Sight and Life 3 2006

SIGHT AND LIFE

Magazine Issue No 1/2007

Carotenoid function

Food vouchers

Nutritional status in Guatemala

DOHaD

SLAN

Education

ANLP

A Life in the Day

Recent literature

Publications

News Food distribution by the United Nations World Food Programme

Building bridges to combat malnutrition

“The life science industry is able to make a major contribution to fighting global malnutrition and hunger,” stated Feike Sijbesma (President of SIGHT AND LIFE and incoming CEO of DSM) at a special session of the BioVision conference in Lyon. He announced a global humanitarian partnership with the United Nations World Food Programme (WFP), the largest provider of food aid to the world's hungry. SIGHT AND LIFE presented the book Nutritional Anemia at BioVision 2007. More on the book and the partnership can be found on page 60. SIGHT AND LIFE Contents

Impact of vouchers for purchasing fresh fruits and vegetables among low-income The African Forum mothers 13 Lusaka, Zambia, May 2006 30

Correspondents

Bruno de Benoist Philip Harvey Florentino S Solon William S Blaner Richard F Hurrell Alfred Sommer Martin Bloem Rolf D W Klemm David I Thurnham George Britton Donald S McLaren Andrew Tomkins Ian Darnton-Hill Regina Moench-Pfanner Emorn Wasantwisut Omar Dary Christine Northrop-Clewes Keith P West Jr Frances R Davidson Delia Rodriguez-Amaya Yu Xiaodong John W Erdman Jr Noel W Solomons Michael B Zimmermann

2 Contents Magazine Issue 1/2007

The fifth African Nutrition Leadership SIGHT AND LIFE presented the book Programme (ANLP) 36 Nutritional Anemia at BioVision 2007 60

Contents

Welcome 4 From farming to human nutrition 34

Antioxidant nutrients and oxidative The fifth African Nutrition Leadership DNA damage in humans 6 Programme (ANLP) 36

Impact of vouchers for purchasing A Life in the Day of Parul Christian 39 fresh fruits and vegetables among low-income mothers 13 Erratum 41

The nutritional status of Guatemalan From vitamin A to multiple micronutrients 42 schoolchildren 18 Recent literature

The 4th World Congress on Letters to the editors 52 Developmental Origins of Health and Disease (DOHaD) 21 Publications 56

The 14th Latin American Congress News 60 on Nutrition (SLAN) 27 Building bridges to combat malnutrition Outstanding Health Research Award The African Forum: An integrated Healthy Eyes Activity Book response to the dual epidemics of HIV/AIDS and food insecurity 30

3 SIGHT AND LIFE Welcome

Welcome Malnutrition scandal

At the end of last year I was distressed by an article on this account, we have initiat- malnutrition in Ethiopia that was published in the New ed a series of activities. York Times on December 28, 2006. It was titled SIGHT AND LIFE hosted a “Malnutrition Is Cheating Its Survivors and Africa’s workshop on nutritional Future.” The article’s author Michael Wines wrote, anemia last September with “In this corrugated land of mahogany mountains and the leading experts from academia and international tan, parched valleys, it is hard to tell which is the organizations (we reported on this in Issue 3/2006 of greater scandal: the thousands of children malnutrition SIGHT AND LIFE Magazine). We also recently kills, or the thousands more it allows to survive.” published a book, Nutritional Anemia, which provides Indeed, more than 200 million children under the age an account of the information communicatetd at the of 5, mostly living in sub-Saharan Africa and South workshop, and highlights for the first time all the crit- Asia, fail to reach their full cognitive, motor and ical factors of nutritional anemia in one volume. I had socioemotional potential because of micronutrient the pleasure of presenting the first copies of this book deficiencies and inadequate cognitive stimulation. to high-ranking representatives from UNICEF, the These children will probably fail at school, fail to World Food Programme, and the Dutch embassy in achieve their income potential, and remain trapped in France during a special session at BioVision, the poverty. A recent series of papers published in The World Life Sciences Forum, in Lyon on March 11, Lancet also addressed this topic, analyzing the link 2007. More on this topic can be found on page 60. But between compromised development of children and we have even more in mind: the Nutritional Anemia modifiable biological and psychosocial risk factors Guidebook, containing short summaries of the book (Lancet 2007;369:60–70, 145–57 and 229–42). The chapters, will be published shortly, and we are plan- authors call for immediate intervention in four key ning a satellite meeting with the experts who con- areas: stunting, inadequate cognitive stimulation, tributed to the book to correspond with the iodine deficiency, and iron deficiency anemia, the evi- Micronutrient Forum in Istanbul. We need to define dence of which is overwhelming. the next steps in the global fight against anemia, including the specific role that SIGHT AND LIFE will For us at SIGHT AND LIFE, it is not a question of play. defining the greater scandal, but rather of responding to the problem behind it. We intend to champion the There are many factors that contribute to the appraisal fight against micronutrient deficiency, in particular of an organization such as SIGHT AND LIFE, for nutritional anemia, and to ensure that it receives the example the quality of correspondents and partners or recognition merited by the magnitude of the problem. the excellence of projects and publications. One indi- The main causes of anemia are a lack of iron, folic cator rarely recognized, but nevertheless crucial for acid, vitamin B12 and vitamin A, but infectious dis- success, is the willingness to change. We have eases such as malaria, worm infestations, and changed our logo and modernized the layout of our HIV/AIDS also play their part. A total of 818 million magazine to make it more attractive to our readers. women and children under the age of 5 are affected by Additionally, the current edition of the magazine con- anemia, according to recent WHO data. Most of them tains a new column, A Life in the Day of…. In the first live in the developing world and about one million die of this new series, Parul Christian from the Johns every year. Despite the severity of this problem, there Hopkins Bloomberg School of Public Health has been little documented progress in the global fight describes her working day and what lies behind it against anemia over the last decades. Hence there is an (page 39). There are more changes to come, as out- urgent need to control this public health problem. On lined in SIGHT AND LIFE’s strategic framework

