In Cambodia, many factors may complicate the detection of iron deficiency. In a cross-sectional survey, we assessed the role of genetic hemoglobin (Hb) disorders, iron deficiency, vitamin A deficiency, infections, and other factors on Hb in young Cambodian children. Data on sociodemographic status, morbidity, and growth were collected from children (n = 3124) aged 6 to 59 mo selected from 3 rural provinces and Phnom Penh municipality. Blood samples were collected (n = 2695) for complete blood count, Hb type (by DNA analysis), ferritin, soluble transferrin receptor (sTfR), retinol-binding protein (RBP), C-reactive protein, and α1-acid glycoprotein (AGP). Genetic Hb disorders, anemia, and vitamin A deficiency were more common in rural than in urban provinces (P < 0.001): 60.0 vs. 40.0%, 58.2 vs. 32.7%, and 7.4 vs. 3.1%, respectively. Major determinants of Hb were age group, Hb type, ferritin, sTfR, RBP, AGP >1.0 g/L (P < 0.001), and rural setting (P < 0.05). Age group, Hb type, RBP, elevated AGP, and rural setting also influenced ferritin and sTfR (P < 0.02). Multiple factors affected anemia status, including the following: age groups 6–11.99 mo (OR: 6.1; 95% CI: 4.3, 8.7) and 12–23.99 mo (OR: 2.7; 95% CI: 2.1, 3.6); Hb type, notably Hb EE (OR: 18.5; 95% CI: 8.5, 40.4); low ferritin (OR: 3.2; 95% CI: 2.2, 4.7); elevated AGP (OR: 1.4; 95% CI: 1.2,1.7); rural setting (OR: 2.3; 95% CI: 1.7, 3.1); low RBP (OR: 3.6; 95% CI: 2.2, 5.9); and elevated sTfR (OR: 2.1; 95% CI: 1.7, 2.7). In Cambodia, where a high prevalence of genetic Hb disorders exists, ferritin and sTfR are of limited use for assessing the prevalence of iron deficiency. New low-cost methods for detecting genetic Hb disorders are urgently required.
IntroductionHidden hunger, a chronic lack of vitamins and minerals in the diet, affects about one-third of the world's population. Deficiencies in micronutrients such as iron, zinc, and vitamin A compromise the physical and cognitive capacity of millions of people, contributing to the perpetuation of poverty, poor health, and underdevelopment [1]. The greatest burden of micronutrient deficiencies is found in low-resource communities where the typical diet is high in starches but low in micronutrients. Iron-deficiency anemia is the most common form of malnutrition, affecting over 2 billion people globally [2]. Fortifying commonly eaten foods with tiny quantities of essential vitamins and minerals is an effective strategy for decreasing micronutrient deficiencies at a population level and is widely practiced in high-income countries. Over the past 15 years, national governments and the global nutrition community have invested significant efforts to bring the benefits of fortification of staple foods to lower-and middle-income countries. Currently 81 countries have legislated mandatory fortification of wheat, maize, and/or rice, making a vital contribution to the global reduction of micronutrient
In Cambodia, many factors may complicate the detection of iron deficiency. In a cross-sectional survey, we assessed the role of genetic hemoglobin (Hb) disorders, iron deficiency, vitamin A deficiency, infections, and other factors on Hb in young Cambodian children. Data on sociodemographic status, morbidity, and growth were collected from children (n = 3124) aged 6 to 59 mo selected from 3 rural provinces and Phnom Penh municipality. Blood samples were collected (n = 2695) for complete blood count, Hb type (by DNA analysis), ferritin, soluble transferrin receptor (sTfR), retinol-binding protein (RBP), C-reactive protein, and a 1 -acid glycoprotein (AGP). Genetic Hb disorders, anemia, and vitamin A deficiency were more common in rural than in urban provinces (P , 0.001): 60.0 vs. 40.0%, 58.2 vs. 32.7%, and 7.4 vs. 3.1%, respectively. Major determinants of Hb were age group, Hb type, ferritin, sTfR, RBP, AGP .1.0 g/L (P , 0.001), and rural setting (P , 0.05). Age group, Hb type, RBP, elevated AGP, and rural setting also influenced ferritin and sTfR (P , 0.02).Multiple factors affected anemia status, including the following: age groups 6-11.99 mo (OR: 6.1; 95% CI: 4.3, 8.7) and 12-23.99 mo (OR: 2.7; 95% CI: 2.1, 3.6); Hb type, notably Hb EE (OR: 18.5; 95% CI: 8.5, 40.4); low ferritin (OR: 3.2; 95% CI: 2.2, 4.7); elevated AGP (OR: 1.4; 95% CI: 1.2,1.7); rural setting (OR: 2.3; 95% CI: 1.7, 3.1); low RBP (OR: 3.6; 95% CI: 2.2, 5.9); and elevated sTfR (OR: 2.1; 95% CI: 1.7, 2.7). In Cambodia, where a high prevalence of genetic Hb disorders exists, ferritin and sTfR are of limited use for assessing the prevalence of iron deficiency. New low-cost methods for detecting genetic Hb disorders are urgently required.
