Background: The Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project is a multiagency and multicountry collaboration that was formed to improve micronutrient assessment and to better characterize anemia.Objectives: The aims of the project were to 1) identify factors associated with inflammation, 2) assess the relations between inflammation, malaria infection, and biomarkers of iron and vitamin A status and compare adjustment approaches, and 3) assess risk factors for anemia in preschool children (PSC) and women of reproductive age (WRA).Design: The BRINDA database inclusion criteria included surveys that 1) were conducted after 2004, 2) had target groups of PSC, WRA, or both, and 3) used a similar laboratory methodology for the measurement of ≥1 biomarker of iron [ferritin or soluble transferrin receptor or vitamin A status (retinol-binding protein or retinol)] and ≥1 biomarker of inflammation (α-1-acid glycoprotein or C-reactive protein). Individual data sets were standardized and merged into a BRINDA database comprising 16 nationally and regionally representative surveys from 14 countries. Collectively, the database covered all 6 WHO geographic regions and contained ∼30,000 PSC and 27,000 WRA. Data were analyzed individually and combined with the use of a meta-analysis.Results: The methods that were used to standardize the BRINDA database and the analytic approaches used to address the project's research questions are presented in this article. Three approaches to adjust micronutrient biomarker concentrations in the presence of inflammation and malaria infection are presented, along with an anemia conceptual framework that guided the BRINDA project's anemia analyses.Conclusions: The BRINDA project refines approaches to interpret iron and vitamin A biomarker values in settings of inflammation and malaria infection and suggests the use of a new regression approach as well as proposes an anemia framework to which real-world data can be applied. Findings can inform guidelines and strategies to prevent and control micronutrient deficiencies and anemia globally.
Vitamin A deficiency (VAD) is an important contributor to child morbidity and mortality. The prevalence of VAD, measured by retinol-binding protein (RBP) or retinol, is overestimated in populations with a high prevalence of inflammation. We aimed to quantify and adjust for the effect of inflammation on VAD prevalence in a nationally representative survey of Liberian children 6 to 35months of age. We compared five approaches to adjust RBP for inflammation and estimate VAD prevalence (defined as RBP<0.7μmol/L): (1) ignoring inflammation; (2) excluding individuals with inflammation (C-reactive protein (CRP) >5mg/L or alpha1-acid glycoprotein (AGP) >1g/)L; (3) multiplying each individual's RBP by an internal correction factor; (4) by an external correction factor; and (5) using regression (corrected RBP=exp(InRBP - β1(lnCRPobs-lnCRPref) - β2(lnAGPobs-lnAGPref)). Corrected RBP was based on a regression model where reference lnCRP and lnAGP were set to the maximum of the lowest decile. The unadjusted prevalence of VAD was 24.7%. Children with elevated CRP and/or AGP had significantly lower RBP concentrations than their apparently healthy peers (geometric mean RBP 0.79μmol/L (95% CI: 0.76, 0.82) vs. 0.95μmol/L (95% CI: 0.92, 0.97), P<0.001). Using approaches 2-5 resulted in a prevalence of VAD of 11.6%, 14.3%, 13.5% and 7.3%, respectively. Depending on the approach, the VAD prevalence is reduced 10-17 percentage points when inflammation is taken into account. Further quantification of the influence of inflammation on biomarkers of vitamin A status from other national surveys is needed to compare and recommend the preferred adjustment approach across populations.