4 Welcome Magazine Issue 1/2007

‘Expanding our Strengths,’ which you can read about Nutrition at the University of Ulster in Northern in the enclosed 2006 Annual Report. The recently Ireland. His first contribution, in which he genteelly announced global humanitarian partnership between introduces both the topic and himself, can be found on the United Nations World Food Programme, DSM, page 42. and SIGHT AND LIFE can also be regarded as a significant change (see page 60). Permit me to revert briefly to the malnutrition scandal which I mentioned at the outset. We need more advo- In the midst of these planned changes, however, we cacy communication on the fact that the damage to have to report one which comes as a surprise: Donald intellectual capacity cannot be reversed in later life, McLaren has announced that he is stepping down from quantifying the loss of gross domestic product when his position as editor of our literature digest. We wish micronutrient deficiencies are left untreated, which is to thank Don for his critical reviews and thoughtful estimated to cost 2–3% of annual growth in the devel- insight based on the ceaseless commitment to scien- oping world. The problem is not a lack of knowledge tific evidence that he has brought to the vitamin A about solutions but rather the absence of a clear polit- community. Fortunately, we will not have to fully do ical and financial commitment that matches the size of without Don’s wisdom because he is busy working on the malnutrition problem. The problem is clearly the 3rd edition of the SIGHT AND LIFE Manual on described. What remains is to take up the challenge Vitamin A Deficiency Disorders, to be published later and to take action. this year. Best regards, I am particularly pleased that we have been able to enlist David Thurnham to prepare a literature digest – extended not in size but in scope – on multiple micronutrients in the future. David is a widely re- spected figure in micronutrient research. Lately, he has been particularly interested in the influence of inflammation on micronutrients, especially vitamin A and iron. David is Emeritus Professor of Human

5 SIGHT AND LIFE Carotenoid function

Antioxidant nutrients and oxidative DNA damage in humans*

Kyung-Jin Yeum, Tufts University, Boston; Giancarlo Aldini, Instituto Chimico Farmaceutico e Tossicologico, University of Milan; Robert M. Russell, Tufts University, Boston

Correspondence: Kyung-Jin Yeum, Jean Mayer, USDA Human Nutrition Research Center on Aging at Tufts University, 711 Washington St., Boston, MA 02111, USA Email: [email protected]

* This research has been supported in part by the US Department of Agriculture, under agreement number 1950-51000-048-01A. The contents of this publication do not necessarily reflect the views or policies of the US Department of Agriculture, nor does mention of trade names, commercial products, or organizations imply endorse- ment by the US Government.

Introduction etables against reactive oxygen is finely balanced and requires the species has led to the increased right amounts, possibly an optimal Oxidative stress has been impli- consumption of antioxidant supple- range, of both the hydrophilic and cated in the pathogenesis of chron- ments such as β-carotene, α-toco- lipophilic antioxidants to be work- ic diseases related to aging, such as pherol and/or multivitamins. It is ing properly in biological systems. cancer and cardiovascular disease not surprising to note that more The optimal ranges of antioxidants (1). Epidemiological studies have than 11% of US adults age 20 years could be reached by a balanced shown that a high fruit and veg- or older consume at least 400 IU of dietary fruit and vegetable intake etable intake is associated with a vitamin E per day from supple- and not by the high dose of a single lower risk of such chronic diseases ments (7). However, intervention or a limited mixture of antioxi- (2-5). It is probable that antiox- studies have failed to show a con- dant supplements, which could idants in fruits and vegetables pre- sistent beneficial effect of antioxi- cause an imbalance of the antioxi- vent damage from harmful reactive dant supplementations such as vita- dant machinery. A recent prospec- oxygen species, which are contin- min E (8) or β-carotene (9, 10) tive study showing the inverse uously produced in the body during against any chronic disease. How association of plasma antioxidant normal cellular functioning and can we explain these apparently concentrations with the risk of introduced from exogenous sources contradictory results between heart disease and cancer supports a (6). When the excessive amount of observational studies and interven- beneficial effect of a balanced reactive oxygen species accumu- tion trials? antioxidant status, which can be lates in vivo, it can cause oxidative attained by eating high fruit and damage to lipids, proteins and It should be pointed out that the vegetable diets (16). DNA. In particular, DNA is one of metabolism and functions of the most biologically significant antioxidants may differ in in vivo Biomarkers for oxidative DNA targets for reactive oxygen species. in comparison with in vitro sys- damage It is generally accepted that the tems. For example, antioxidant imbalance between oxidative DNA nutrients not only can switch from Single-cell microgel electrophore- damage and repair contributes to being antioxidant to prooxidant sis was developed to detect DNA the risk of cancer development. (11), but also can interact with damage and repair. In this tech- each other during gastrointestinal nique, damaged or broken DNA The possible protective effect of absorption and metabolism (12- migrates further away from the antioxidants rich in fruits and veg- 15). The in vivo antioxidant system original intact nucleus when placed

