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The choice of iron fortificant usually represents a balance between bioavailability of the compound and its tendency to cause organoleptic problems. The aim of this study was to evaluate the efficacy of sodium iron EDTA (NaFeEDTA) and ferrous fumarate at levels compatible with South African brown bread (10 mg/kg flour for NaFeEDTA and 20 mg/kg flour for ferrous fumarate) in a randomized controlled trial; electrolytic iron was evaluated at the level currently used in South Africa (35 mg/kg flour). Schoolchildren (n = 361), aged 6-11 y, from a low socioeconomic community with hemoglobin (Hb) [less than or equal to] 125 g/L were randomly assigned to 1 of 4 groups that received 4 slices of brown bread supplying either: 1) no fortification iron 2) 2.35 mg iron as NaFeEDTA; 3) 4.70 mg iron as ferrous fumarate; and 4) 8.30 mg iron as electrolytic iron per intervention day. These amounts simulated a bread intake of 6 slices per day over the 34-wk study period at fortification levels of 0, 10, 20, and 35 mg/kg flour, respectively. Hb concentration and iron status were assessed at baseline and after 34 wk of intervention. The iron interventions did not affect Hb concentration, transferrin saturation, or serum ferritin, iron, or transferrin receptor concentrations relative to the control group. Our results suggest that electrolytic iron at the level currently used in South Africa is not effective in improving iron or Hb status. Neither do NaFeEDTA or ferrous fumarate appear to be suitable alternatives for the fortification of wheat flour when included at levels that do not cause color changes.

Growth faltering, anemia, and multiple micronutrient deficiency are common during infancy in developing countries. This South African trial was part of a multicenter study aimed at testing the efficacy of multiple micronutrient supplementation on growth, anemia, micronutrient status, and morbidity during infancy across 4 countries. A total of 265 infants aged 6-12 mo were individually randomized to 1 of 4 intervention groups: a daily multiple micronutrient supplement (DMM), a daily placebo supplement (P); a multiple micronutrient supplement 1 d of the week and placebo supplement on the other days of the week (WMM), and a daily iron supplement (DI). For 6 mo, the blinded supplements were provided to mothers at monthly health clinic sessions, and consumption was verified during weekly household visits by community health workers, when morbidity was also checked. Weight and height of the infants were measured monthly, and blood samples were taken at the beginning and at the end for assessing the infants micronutrient status. There were no significant differences in nutritional status of the groups at baseline with 40% of infants with anemia (hemoglobin < 110 g/L), 16% vitamin A deficiency (plasma retinol < 0.7/ [micro]mol/L), 47% zinc deficiency (plasma zinc < 10.7 [micro]mol/L), 2% underweight, and 11% stunting. There was no difference in growth or morbidity between the micronutrient supplemented groups and the P group during the 6-mo study. The DMM was the most effective intervention tested, not only for improving anemia but also for improving iron, zinc, riboflavin, and tocopherol status. KEY WORDS: * iron * zinc * multiple micronutrient supplementation * infant's growth * anemia

Objective: To assess the contribution of liver to the vitamin A intake of 24-59-month-old children from an impoverished South African community where liver is frequently consumed and vitamin A deficiency previously shown to be absent.Design: Cross-sectional.Setting: Northern Cape Province, South Africa.Subjects: Children aged 24-59 months (n 150). Vitamin A intake from liver was assessed using a single 24 h recall and a quantified liver frequency questionnaire. In addition, information on vitamin A intake via the national fortification programme was obtained from the 24 h recall and information on vitamin A supplementation from the Road-to-Health Chart. Height, weight and socio-economic data were also collected.Results: Stunting, underweight and wasting were prevalent in 36·9 %, 25·5 % and 12·1 % of children. Mean daily vitamin A intake from liver was 537 and 325 μg retinol equivalents measured by the 24 h recall and liver frequency questionnaire, respectively. Liver was consumed in 92·7 % of households and by 84·7 % of children; liver intake was inversely related to socio-economic status (P < 0·05). The food fortification programme contributed 80 μg retinol equivalents and the vitamin A supplementation programme 122 μg retinol equivalents to daily vitamin A intake.Conclusions: The study showed that liver alone provided more than 100 % of the Estimated Average Requirement of the pre-school children in this impoverished community. The results also challenge the notion generally held by international health bodies that vitamin A deficiency, poor anthropometric status and poverty go together, and reinforces the fact that South Africa is a culturally diverse society for which targeted interventions are required. [ABSTRACT FROM AUTHOR]