by
Rebecca D. Merrill;
Rachel M. Burke;
Christine A. Northrop-Clewes;
Pura Rayco-Solon;
Rafael Flores-Ayala;
Sorrel M.L. Namaste;
Mary K. Serdula;
Parminder S Suchdev
Background: In many settings, populations experience recurrent exposure to inflammatory agents that catalyze fluctuations in the concentrations of acute-phase proteins and certain micronutrient biomarkers such as C-reactive protein (CRP), α-1-acid glycoprotein (AGP), ferritin, and retinol. Few data are available on the prevalence and predictors of inflammation in diverse settings.Objective: We aimed to assess the relation between inflammation (CRP concentration > 5 mg/L or AGP concentration > 1 g/L) and covariates, such as demographics, reported illness, and anthropometric status, in preschool children (PSC) (age range: 6-59 mo) and women of reproductive age (WRA) (age range: 15-49 y).Design: Cross-sectional data from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project from 29,765 PSC in 16 surveys and 25,731 WRA in 10 surveys were used to model bivariable and multivariable relations.Results: The inflammation prevalence was 6.0-40.2% in PSC and 7.9-29.5% in WRA (elevated CRP) and 21.2-64.3% in PSC and 7.1-26.7% in WRA (elevated AGP). In PSC, inflammation was consistently positively associated with recent fever and malaria but not with other recent illnesses. In multivariable models that were adjusted for age, sex, urban or rural residence, and socioeconomic status, elevated AGP was positively associated with stunting (height-for-age z score < -2) in 7 of 10 surveys. In WRA, elevated CRP was positively associated with obesity [body mass index (in kg/m2) ≥30] in 7 of 9 surveys. Other covariates showed inconsistent patterns of association with inflammation. In a pooled analysis of surveys that measured malaria, stunting was associated with elevated AGP but not CRP in PSC, and obesity was associated with both elevated CRP and AGP in WRA.Conclusions: Recent morbidity and abnormal anthropometric status are consistently associated with inflammation across a range of environments, whereas more commonly collected demographic covariates were not. Because of the challenge of defining a general demographic population or environmental profile that is more likely to experience inflammation, inflammatory markers should be measured in surveys to account for their effects.
The objective of this study was to examine the association between nutritional status and dietary intake in community-dwelling older adults with heart failure (HF). A cross-sectional analysis of NHANES III data was conducted. The analytic sample was comprised of n = 445 individuals aged 50+ years with congestive HF (54.4% male, 22.9% non-Hispanic Black, 43.8% low-income). Nutritional status was measured using the Prognostic Nutritional Index (PNI). Participants were classified by PNI quintiles with lower PNI scores indicating lower nutritional status. Participants in quintile 5 showed significantly greater intakes of energy, protein, vegetables, magnesium, zinc, copper, potassium, red meat, saturated fat, and sodium. In multivariate analyses, increased intake of red meat (β = 0.253, p = 0.040) and vegetables (β = 0.255, p = 0.038) was associated with significantly better nutritional status. In the absence of comprehensive nutritional guidance for HF patients, it appears that small increases in energy, protein (red meat), and vegetable consumption are associated with improved nutritional status.
Multi-sectoral programs that involve stakeholders in agriculture, nutrition and health care are essential for responding to nutrition problems such as vitamin A deficiency among pregnant and lactating women and their infants in many poor areas of lower income countries. Yet planning such multi-sectoral programs and designing appropriate evaluations, to respond to different disciplinary cultures of evidence, remain a challenge. We describe the context, program development process, and evaluation design of the Mama SASHA project (Sweetpotato Action for Security and Health in Africa) which promoted production and consumption of a bio-fortified, orange-fleshed sweetpotato (OFSP). In planning the program we drew upon information from needs assessments, stakeholder consultations, and a first round of the implementation evaluation of a pilot project. The multi-disciplinary team worked with partner organizations to develop a program theory of change and an impact pathway which identified aspects of the program that would be monitored and established evaluation methods. Responding to the growing demand for greater rigour in impact evaluations, we carried out quasi-experimental allocation by health facility catchment area, repeat village surveys for assessment of change in intervention and control areas, and longitudinal tracking of individual mother-child pairs. Mid-course corrections in program implementation were informed by program monitoring, regular feedback from implementers and partners' meetings. To assess economic efficiency and provide evidence for scaling we collected data on resources used and project expenses. Managing the multi-sectoral program and the mixed methods evaluation involved bargaining and trade-offs that were deemed essential to respond to the array of stakeholders, program funders and disciplines involved.
by
Sorrel ML Namaste;
Fabian Rohner;
Jin Huang;
Nivedita L Bhushan;
Rafael Flores-Ayala;
Roland Kupka;
Zuguo Mei;
Rahul Rawat;
Anne Williams;
Daniel J Raiten;
Christine A Northrop-Clewes;
Parminder Suchdev
Background: The accurate estimation of iron deficiency is important in planning and implementing interventions. Ferritin is recommended as the primary measure of iron status, but interpretability is challenging in settings with infection and inflammation.