6 Carotenoid function Magazine Issue 1/2007

in an electrophoretic field. After appropriate staining with fluores- cent dye, the results appear as an 0 1 2 image similar in shape to a comet, where the head represents intact DNA and the tail consists of damaged DNA made up of single and double strand DNA breaks or frag- 3 4 ments (17). The greater the length of the tail and the smaller the head, the greater the amount of DNA Figure 1: Visual classification of DNA damage, according to the relative damage. The comets can be classi- proportion of DNA in the tail (scores 0-4), obtained by alkali fied into several categories based single-cell gel electrophoresis on the length of migration and/or the perceived relative proportion of gle and double strand breaks. the oxidative DNA damage, even the DNA in the tail, as shown in though it remains to be confirmed Figure 1. Score 0 represents un- Oxidative DNA damage and if it is representative of target tis- damaged DNA, score 4 indicates chronic diseases sues. As shown in Table 1, signifi- the most heavily damaged DNA. cantly elevated basal DNA damage The pathological process of a was reported in coronary artery dis- Modified techniques (18) using chronic disease such as cancer is ease patients (19), breast cancer strong alkali increase the sensitivity often associated with genetic insta- patients (20, 21), and head and of single cell gel electrophoresis by bility, which can be determined by neck cancer patients (22) compared unwinding normally curled DNA DNA damage. Peripheral lympho- to DNA damage in healthy sub- strands, thereby detecting both sin- cytes are convenient to determine jects. In particular, risk assessment

Table 1: Clinical applications of the comet assay

Subjects Age (years) Lymphocyte Reference DNA damage (significance) Coronary artery disease 19 • Cases, n=53 57 ± 9 Elevated • Controls, n=42 56 ± 11 (P<0.001) Head and neck squamous cell cancer 22 • Cases, n=38 13 – 78 Elevated • Controls, n=44 Breast cancer 21 • Cases, n=70 54 ± 10 Elevated • Controls, n=70 52 ± 11 (P<0.001) Breast cancer 20 • Cases, n=40 Not reported Elevated • Controls, n=60 (P<0.05) Breast Cancer 23 • Breast cancer, n=88 18 – 70 Cancer > FDFR > • First degree female relatives 18 – 70 control (FDFR) of breast cancer patients, (P<0.001) n=188 • Controls, n=121 18 – 70

7 SIGHT AND LIFE Carotenoid function

in first degree female relatives of Beneficial effects of dietary DNA damage and repair (27) deter- breast cancer patients using the antioxidants on oxidative mined by urinary and blood lev- alkaline comet assay (23) indicated DNA damage els of 8-hydroxydeoxyguanosine. a significant increase in DNA dam- Table 2 shows the intervention age, progressing from healthy con- The relationship between the con- studies involving carotenoid rich trols to first degree female relatives sumption of fruits and vegetables diets and lymphocyte DNA damage of breast cancer patients, and from and DNA damage has been sug- determined by single-cell gel elec- first degree female relatives of gested by the observation of lower trophoresis (comet assay). Short breast cancer patients to newly DNA damage in the summer than term dietary intervention studies diagnosed untreated breast cancer in the winter corresponding to the (14-26 d) using carotenoid rich patients. difference in the seasonal intake of foods such as 600 mL of orange dietary antioxidants in 11 middle juice for 21 days (28), 25 g of It should be noted, however, that aged male volunteers (25). In gen- tomato puree for 14 days (29), or the currently available case-control eral, intervention trials involving 60 g of tomato puree for 21 days studies to determine the association increased fruit and vegetable intake (30), and/or 150 g of spinach for 21 of DNA damage with cancer risk have shown beneficial effects of days (31) resulted in reduced are based on relatively small carotenoid rich fruits and vegeta- oxidative DNA damage in healthy groups of subjects. In addition, it is bles regarding DNA damage. women. Similar results were difficult to compare DNA damage observed in a group of men and among studies because of the dis- Decreased oxidative DNA damage women treated with 250 mL of a cordance of methodological condi- has been reported with 12 ser- tomato extract drink for 26 days tions, such as the duration of alkali vings/d of fruits and vegetables (32). Also, a 14 day intervention unwinding, the electrophoresis sys- for 14 days (26). In contrast, 600 g with tomato juice, carrot juice or tem conditions, and the visual scor- of fruit and vegetable consumption dried spinach powder (33) or a ing system used (24). for 4 wk showed no effect on polyphenol-rich juice intervention

Table 2: Studies on the effects of carotenoid rich fruits and vegetables on lymphocyte DNA damage

Subjects Age (years) Intervention Duration DNA damage Reference (study design) (days) (significance) Male 25.4 ± 2.4 • Tomato drinks (250 mL) 26 each Decreased 32 Female 26.1 ± 3.2 • Placebo (cross-over, (P<0.001) (n=26) double blinded) Female 20 – 27 • Orange juice (600 mL) + 21 each Inversely 28 (n=16) standard diet related to • Standard diet plasma vitamin C (cross-over) (P<0.005) Female 25.4 ± 2.2 • Tomato puree 25 g/d 14 Decreased 29 (n=9) (P<0.005) Female 23.1 ± 1.1 • Tomato puree 60 g/d 21 each Decreased 30 (n=10) • Tomato free diet (P<0.05) (cross-over) Female 25.2 ± 2.2 • Spinach 150 g 21 each Decreased 31 (n=9) • Spinach + tomato puree 25 g (P<0.01) (consecutively) Male 27 – 40 • Tomato juice 330 mL/d 14 each Decreased 33 (n=23) • Carrot juice 330 mL/d (P<0.05) • Spinach powder 10 g/d (consecutively)

