index (BMI: in kg/m 2 ); 45.2 6 4.7] who underwent RYGBP. The Roux-en-Y loop length was 125‐150 cm. Determinations were carried out before and 6, 12, and 18 mo after surgery. Fifty-one individuals completed all 4 evaluations. Results: The hemoglobin concentration decreased significantly throughout the study (repeated-measures analysis of variance). The percentage of anemic subjects changed from 1.5% at the beginning of the study to 38.8% at 18 mo. The proportion of patients with low serum ferritin increased from 7.5% to 37.3%. The prevalence of iron deficiency anemia was 23.9% at the end of the experimental period. Iron absorption from both a standard diet and from a standard dose of ferrous ascorbate decreased significantly after 6 mo of RYGBP to 32.7% and 40.3% of their initial values, respectively. No further significant modifications were noted. Conclusion: Iron absorption is markedly reduced after RYGBP with no further modifications, at least until 18 mo after surgery. Am J Clin Nutr 2009;90:527‐32.