Determining the magnitude of the thalassemia problem in a country is important for implementing a national prevention and control program. In order to acquire accurate thalassemia prevalence data, the gene frequency of α- and β-thalassemia (α- and β-thal) in different regions of a country should be determined. The molecular basis of thalassemia in Cambodia was performed by polymerase chain reaction (PCR)-based techniques in a community-based cross-sectional survey of 1631 unrelated individuals from three regions, Battambang, Preah Vihear and Phnom Penh. Thalassemia mutations were detected in 62.7% of the three studied population of Cambodia. Hb E (HBB: c.79G > A) was the most common β-globin gene mutation with a frequency ranging from 0.139 to 0.331, while the most frequent α-globin gene mutation was the -α(3.7) (rightward) deletion (0.098-0.255). The other frequencies were 0.001-0.003 for β-thal, 0.008-0.011 for α-thal-1 (- -(SEA)), 0.003-0.008 for α-thal-2 [-α(4.2) (leftward deletion)], 0.021-0.044 for Hb Constant Spring (Hb CS, HBA2: c.427T > C) and 0.009-0.036 for Hb Paksé (HBA2: c.429A > T). A regional specific thalassemia gene frequency was observed. Preah Vihear had the highest prevalence of Hb E (55.9%), α-thal-2 (24.0%) and nondeletional α-thal (15.1%), whereas Phnom Penh had the lowest frequency of thalassemia genes. Interestingly, in Preah Vihear, the frequency of Hb Paksé was extremely high (0.036), almost equivalent to that of Hb CS (0.044). Our results indicate the importance of micromapping and epidemiology studies of thalassemia, which will assist in establishing the national prevention and control program in Cambodia.
Increased intake of animal-source foods is a key means to improve nutritional status in populations with high levels of nutrient deficiencies. However, there are few examples of programming models that have successfully improved both access to and consumption of animal products in resource-poor settings. This chapter presents a case study of a community-based intervention to increase household access to and consumption of animal-source foods, implemented as part of a comprehensive, 9-year nutrition and health programme in Malawi. A community-managed revolving fund scheme was used to distribute small animals to rural households, accompanied by training on animal husbandry and intensive nutrition education to promote consumption of the animal products. This was integrated into a broader anaemia control strategy, which included iron supplementation and malaria control. Cross-sectional surveys were used to evaluate programme effectiveness, including comparison of beneficiary communities with non-programme areas. Household rearing of all small animals increased from 43% to 65% in programme areas. Significantly more households in the programme area both raised and consumed the target animals at the final evaluation. Anaemia prevalence in pregnant women decreased from 59% to 48% in the programme area, but increased to 68% in the comparison group. In preschool children, anaemia prevalence decreased similarly in both groups. The revolving fund scheme successfully increased access to and consumption of small animals in programme communities. Anaemia prevalence decreased in women, but the specific contribution of the animals to this cannot be separated from the combined impact of the integrated programme.
This chapter examines the success and sustainability potential of medium-scale fortification (MSF) and small-scale fortification (SSF) to increase rural access to and usage of fortified flours within the Canadian International Development Agency (CIDA)-funded Micronutrient and Health (MICAH) Programme in Malawi. World Vision implemented the MICAH programme (1996-2005) to address anaemia and micronutrient malnutrition of women and children in Malawi. MICAH consisted of a package of community-based multi-sectoral interventions implemented with multiple partners. SSF and MSF of maize flour consumed by the general population, and a specially formulated local complementary food (likuni phala), were part of an anaemia control package that also included small animal production and consumption, backyard gardens, community-based iron supplementation, deworming of children and malaria control. Project evaluations provided strong evidence of impact over the 9 years of implementation. For example: anaemia in children under 5 years decreased from 86% (1996) to 60% (2004); anaemia in non-pregnant women decreased from 51% (2000) to 39% (2004). The Domasi Fortification Unit, the MSF operation initiated by MICAH, has continued (to date, 2010) as a self-sustaining, fully commercialized producer of fortified foods, supplying other fortification units and feeding programmes throughout Malawi. Linking SSF sites with MSF operations is a promising approach to successful scale up and sustainability of community-based fortification.
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