8 Carotenoid function Magazine Issue 1/2007

(34) were all reported to be beneficial against basal plements of lycopene and lutein are similar to those of DNA damage in healthy men. Finally, dietary inter- pureed and oil-containing tomato-based foods (37) and ventions for 3 wk with tomato sauce, providing green leafy vegetables (38) respectively, similar bio- 30 mg lycopene/d, resulted in significantly decreased logical actions of pure forms of these carotenoids must oxidative DNA damage in prostate cancer patients (35, be expected. 36). Effects of antioxidant supplements on oxidative Even though most of the currently available interven- DNA damage tion studies determining effects of carotenoid rich diets against DNA damage have limitations such as small In an effort to identify the biological actions of spec- number of subjects, differing age groups, short dura- ific antioxidant nutrients present in fruits and vegeta- tions of study, short duration of wash-out period, and bles, intervention studies have been conducted using non-blinded subjects and investigators as to treatment, individual antioxidants or combinations of antioxidant the protective effect of carotenoid rich fruits and veg- supplements. Intervention trials using antioxidant sup- etables against oxidative DNA damage seems strong. plements have shown mixed results regarding DNA Assuming that in humans the bioavailabilities in sup- damage (i.e., decreased oxidative DNA damage or no

Table 3: Studies on the effects of antioxidants on lymphocyte DNA damage and repair

Subjects Age Intervention Duration DNA damage/repairReference (years) (study design) (days) Male 25 – 45 • α/β-carotene 15 mg 12 wk No effect 39 Female • Lutein 15 mg Inverse correlation (n=40) • Lycopene 15 mg between serum • Placebo carotenoids and (randomized) oxidized pyrimidines

Male 24 – 34 • β-carotene 15 mg 7 d each Increased DNA repair 40 (n=5) • Lycopene 15 mg by β-carotene and Female • Lutein 15 mg lycopene, not by lutein (n=3) (consecutively with 3 wk wash-out) Male 18 – 50 • Vitamin C 60 mg 21 d No effect 41 (n=64) • Placebo Male 50 – 59 • Vitamin C 100 mg, vitamin E 20 wk Decreased DNA 42 smoker 280 mg and β-carotene 25 mg damage (P<0.002) (n=50) • Placebo Nonsmoker (randomized) (n=50)

Male 18 – 50 • β-carotene 8.2 mg, 21 d Increased DNA repair 41 nonsmoker α-carotene 3.7 mg and (n=64) α-tocopherol 1.75 mg • Placebo Female 50 – 70 • 4 mg each of lutein, 57 d Decreased DNA 43 (n=37) β-carotene and lycopene damage (P<0.01) • Lutein 12 mg • β-carotene 12 mg • Lycopene 12 mg • Placebo (double blind, randomized)

9 SIGHT AND LIFE Carotenoid function

effect on DNA damage and repair), 1.6 as shown in Table 3. The effect of a single carotenoid against DNA 1.4 o i t

damage is still controversial, a r 1.2 r o whereas the combination of antiox- t c a f l idant supplements have shown rel- i 1.0 a t t n

atively consistent protective effects e m

o 0.8

against DNA damage. C

0.6 Collins and colleagues (39) reported that there was no effect on 0.4 endogenous DNA damage follow- (D1/D1) (D15/D1) (D29/D1) (D43/D1) (D57/D1) ing supplementation with 15 mg/d each of α/β-carotene, lutein or lycopene for 12 wk in men and Figure 2: Effect of carotenoids on the basal lymphocyte DNA damage. women (25–45 yr) in a placebo Placebo (n=6); Mixed Car (n=8), 4 mg each of lutein, β-caro- controlled parallel study design. tene and lycopene/d for 56 days; lutein (n=8), 12 mg of However, it is interesting to note lutein/d for 56 days; β-carotene (n=7), 12 mg of β-carotene for that there was an inverse correla- 56 days; lycopene (n=8), 12 mg lycopene/d for 56 days. DNA damage was measured as the percentage DNA in the tail of a tion between total serum caro- comet assay. The comet tail factor ratio was calculated by tenoids and oxidized pyrimidines in dividing each day’s value by the day 1 value (baseline). Closed their study. On the other hand, symbols indicate significant differences from day 1 (P<0.05, another study using the same repeated-measures ANOVA with Dunnett’s multiple comparison). Data adapted from Table 3 in (43); with permission amount of lutein, β-carotene or lycopene supplementation as reported above, each for 1 wk, Recently, Zhao et al. (43) reported tective against basal DNA damage showed significant increases in that a mixed carotenoid supplement in this study. As shown in Figure DNA repair in younger men and significantly decreased DNA dam- 3, 4 mg of lutein can be obtained 1 women (24–34 yr), probably due age in post-menopausal women, as from approximately /4 cup of to the antioxidant effect of caro- shown in Figure 2. cooked spinach, 4 mg β-carotene 1 1 tenoids rather than a direct effect from about 1 /3 medium carrot or /4 on the repair process (40). Even It is important to note that physio- cup of pumpkin, and 4 mg of though different antioxidants and logic doses of three major caro- lycopene from one medium tomato 3 dosages were used, intervention tenoids found in fruit and vegeta- or /4 tablespoon of tomato paste. studies using a combination of anti- bles (i.e., 4 mg each of lutein, β- However, it should be pointed out oxidant supplements have shown carotene and lycopene) were pro- that pure carotenoid dissolved in oil significant protective effects against DNA damage (e.g., a com- 4 mg -carotene bination of 100 mg of vitamin C, β 280 mg of vitamin E and 25 mg of 4 mg lutein 4 mg lycopene β-carotene (42); a combination of 8 mg of lycopene, 0.5 mg of β- carotene, and 11 mg of vitamin C (44); and a combination of 8.2 mg β-carotene, 3.7 mg α-carotene, and 1.75 mg of α-tocopherol (41)). In 1 addition, Pool-Zobel and cowork- /4 cup of cooked 1 medium tomato or 3 ers reported that supplementation spinach /4 tsp tomato paste of the diet of healthy individuals with tomato, carrot or spinach sig- 1 1 and /3 medium carrots nificantly reduced endogenous lev- 1 or /4 cup of pumpkin els of strand breaks in lymphocyte Figure 3: Dietary sources of carotenoids providing 4 mg each of lutein, DNA (33, 45). β-carotene and lycopene