Objective: We assessed the relation between ferritin concentrations and inflammation and malaria in preschool children (PS C) (age range: 6-59 mo) and women of reproductive age (WRA) (age range: 15-49 y) and investigated adjustment algorithms to account for these effects.
Design: Cross-sectional data from 15 surveys for PSC (n = 27,865) and 8 surveys for WRA (24,844), from the Biomarkers Reflecting the Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed individually and combined with the use of a meta-analysis. Several approaches were explored to estimate depleted iron stores (ferritin concentration < 12 μg/L in PSC and < 15 μg/L in WRA) in inflammation and malaria settings as follows: 1) increase ferritin-concentration cutoff to < 30 μg/L; 2) exclude individuals with C-reactive protein (CRP) concentrations > 5 mg/L or α-1-acid glycoprotein (AGP) concentrations > 1 g/L; 3) apply arithmetic correction factors; and 4) use a regression correction approach.
Results: Depleted iron-store estimates incrementally increased as CRP and AGP deciles decreased (4% compared with 30%, and 6% compared with 29% from highest compared with lowest CRP deciles for pooled PSC and WRA, respectively, with similar results for AGP). Depending on the approach used to adjust for inflammation (CRP plus AGP), the estimated prevalence of depleted iron stores increased by 7-25 and 2-8 absolute median percentage points for PSC and WRA, respectively, compared with unadjusted values. Adjustment for malaria in addition to CRP and AGP did not substantially change the estimated prevalence of depleted iron stores.
Conclusions: Our results lend support for the use of internal regression correction to estimate the prevalence of depleted iron stores in regions with inflammation. This approach appears to mathematically reflect the linear relation of ferritin concentrations with acute-phase proteins. More research is warranted to validate the proposed approaches, but this study contributes to the evidence base to guide decisions about how and when to adjust ferritin for inflammation.
The ratios of anthropometric measures are used to estimate obesity while controlling for allometric scaling. A good index should be uncorrelated with its denominator; this often requires exponentiation of the denominator. The stability of the derived exponents across populations is not known. We obtained subscapular (SUBS) and triceps (TRI) skinfolds, weight (WT), height (HT), waist circumference (WC), fat mass (FM), and fat-free mass (FFM) in a population of Guatemalan adults [height 1.63 ± 0.06 m (868 males); 1.51 ± 0.06 m (1047 females)]. We derived exponents for the indices WT/HTP, SUBS/TRIP, TRI/SUBSP, WC/HTP, FM/WTP, and FM/FFMP such that the ratios were free from association with their denominators. The derived exponents were (Men: SUBS/TRI0.88, FM/WT2.69, FM/FFM2.86, WC/HT0.68, and WT/HT2.17; Women: SUBS/TRI0.93, FM/WT2.01, FM/FFM3.37, WC/HT0.47, WT/HT2.03). For all examined indices the derived exponents differed (P < 0.05) from 1 and differed (P < 0.05) between men and women. The exponents for the men also differed from those previously published for Brazilian men (JCK Wells and CG Victora [2005]: Int J Obes 29:483–489). The derived indices were not more strongly correlated with adiposity than were simple unexponentiated ratios. Although exponentiation of the denominator eliminates the association of index with its denominator, the resulting exponents lack generalizability across populations, especially those where stunting remains prevalent.
Background
BMI and waist circumference (WC) are used to screen for cardio-metabolic risk; however it is unclear how well these indices perform in populations subject to childhood stunting.
Objectives
To evaluate BMI and WC as indicators of cardio-metabolic risk and to determine optimal cut-off points among 1325 Guatemalan adults (44 % stunted: ≤150 cm women; ≤162 cm men).
Methods
Cardio-metabolic risk factors were systolic/diastolic blood pressure ≥130/≥85 mmHg, glucose ≥5.5 mmol/l, TAG ≥1.7 mmol/l, ratio of total cholesterol to HDL-cholesterol ≥5.0, and the presence of two or more and three or more of the preceding risk factors. Receiver operating characteristic (ROC) curve analysis was used.
