Maternal anemia is a well‐recognized global health problem; however, there remain questions on specific hemoglobin (Hb) thresholds that predict health risk or protection for mother and child. We conducted a systematic review and meta‐analysis to examine the associations of maternal Hb concentrations with a range of maternal and infant health outcomes, accounting for the timing of measurement (preconception, and first, second, and third trimesters), etiology of anemia, and cutoff category. The systematic review included 272 studies and the meta‐analysis included 95 studies. Low maternal Hb (<110 g/L) was associated with poor birth outcomes (low birth weight, preterm birth, small‐for‐gestational‐age (SGA), stillbirth, and perinatal and neonatal mortality) and adverse maternal outcomes (postpartum hemorrhage, preeclampsia, and blood transfusion). High maternal Hb (>130 g/L) was associated with increased odds of SGA, stillbirth, preeclampsia, and gestational diabetes. Relationships varied by the timing of measurement and cutoff category (stronger associations with lower cutoffs); limited data were available on anemia etiology. There were insufficient data for other maternal outcomes and long‐term child health outcomes. Current data are insufficient for determining if revisions to current Hb cutoffs are required. Pooled high‐quality individual‐level data analyses, as well as prospective cohort studies, would be valuable to inform the reevaluation of Hb cutoffs.

We investigated the causes of stunting and wasting using nationally representative data on preschool children from India (2005-2006, N = 41,306) and Guatemala (2008-2009, N = 10,317). We estimated stunting and wasting using the 2006 WHO standard and the 1976 WHO/National Center for Health Statistics (NCHS) reference. India and Guatemala had high levels of stunting; wasting was common in India but rare in Guatemala. Use of the WHO standard (based on breast-fed children) increased the prevalence of stunting in both countries but dramatically changed the pattern of wasting by age in India. In Indian children 0-5 mo of age, wasting more than tripled, from 8% to 30%, leading to the highest prevalence of wasting. Using the NCHS reference, the lowest and highest prevalence among Indian children occurred in children 0-5 and 12-23 mo, respectively. Also, we showed that household wealth and the condition of women were related to both stunting and wasting; review of the literature on wasting failed to identify factors that were not also related to stunting (e.g., seasonality, infections, and intrauterine growth retardation). Possible explanations for high levels of wasting in India include the poor status of women, the "thin-fat" infant phenotype, chronic dietary insufficiency, poor dietary quality, marked seasonality, and poor levels of sanitation. Use of the WHO standard calls for urgent attention to improving prenatal and infant nutrition and uncovers an alarming level of wasting in the young infant in India that use of the NCHS growth reference (based on bottle-fed infants) had masked.

High beta-carotene maize, biofortified with beta-carotene through plant breeding, is being developed as a cost-effective, sustainable agronomic approach to alleviating the problem of vitamin A deficiency in Africa. We used high beta-carotene maize (10.49+/-0.16 microg beta-carotene/g) to prepare traditional maize porridges and compared the carotenoid contents in the following: (1) whole kernels; (2) wet milled flour; (3) wet milled flour, fermented; (4) wet milled flour, cooked; (5) wet milled flour, fermented and cooked. The cumulative losses of beta-carotene in the final, cooked products were 24.5% (95% CI 22.8-26.2%) and 24.8% (95% CI 23.1-26.5%), for the fermented and unfermented porridges, respectively. Thus, fermentation, a traditional technology with documented nutritional and other health benefits, does not adversely affect the retention of beta-carotene in porridges prepared with high beta-carotene maize. The relatively good retention of beta-carotene during traditional maize processing provides additional experimental support for the feasibility of maize biofortification as a means to alleviate vitamin A deficiency.

Serum hepcidin, but not prohepcidin, was inversely associated with iron absorption from supplemental and food-based nonheme-iron sources in iron-replete healthy women.

Background Food fortification is one approach for addressing anemia, but information on program effectiveness is limited. Objective We evaluated the impact of Costa Rica’s fortification program on anemia in women aged 15–45 y and children aged 1–7 y. Design Reduced iron, an ineffective fortificant, was replaced by ferrous fumarate in wheat flour in 2002, and ferrous bisglycinate was added to maize flour in 1999 and to liquid and powdered milk in 2001. We used a one-group pretest-posttest design and national survey data from 1996 (baseline; 910 women, 965 children) and 2008–2009 (endline; 863 women, 403 children) to assess changes in iron deficiency (children only) and anemia. Data were also available for sentinel sites (1 urban, 1 rural) for 1999–2000 (405 women, 404 children) and 2008–2009 (474 women, 195 children), including 24-h recall data in children. Monitoring of fortification levels was routine. Results Foods were fortified as mandated. Fortification provided about one-half the estimated average requirement for iron in children, mostly and equally through wheat flour and milk. Anemia was reduced in children and women in national and sentinel site comparisons. At the national level, anemia declined in children from 19.3% (95% CI: 16.8%, 21.8%) to 4.0% (95% CI: 2.1%, 5.9%) and in women from 18.4% (95% CI: 15.8%, 20.9%) to 10.2% (95% CI: 8.2%, 12.2%). In children, iron deficiency declined from 26.9% (95% CI: 21.1%, 32.7%) to 6.8% (95% CI: 4.2%, 9.3%), and iron deficiency anemia, which was 6.2% (95% CI: 3.0%, 9.3%) at baseline, could no longer be detected at the endline. Conclusions A plausible impact pathway suggests that fortification improved iron status and reduced anemia. Although unlikely in the Costa Rican context, other explanations cannot be excluded in a pre/post comparison.