10 Carotenoid function Magazine Issue 1/2007

(46, 47) or formulated in beadlets cyte DNA damage reflects similar 10. Omenn GS, Goodman GE, Thornquist (48) is efficiently absorbed, where- damage in the other target tissues, MD, et al. Effects of a combination of as carotenoids in uncooked vege- and whether increased oxidative β-carotene and vitamin A on lung cancer and cardiovascular disease. N Engl J tables, such as β-carotene in carrot DNA damage is in fact directly Med 1996;334:1150-5. (49, 50) or lycopene in tomato juice associated with chronic disease 11. Palozza P, Luberto C, Calviello G, et al. (51) are poorly absorbed. development), currently available Antioxidant and prooxidant role of research studies indicate that either β-carotene in murine normal and tumor Further studies on the effect of carotenoid rich fruit and vegetable thymocytes: effects of oxygen partial pressure. Free Radic Biol Med 1997; physiological doses of carotenoids diets, a combination of antioxidants 22:1065-73. in combination with other antioxi- or a combination of carotenoids can 12. van den Berg H, van Vliet T. Effect of dants contained in fruits and veg- be protective against oxidative simultaneous, single oral doses of etables, and more importantly the DNA damage, rather than the use β-carotene with lutein or lycopene on effect of dietary fruits and vege- of a single antioxidant. On the other the β-carotene and retinyl ester respons- tables on oxidative DNA damage, hand, we should be cautious about es in the triacylglycerol-rich lipoprotein fraction of men. Am J Clin Nutr are needed to support the role of a the possibility of over-dosing of 1998;68:82-9. diet high in fruit and vegetables in individual antioxidants, which 13. Paetau I, Chen H, Goh NM, et al. the prevention of chronic diseases could cause an imbalance of our Interactions in the postprandial appear- such as cardiovascular diseases and body’s antioxidant defense system. ance of β-carotene and canthaxanthin in cancer. plasma triacylglycerol-rich lipoproteins in humans. Am J Clin Nutr References 1997;66:1133-43. Conclusion 14. Kostic D, White WS, Olson JA. Intes- 1. Benzie IF. Evolution of antioxidant tinal absorption, serum clearance, and Considering that oxidative stress defence mechanisms. Eur J Nutr 2000; interactions between lutein and 39:53-61. -carotene when administered to human can be increased by the aging 2. Liu S, Lee IM, Ajani U, et al. Intake of β process and that reactive oxygen adults in separate or combined oral vegetables rich in carotenoids and risk doses. Am J Clin Nutr 1995;62:604-10. species are associated with patho- of coronary heart disease in men: The 15. White WS, Stacewicz-Sapuntzakis M, logical processes, the improvement Physicians' Health Study. Int J Epide- Erdman JW Jr, et al. Pharmacokinetics miol 2001;30:130-5. of our body defense systems of β-carotene and canthaxanthin after 3. Greenberg ER, Sporn MB. Antioxidant ingestion of individual and combined against oxidative damage may lead vitamins, cancer, and cardiovascular toward achieving better health and doses by human subjects. J Am Coll disease. N Engl J Med 1996;334: Nutr 1994;13:665-71. reducing the risk of age-related 1189-90. 16. Buijsse B, Feskens EJ, Schlettwein- chronic diseases. 4. Gaziano JM, Hennekens CH. The role Gsell D, et al. Plasma carotene and of -carotene in the prevention of car- β α-tocopherol in relation to 10-y all- Data from the 1999-2000 National diovascular disease. Ann N Y Acad Sci cause and cause-specific mortality in 1993;691:148-55. European elderly: the Survey in Europe Health and Nutrition Examination 5. Hung HC, Joshipura KJ, Jiang R, et al. Survey (NHANES) revealed that on Nutrition and the Elderly, a Fruit and vegetable intake and risk of Concerted Action (SENECA). Am J 52% of adults reported taking a major chronic disease. J Natl Cancer Clin Nutr 2005;82:879-86. dietary supplement, of whom 35% Inst 2004;96:1577-84. 17. Collins A, Dusinska M, Franklin M, et took a multivitamin/multimineral 6. Gate L, Paul J, Ba GN, et al. Oxidative al. Comet assay in human biomonitor- stress induced in pathologies: the role of ing studies: reliability, validation, and supplement (52). In particular, 63% antioxidants. Biomed Pharmacother of adults over 60 years in age took applications. Environ Mol Mutagen 1999;53:169-80. 1997;30:139-46. more than one supplement per 7. Ford ES, Ajani UA, Mokdad AH. Brief 18. Singh NP, Danner DB, Tice RR, et al. day. However, it is still contro- communication: The prevalence of high Basal DNA damage in individual versial whether a single or limited intake of vitamin E from the use of sup- human lymphocytes with age. Mutat mixture of antioxidant supplements plements among U.S. adults. Ann Intern Res 1991;256:1-6. Med 2005;143:116-20. 19. Demirbag R, Yilmaz R, Kocyigit A. can actually increase the body’s 8. Lee IM, Cook NR, Gaziano JM, et al. defense systems, thereby slowing Relationship between DNA damage, Vitamin E in the primary prevention of total antioxidant capacity and coronary down the aging process or prevent- cardiovascular disease and cancer: the artery disease. Mutat Res 2005;570: ing the development of chronic dis- Women's Health Study: a randomized 197-203. eases. controlled trial. JAMA 2005;294:56-65. 20. Sanchez P, Penarroja R, Gallegos F, 9. Baron JA, Cole BF, Mott L, et al. et al. DNA damage in peripheral lym- Neoplastic and antineoplastic effects of Even though there are several ques- phocytes of untreated breast cancer β-carotene on colorectal adenoma recur- patients. Arch Med Res 2004;35:480-3. tions that remain to be answered rence: results of a randomized trial. J (i.e., whether peripheral lympho- Natl Cancer Inst 2003;95:717-22.