Results
Areas under the ROC curve were in the range of 0.59–0.77 for BMI and 0.59–0.78 for WC among men and 0.66–0.72 and 0.64–0.72 among women, respectively. Optimal cut-off points for BMI were 24.7–26.1 kg/m2 among men (24.5–26.1 kg/m2 stunted; 24.8–26.3 kg/m2 non-stunted) and 26.5–27.6 kg/m2 among women (26.3–27.8 kg/m2 stunted; 26.6–27.9 kg/m2 non-stunted). Optimal cut-off points for WC were 87.3–91.1 cm among men (85.3–89.4 cm stunted; 88.5–93.3 cm non-stunted) and 91.3–95.3 cm among women (90.9–94.4 cm stunted; 91.8–95.6 cm non-stunted).
Conclusion
Optimal cut-off points for BMI were slightly higher among women than men with no meaningful differences by stature. Optimal cut-off points for WC were several centimetres lower for stunted compared with non-stunted men, and both were substantially lower than the current recommendations among Western populations. Cut-off points derived from Western populations may not be appropriate for developing countries with a high prevalence of stunting.
Background
Rapidly transitioning societies are experiencing dramatic increases in obesity and cardio-metabolic risk; however, few prospective studies from developing countries have quantified these increases or described their joint relationships.
Methods
We collected dietary, physical activity, demographic, anthropometric and cardio-metabolic risk factor data from 376 Guatemalan young adults in 1997–98 (aged 20–29 years) and in 2002–04 (aged 25–34 years).
Results
In total, 42% of men and 56% of women experienced weight gain >5kg in 5 years. Percent body fat (%BF) and waist circumference (WC) increased by 4·2% points and 5·5 cm among men, and 3·2% points and 3·4 cm among women, respectively. Five-year increases in both %BF and WC were associated with lower physical activity, urban residence and shorter height among men but not among women (test for heterogeneity P<0·05 for residence and physical activity). Changes in %BF and WC and concomitant changes in cardio-metabolic risk factors were similar for men and women. In standardised regression, change in %BF was associated with changes in TAG (β=0·19; 95% CI 0·08, 0·30), total:HDL cholesterol (β=0·22; 95% CI 0·12, 0·33) and systolic (β=0·22; 95% CI 0·12, 0·33) and diastolic (β=0·18; 95% CI 0·08, 0·28) blood pressure, but not with glucose; associations were similar for WC.
Conclusions
Over 5 years this relatively young population of Guatemalan adults experienced rapid increases in multiple measures of adiposity, which were associated with adverse changes in lipid and blood pressure levels.
We assessed the association of four diet quality scores with multiple cardio-metabolic outcomes among Guatemalan young adults experiencing the nutrition transition. We obtained cross-sectional dietary, demographic, anthropometric and cardio-metabolic risk factor data from 1220 Guatemalan adults (mean age 32·7 (SD 5·8) years) in 2002–4, and computed a Recommended Food Score (RFS), Not Recommended Food Score (NRFS), Food Variety Score (FVS) and the Dietary Quality Index-International (DQI-I). All four scores were correlated with energy intake (r 0·23–0·49; all P<0·01), but had varying associations with socio-demographic characteristics, lifestyle factors and nutrient intakes. None of the scores was inversely associated with the metabolic syndrome or its components; rather some were positively associated with risk factors. Among both men and women the DQI-I was positively associated with BMI (kg/m2; β = 0·10, 95 % CI 0·003, 0·21 (men); β = 0·07, 95 % CI 0·01, 0·14 (women)) and waist circumference (cm; β = 0·02, 95 % CI 0·01, 0·03 (men); β = 0·02, 95 % CI = 0·01, 0·02 (women)). Among men, the RFS was positively associated with TAG (mg/l; β = 0·11, 95 % CI 0·02, 0·21) and glucose (mg/l; β = 0·13: 95 % CI 0·03, 0·22). We conclude that indices of diet quality are not consistently associated with chronic disease risk factor prevalence in this population of Guatemalan young adults.