This study aimed to develop a set of mean ± standard deviation (SD) intake values for South African (SA) children for 36 of the 45 food parameters included in the original Dietary Inflammatory Index (DII®) tool. The SA food composition database contains 30 of the 45 food parameters included in the original DII®, and a supplementary database was developed for six of the food parameters not included in the SA database. The SA child mean ± SD intake of macronutrients, micronutrients and select flavonoids was calculated by age in years, using eight data sets from dietary surveys conducted in SA in the last three decades. A total sample of 5412 children was included in the calculation of the mean ± SD. The current study sample was determined to be representative of 1–<10-year-old children in SA, and the plausibility of the mean intake values was confirmed by being in line with age-appropriate recommendations. Furthermore, an increase in energy, macronutrient, and most micronutrient intakes with increase in age was evident. The generated mean ± SD values for SA children can be used for calculation of the inflammatory potential of the dietary intake of SA children in the age range of 1–<10-year-old children. [ABSTRACT FROM AUTHOR]

ObjectiveTo assess serum retinol, liver intake patterns, breast-feeding history and anthropometric status in pre-school children of a low socio-economic community where liver is regularly consumed.DesignCross-sectional study.SettingNorthern Cape Province, South Africa.SubjectsChildren aged 1–6 years (n 243) who attended the local primary health-care facility and had not received a vitamin A supplement in the 6 months preceding the study. Non-pregnant female caregivers (n 225), below 50 years of age, were also assessed.ResultsDespite stunting, underweight and wasting being prevalent in 40·5 %, 23·1 % and 8·4 % of the children, only 5·8 % had serum retinol concentrations < 20 μg/dl, which is in sharp contrast to the national prevalence of 63·6 %. None of the caregivers were vitamin A deficient. Liver was eaten by 89·2 % of children, with 87 % of households eating liver at least once monthly and 30 % eating it at least once weekly; liver was introduced into the diet of the children at a median age of 18 months. Ninety-three per cent of the children were being breast-fed or had been breast-fed in the past; children were breast-fed to a median age of 18 months. A significant negative correlation was found between educational level of the caregiver and frequency of liver intake (r = −0·143, P=0·032). There was no correlation between serum retinol and indicators of anthropometric or socio-economic status.ConclusionsThe blanket approach in applying the national vitamin A supplementation programme may not be appropriate for all areas in the country, even though the community may be poor and undernourished. [ABSTRACT FROM AUTHOR]

Background: Stable isotope techniques using 13 C to assess vitamin A (VA) dietary sources, absorption, and total body VA stores (TBSs) require determination of baseline 13 C abundance. 13 C-natural abundance is approximately 1.1% total carbon, but varies with foods consumed, supplements taken, and food fortification with synthetic retinyl palmitate., Objectives: We determined 13 C variation from purified serum retinol and the resulting impact on TBSs using pooled data from preschool children in Burkina Faso, Cameroon, Ethiopia, South Africa, Tanzania, and Zambia and Zambian women., Methods: Seven studies included children (n = 639; 56 ± 25 mo; 48% female) and one in women (n = 138; 29 ± 8.5 y). Serum retinol 13 C-natural abundance was determined using GC-C-IRMS. TBSs were available in 7 studies that employed retinol isotope dilution (RID). Serum CRP and α 1 -acid-glycoprotein (AGP) were available from 6 studies in children. Multivariate mixed models assessed the impact of covariates on retinol 13 C. Spearman correlations and Bland-Altman analysis compared serum and milk retinol 13 C and evaluated the impact of using study- or global-retinol 13 C estimates on calculated TBSs., Results: 13 C-natural abundance (%, median [Q1, Q3]) differed among countries (low: Zambia, 1.0744 [1.0736, 1.0753]; high: South Africa, 1.0773 [1.0769, 1.0779]) and was associated with TBSs, CRP, and AGP in children and with TBSs in women. 13 C-enrichment from serum and milk retinol were correlated (r = 0.52; P = 0.0001). RID in children and women using study and global estimates had low mean bias (range, -3.7% to 2.2%), but larger 95% limits of agreement (range, -23% to 37%)., Conclusions: 13 C-natural abundance is different among human cohorts in Africa. Collecting this information in subgroups is recommended for surveys using RID. When TBSs are needed on individuals in clinical applications, baseline 13 C measures are important and should be measured in all enrolled subjects., (Copyright © 2023. Published by Elsevier Inc.)