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21. Smith TR, Miller MS, Lohman KK, et 33. Pool-Zobel BL, Bub A, Muller H, et al. 45. Pool-Zobel BL, Bub A, Liegibel UM, al. DNA damage and breast cancer risk. Consumption of vegetables reduces et al. Mechanisms by which vegetable Carcinogenesis 2003;24:883-9. genetic damage in humans: first results consumption reduces genetic damage in 22. Palyvoda O, Polanska J, Wygoda A, of a human intervention trial with humans. Cancer Epidemiol Biomarkers et al. DNA damage and repair in lym- carotenoid-rich foods. Carcinogenesis Prev 1998;7:891-9. phocytes of normal individuals and can- 1997;18:1847-50. 46. Goodman DS, Blomstrand R, Werner cer patients: studies by the comet assay 34. Bub A, Watzl B, Blockhaus M, et al. B, et al. The intestinal absorption and and micronucleus tests. Acta Biochim Fruit juice consumption modulates metabolism of vitamin A and β- Pol 2003; 50:181-90. antioxidative status, immune status and carotene in man. J Clin Invest 23. Rajeswari N, Ahuja YR, Malini U, et al. DNA damage. J Nutr Biochem 2003; 1966;45:1615-23. Risk assessment in first degree female 14:90-8. 47. Tang G, Qin J, Dolnikowski GG, et al. relatives of breast cancer patients using 35. Chen L, Stacewicz-Sapuntzakis M, Short-term (intestinal) and long-term the alkaline Comet assay. Carcino- Duncan C, et al. Oxidative DNA dam- (postintestinal) conversion of β- genesis 2000;21:557-61. age in prostate cancer patients consum- carotene to retinol in adults as assessed 24. Faust F, Kassie F, Knasmuller S, et al. ing tomato sauce-based entrees as a by a stable-isotope reference method. The use of the alkaline comet assay with whole-food intervention. J Natl Cancer Am J Clin Nutr 2003;78:259-66. lymphocytes in human biomonitoring Inst 2001;93:1872-9. 48. Huang C, Tang YL, Chen CY, et al. The studies. Mutat Res 2004;566:209-29. 36. Bowen P, Chen L, Stacewicz-Sapunt- bioavailability of β-carotene in stir- or 25. Dusinska M, Vallova B, Ursinyova M, zakis M, et al. Tomato sauce supple- deep-fried vegetables in men deter- et al. DNA damage and antioxidants; mentation and prostate cancer: lycopene mined by measuring the serum response fluctuations through the year in a central accumulation and modulation of bio- to a single ingestion. J Nutr 2000;130: European population group. Food Chem markers of carcinogenesis. Exp Biol 534-40. Toxicol 2002;40:1119-23. Med (Maywood) 2002;227:886-93. 49. Tang G, Qin J, Dolnikowski GG, et al. 26. Thompson HJ, Heimendinger J, 37. Hoppe PP, Kramer K, van den Berg H, Spinach or carrots can supply signifi- Haegele A, et al. Effect of increased et al. Synthetic and tomato-based lyco- cant amounts of vitamin A as assessed vegetable and fruit consumption on pene have identical bioavailability in by feeding with intrinsically deuterated markers of oxidative cellular damage. humans. Eur J Nutr 2003;42:272-8. vegetables. Am J Clin Nutr 2005; Carcinogenesis 1999;20:2261-6. 38. Riso P, Brusamolino A, Ciappellano S, 82:821-8. 27. Moller P, Vogel U, Pedersen A, et al. et al. Comparison of lutein bioavailabil- 50. Livny O, Reifen R, Levy I, et al. No effect of 600 grams fruit and vege- ity from vegetables and supplement. Int β-carotene bioavailability from differ- tables per day on oxidative DNA dam- J Vitam Nutr Res 2003; 73:201-5. ently processed carrot meals in human age and repair in healthy nonsmokers. 39. Collins AR, Olmedilla B, Southon S, et ileostomy volunteers. Eur J Nutr 2003; Cancer Epidemiol Biomarkers Prev al. Duthie SJ. Serum carotenoids and 42:338-45. 2003;12:1016-22. oxidative DNA damage in human lym- 51. Stahl W, Sies H. Uptake of lycopene 28. Riso P, Visioli F, Gardana C, et al. phocytes. Carcinogenesis 1998;19: and its geometrical isomers is greater Effects of blood orange juice intake on 2159 -62. from heat-processed than from un- antioxidant bioavailability and on dif- 40. Torbergsen AC, Collins AR. Recovery processed tomato juice in humans. J ferent markers related to oxidative of human lymphocytes from oxidative Nutr 1992;122:2161-6. stress. J Agric Food Chem 2005;53: DNA damage; the apparent enhance- 52. Radimer K, Bindewald B, Hughes J, 941-7. ment of DNA repair by carotenoids is et al. Dietary supplement use by US 29. Porrini M, Riso P. Lymphocyte probably simply an antioxidant effect. adults: data from the National Health lycopene concentration and DNA pro- Eur J Nutr 2000;39:80-5. and Nutrition Examination Survey, tection from oxidative damage is 41. Astley SB, Elliott RM, Archer DB, et al. 1999-2000. Am J Epidemiol 2004;160: increased in women after a short period Evidence that dietary supplementation 339-49. of tomato consumption. J Nutr with carotenoids and carotenoid-rich 2000;130:189-92. foods modulates the DNA damage: 30. Riso P, Pinder A, Santangelo A, et al. repair balance in human lymphocytes. Does tomato consumption effectively Br J Nutr 2004;91:63-72. increase the resistance of lymphocyte 42. Duthie SJ, Ma A, Ross MA, et al. DNA to oxidative damage? Am J Clin Antioxidant supplementation decreases Nutr 1999;69:712-8. oxidative DNA damage in human lym- 31. Porrini M, Riso P, Oriani G. Spinach phocytes. Cancer Res 1996;56:1291-5. and tomato consumption increases lym- 43. Zhao X, Aldini G, Johnson EJ, et al. phocyte DNA resistance to oxidative Modification of lymphocyte DNA dam- stress but this is not related to cell age by carotenoid supplementation in carotenoid concentrations. Eur J Nutr postmenopausal women. Am J Clin 2002;41:95-100. Nutr 2006;83:163-9. 32. Porrini M, Riso P, Brusamolino A, et al. 44. Riso P, Visioli F, Erba D, et al. Lyco- Daily intake of a formulated tomato pene and vitamin C concentrations drink affects carotenoid plasma and increase in plasma and lymphocytes lymphocyte concentrations and after tomato intake. Effects on cellular improves cellular antioxidant protec- antioxidant protection. Eur J Clin Nutr tion. Br J Nutr 2005;93:93-9. 2004;58:1350-8.