The determinants of placental transport of dietary iron remain largely uncharacterized. The objective of this research was to elucidate determinants of fetal Fe transfer from maternally ingested dietary heme and non-heme Fe. The study was undertaken in 19 pregnant females (16-32 y) who ingested intrinsically labeled (58)Fe-heme and a nonheme Fe source ((57)FeSO(4)) during the third trimester of pregnancy. At delivery, maternal and cord blood was obtained to assess neonatal (57)Fe and (58)Fe enrichment as a function of maternal/neonatal Fe status [serum ferritin (SF), transferrin receptor, hemoglobin (Hb), total body Fe, and hepcidin]. There was a greater percentage of maternally absorbed (58)Fe tracer present in the neonates compared to the (57)Fe tracer (5.4 ± 2.4 vs. 4.0 ± 1.6; P < 0.0001). Net dietary nonheme Fe (mg) and heme Fe (mg) transferred to the fetus were both inversely correlated with measures of maternal serum hepcidin (P = 0.002, r(2) = 0.43; P = 0.004, r(2) = 0.39) and SF (P = 0.0008, r(2) = 0.49; P = 0.003, r(2) = 0.41) and directly associated with neonatal Hb (P = 0.004, r(2) = 0.39; P = 0.008, r(2) = 0.35). The results of this study suggest that during pregnancy there appears to be preferential fetal use of maternally ingested Fe derived from a dietary, animal-based heme source compared to Fe ingested as ferrous sulfate. Maternal serum hepcidin and maternal/neonatal Fe status may play a role in placental uptake of dietary heme and nonheme Fe.

The accurate estimation of vitamin A deficiency (VAD) is critical to informing programmatic and policy decisions that could have important public health implications. However, serum retinol and retinol binding protein (RBP) concentrations, two biomarkers often used to estimate VAD, are temporarily altered during the acute phase response, potentially overestimating the prevalence of VAD in populations with high levels of inflammation. In 22 nationally-representative surveys, we examined (1) the association between C-reactive protein (CRP) or α1-acid glycoprotein (AGP) and retinol or RBP, and (2) how different adjustment approaches for correcting for inflammation compare with one another. In preschool age children (PSC) and school age children (SAC), the association between inflammation and retinol and RBP was largely statistically significant; using the regression approach, adjustments for inflammation decreased the estimated prevalence of VAD compared to unadjusted VAD (range: −22.1 to −6.0 percentage points). In non-pregnant women of reproductive age (WRA), the association between inflammation and vitamin A biomarkers was inconsistent, precluding adjustments for inflammation. The burden of VAD can be overestimated if inflammation is not accounted for, and the regression approach provides a method for adjusting retinol and RBP for inflammation across the full range of concentrations in PSC and SAC.

BackgroundIn Bihar, India, high maternal anemia prevalence and low iron and folic acid supplement (IFA) receipt and consumption have continued over time despite universal IFA distribution and counseling during pregnancy.PurposeTo examine individual and facility-level determinants of IFA receipt and consumption among pregnant women in rural Bihar, India.MethodsUsing District Level Household Survey (2007–08) data, multilevel modeling was conducted to examine the determinants of two outcomes: IFA receipt (any IFA receipt vs. none) and IFA consumption (≥90 days vs. <90 days). Individual-level and facility-level factors were included. Factor analysis was utilized to construct antenatal care (ANC) quality and health sub-center (HSC) capacity variables.ResultsOverall, 37% of women received any IFA during their last pregnancy. Of those, 24% consumed IFA for 90 or more days. Women were more likely to receive any IFA when they received additional ANC services and counseling, and attended ANC earlier and more frequently. Significant interactions were found between ANC quality factors (odds ratio (OR): 0.37, 95% confidence interval (CI): 0.25, 0.56) and between ANC services and ANC timing and frequency (OR: 0.68, 95% CI: 0.56, 0.82). No HSC factors were significantly associated with IFA receipt. Women were more likely to consume IFA for ≥90 days if they attended at least 4 ANC check-ups and received more ANC services. IFA supply at the HSC (OR: 1.37, 95% CI: 1.04, 1.82) was also significantly associated with IFA consumption.ConclusionsOur findings indicate that individual and ANC factors (timing, frequency, and quality) play a key role in facilitating IFA receipt and consumption. Although HSC capacity factors were not found to influence our outcomes, significant variation at the facility level indicates unmeasured factors that could be important to address in future interventions.