This study aimed to develop a set of mean ± standard deviation (SD) intake values for South African (SA) children for 36 of the 45 food parameters included in the original Dietary Inflammatory Index (DII ® ) tool. The SA food composition database contains 30 of the 45 food parameters included in the original DII ® , and a supplementary database was developed for six of the food parameters not included in the SA database. The SA child mean ± SD intake of macronutrients, micronutrients and select flavonoids was calculated by age in years, using eight data sets from dietary surveys conducted in SA in the last three decades. A total sample of 5412 children was included in the calculation of the mean ± SD. The current study sample was determined to be representative of 1-<10-year-old children in SA, and the plausibility of the mean intake values was confirmed by being in line with age-appropriate recommendations. Furthermore, an increase in energy, macronutrient, and most micronutrient intakes with increase in age was evident. The generated mean ± SD values for SA children can be used for calculation of the inflammatory potential of the dietary intake of SA children in the age range of 1-<10-year-old children.

Previous research has demonstrated a virtual absence of vitamin A deficiency and adequacy of vitamin A intake through consumption of liver in preschool children of a community in the Northern Cape province of South Africa where sheep farming is common, and liver, an exceptionally rich source of vitamin A, is frequently eaten. Only 60-75 g of liver per month is needed to meet the vitamin A requirement of preschool children. Because this may have implications for routine vitamin A supplementation, and because liver consumption for the rest of the province is unknown, the study aim was to establish the prevalence and frequency of liver intake in a provincial-wide survey. An unquantified liver-specific food frequency questionnaire, covering a period of 1 month, complemented by a 1-year recall, was administered to mothers of 2- to 5-year-old children (n = 2,864) attending primary health care facilities in all five districts and 26 subdistricts. A total of 86% of children were reported to eat liver, which was eaten in all districts by at least 80% of children. The overall median frequency of liver intake was 1.0 [25th, 75th percentiles: 0.5, 3.0] times per month and ranged from 1.0 [0.3, 2.0] to 2.0 [1.0, 4.0] for the various districts. Based on a previously reported portion size of 66 g, these results suggest vitamin A dietary adequacy in all districts and possibly also vitamin A intake exceeding the Tolerable Upper Intake Level in some children. Routine vitamin A supplementation in this province may not be necessary and should be reconsidered., (© 2019 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Vitamin A (VA) deficiency is a serious public health problem, especially in preschool children who are at risk of increased mortality. In order to address this problem, the World Health Organization recommends periodic high-dose supplementation to children 6-59 months of age in areas of highest risk. Originally, supplementation was meant as a short-term solution until more sustainable interventions could be adopted. Currently, many countries are fortifying commercialized common staple and snack foods with retinyl palmitate. However, in some countries, overlapping programs may lead to excessive intakes. Our review uses case studies in the United States, Guatemala, Zambia, and South Africa to illustrate the potential for excessive intakes in some groups. For example, direct liver analysis from 27 U.S. adult cadavers revealed 33% prevalence of hypervitaminosis A (defined as ≥1 μmol/g liver). In 133 Zambian children, 59% were diagnosed with hypervitaminosis A using a retinol isotope dilution, and 16% had ≥5% total serum VA as retinyl esters, a measure of intoxication. In 40 South African children who frequently consumed liver, 72.5% had ≥5% total serum VA as retinyl esters. All four countries have mandatory fortified foods and a high percentage of supplement users or targeted supplementation to preschool children., (© 2018 New York Academy of Sciences.)