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Impact of vouchers for purchasing fresh fruits and vegetables among low-income mothers Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Los Angeles County, USA

Dena R. Herman, Department of Community Health Sciences, UCLA School of Public Health, Los Angeles; Gail G. Harrison, UCLA School of Public Health, and UCLA Center for Health Policy Research; Eloise Jenks, Public Foundation Enterprises WIC Program, Irwindale

Correspondence: Dena R. Herman, Nutrilite, Division of Access Business Group, 5600 Beach Blvd., Buena Park, CA 90621 Email: [email protected]

Introduction fruit and vegetable consumption; mended, particularly among low- and income individuals. Fruits and vegetables are important • Low fruit and vegetable consump- components of a healthy diet and tion is among the top 10 selected In the United States, the Special increased daily consumption could risk factors for global mortality. Supplemental Nutrition Program help prevent major diseases such as for Women, Infants, and Children certain cancers (1, 2) and cardiovas- Given this evidence for health (WIC) is a governmentally/feder- cular diseases (3). Recommen- benefits, the question arises as to ally funded, locally administered dations from various international why it is that consumption of fresh public health program that provides and US agencies are that optimal produce is often lower than recom- supplemental foods of high nutri- diets for preventing chronic disease should include 400 to 800 g/day of fruits and vegetables (1), equivalent to five to nine servings (4). In 2003, the World Health Organization held a meeting on fruit and vegetable consumption in relation to health promotion and prevention of chronic disease (5). Many of the key findings of the WHO report emphasized the magnitude of impact that a change in dietary quality could make for populations around the world. Among the key points highlighted by the WHO were:

• Up to 2.7 million lives could be Carrots and beets saved annually with sufficient