Micronutrient powders (MNP) are often added to complementary foods high in inhibitors of iron and zinc absorption. Most MNP therefore include high amounts of iron and zinc, but it is no longer recommended in malarial areas to use untargeted MNP that contain the Reference Nutrient Intake for iron in a single serving. The aim was to test the efficacy of a low-iron and -zinc (each 2.5 mg) MNP containing iron as NaFeEDTA, ascorbic acid (AA), and an exogenous phytase active at gut pH. In a double-blind controlled trial, South African school children with low iron status (n = 200) were randomized to receive either the MNP or the unfortified carrier added just before consumption to a high-phytate maize porridge 5 d/wk for 23 wk; primary outcomes were iron and zinc status and a secondary outcome was somatic growth. Compared with the control, the MNP increased serum ferritin (P < 0.05), body iron stores (P < 0.01) and weight-for-age Z-scores (P < 0.05) and decreased transferrin receptor (P < 0.05). The prevalence of iron deficiency fell by 30.6% (P < 0.01) and the prevalence of zinc deficiency decreased by 11.8% (P < 0.05). Absorption of iron from the MNP was estimated to be 7-8%. Inclusion of an exogenous phytase combined with NaFeEDTA and AA may allow a substantial reduction in the iron dose from existing MNP while still delivering adequate iron and zinc. In addition, the MNP is likely to enhance absorption of the high native iron content of complementary foods based on cereals and/or legumes.

Objectives: To estimate the extent of iron deficiency anaemia (IDA) among children aged 0 - 4 years and pregnant women aged 15 - 49 years, and the burden of disease attributed to IDA in South Africa in 2000., Design: The comparative risk assessment (CRA) methodology of the World Health Organization (WHO) was followed using local prevalence and burden estimates. IDA prevalence came from re-analysis of the South African Vitamin A Consultative Group study in the case of the children, and from a pooled estimate from several studies in the case of the pregnant women (haemoglobin level < 11 g/dl and ferritin level < 12 microg/l). Monte Carlo simulation-modelling was used for the uncertainty analysis., Setting: South Africa., Subjects: Children under 5 years and pregnant women 15 - 49 years., Outcome Measures: Direct sequelae of IDA, maternal and perinatal deaths and disability-adjusted life years (DALYs) from mild mental disability related to IDA. Results. It is estimated that 5.1% of children and 9 - 12% of pregnant women had IDA and that about 7.3% of perinatal deaths and 4.9% of maternal deaths were attributed to IDA in 2000. Overall, about 174,976 (95% uncertainty interval 150,344 - 203,961) healthy years of life lost (YLLs), or between 0.9% and 1.3% of all DALYs in South Africa in 2000, were attributable to IDA., Conclusions: This first study in South Africa to quantify the burden from IDA suggests that it is a less serious public health problem in South Africa than in many other developing countries. Nevertheless, this burden is preventable, and the study highlights the need to disseminate the food-based dietary guidelines formulated by the National Department of Health to people who need them and to monitor the impact of the food fortification programme.

Objectives: To estimate the burden of disease attributable to vitamin A deficiency in children aged 0 - 4 years and pregnant women aged 15 - 49 years in South Africa in 2000., Design: The framework adopted for the most recent World Health Organization comparative risk assessment (CRA) methodology was followed. Population-attributable fractions were calculated from South African Vitamin A Consultative Group (SAVACG) survey data on the prevalence of vitamin A deficiency in children and the relative risks of associated health problems, applied to revised burden of disease estimates for South Africa in the year 2000. Small community studies were used to derive the prevalence in pregnant women. Monte Carlo simulation-modelling techniques were used for the uncertainty analysis., Setting: South Africa., Subjects: Children under 5 years and pregnant women 15 - 49 years., Outcome Measures: Direct sequelae of vitamin A deficiency, including disability-adjusted life years (DALYs), as well as mortality associated with measles, diarrhoeal diseases and other infections, and mortality and DALYs associated with malaria in children and all-cause maternal mortality., Results: One-third of children aged 0 - 4 years and 1 - 6% of pregnant women were vitamin A-deficient. Of deaths among young children aged 0 - 4 years in 2000, about 28% of those resulting from diarrhoeal diseases, 23% of those from measles, and 21% of those from malaria were attributed to vitamin A deficiency, accounting for some 3,000 deaths. Overall, about 110,467 ( 95% uncertainty interval 86,388 - 136,009) healthy years of life lost, or between 0.5% and 0.8% of all DALYs in South Africa in 2000 were attributable to vitamin A deficiency., Conclusions: The vitamin A supplementation programme for children and the recent food fortification programme introduced in South Africa in 2003 should prevent future morbidity and mortality related to vitamin A deficiency. Monitoring the effectiveness of these interventions is strongly recommended.