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tional quality, nutrition education, However, the list of foods supplied by the program have not been updated and referrals for health care for low- since 1980. As an outcome of that discussion, the WIC authorities of the income and nutritionally at-risk Public Health Foundation Enterprises (PHFE) WIC program in Los women during pregnancy and the Angeles and their colleagues at the UCLA School of Public Health, postpartum period, as well as to embarked on a pilot survey and intervention to better understand the feasi- their infants and young children up bility and impact of a novel approach to encourage and enhance the fruit to the age of 5 years (6). The foods and vegetable consumption of the women and children served by the WIC provided are supposed to be supple- program. The PHFE WIC program is one of the largest programs in the mental, and not to constitute one’s United States, serving approximately 318,000 women, infants, and chil- whole diet. Furthermore, they are dren every month. The population the program serves is ethnically diverse meant to mitigate dietary deficien- but is made up of a large proportion of Latino/Hispanic families (approxi- cies prevalent in the target popula- mately 85%). tions. Survey methods When the WIC Program was first implemented in the 1970s, undernu- In August 2001, 602 postpartum, WIC women participants and their fam- trition was the predominant con- ilies were recruited to take part in two interventions strategies. cern. Legislation directed the pro- Approximately 200 women were assigned to each of the programs to program to focus on providing foods mote access to fresh produce and the remaining 200 women served as a that were good sources of calcium, non-intervention control population. The overall purpose of the activity iron, vitamin A, vitamin C, and pro- was to measure the effectiveness of providing vouchers to increase the tein primarily through energy/ consumption of fresh fruits and vegetables. Participants were issued micronutrient-dense sources/foods $10.00 (US) worth of vouchers per week to buy produce of the partici- and beverages including milk, pant’s choice at either a supermarket (intervention #1) or a year-round cheese, eggs, infant formula, forti- farmers market (intervention #2). Vouchers were issued every 2 months, fied cereals, fruit juice, peanut but- and could be spent at any time over the ensuing 2 month period. The inter- ter and dry beans (7). Currently, the vention participants received these vouchers for 6 months for a total of program serves approximately $240.00 per participant (family). At a third (control) site, no fruit and veg- 8 million people in the US at any etable subsidy was given, but participants received a set of vouchers for a given time, including about half of lesser-value to redeem for disposable diapers. all newborn infants and their mothers, and one-quarter of young Participants’ consumption of fruits and vegetables was tracked over the 14 American children (6). month duration of the study, with monitoring of intake both before and after the intervention and over time in the community that served as the As the public health paradigm has control. Participants were asked what they had purchased with the fruit and shifted from an exclusive concern vegetable vouchers they received, while rates of voucher redemption were for eradicating nutrient deficien- tracked. cies, to one that includes promoting better health and resistance to 100 90.9 90 Hispanic chronic diseases, the operation of 83.2 84.1 80 the WIC Program has come under African-American reexamination. Over the last several 70 White years, there has been considerable 60 discussion at the national and local Asian-American 50 levels of the possibility of adding Native-American fresh fruits and vegetables to the 40 P

e 30 r

WIC food packages for women and c e n 20 children, given the evidence of their t

( % 8.5 value in the construction of optimal ) 10 7.5 5.8 4.8 4.1 2.9 2.6 3.6 1.5 diets (8). In addition, there have 0 0.6 been major shifts in the dietary defi- Farmers Market Supermarket Control ciencies of the populations WIC serves, and a more racially and eth- Figure 1: Ethnicity of study population by intervention type nically diverse WIC population (9).

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Study participants represented an ethnically populations of African-Americans, (3.9%), Whites diverse population (3.0%), Asian-Americans (3.0%), and Native Americans (0.2%). Figure 1 shows a further ethnic The women who participated in this study came from breakdown of the study population by type of interven- ethnically diverse backgrounds and had demographic tion. In addition, women were on average 27 years old characteristics similar to those of the larger population and of child-bearing age (range: 17– 43 years), had served by the PHFE WIC Program. Overall, the major- completed on average approximately 10 years of ity of women were Hispanic (86.3%), with smaller schooling (range: 0–19 years), and had about four

Table 1: Individual fruits and vegetables as percent of total fruit and vegetable items. Reported purchased during six-month intervention period, by site (10)*

Farmers Market Site Supermarket Site Fruits % Vegetables % Fruits % Vegetables % Apples 25.4 Tomatoes 14.2 Bananas 28.3 Carrots 18.8 Oranges 19.2 Lettuce 13.2 Apples 26.5 Tomatoes 15.4 Peaches 13.9 Broccoli 11.7 Oranges 15.8 Lettuce 14.3 Grapes 8.4 Carrots 9.8 Grapes 4.9 Broccoli 11.5 Strawberries 7.1 Potatoes 9.1 Pears 4.1 Potatoes 10.4 Watermelons 4.7 Green beans 7.1 Watermelons 4.0 Squash 3.9 Cantaloupes 4.5 Corn 5.0 Peaches 3.5 Onions 3.8 Pears 4.1 Squash 4.7 Strawberries 2.3 Spinach 2.7 Bananas 3.2 Spinach 4.4 Cantaloupes 1.9 Zucchini 2.6 Plums 3.1 Zucchini 4.0 Papayas 1.5 Cauliflower 2.4 Nectarines 2.0 Onions 2.2 Melons 1.4 Cabbages 2.1 Grapefriuts 0.9 Cauliflower 2.1 Pineapples 1.1 Cucumbers 2.0 Apricots 0.7 Cucumbers 2.0 Plums 1.0 Green beans 1.9 Melons 0.5 Cabbages 2.0 Mangos 1.0 Corn 1.3 Tangerines 0.5 Cilantro 1.7 Nectarines 0.7 Avocados 1.1 Cherries 0.4 Avocados 1.5 Lemons 0.5 Chilies 1.1 Mandarins 0.4 Radishes 1.0 Apricots 0.3 Cilantro 0.7 Raspberries 0.3 Bell peppers 1.1 Cherries 0.3 Celery 0.7 Blueberries 0.2 Celery 0.6 Limes 0.3 Bell peppers 0.4 Limes 0.2 Green onions 0.4 Tangerines 0.3 Chayote 0.4 Mangos 0.1 Chili peppers 0.3 Guavas 0.3 Mushrooms 0.3 Pineapples 0.1 Mixed salad 0.2 Coconuts 0.1 Mixed salad 0.3 Pomegranates 0.1 Eggplants 0.2 Honeydews 0.1 Beets 0.3 Papayas 0.1 Bean sprouts 0.2 Grapefruits 0.1 Sweet potatoes 0.3 Kiwis 0.1 Asparagus 0.2 Mandarins 0.1 Radishes 0.2 Guavas 0.1 Garlic 0.2 Kiwis 0.1 Peppers 0.2 Beets 0.2 Green onions 0.1 Artichokes 0.2 Garlic 0.1 Winter squash 0.2 Eggplants 0.1 Romaine 0.1 Bean sprouts 0.1 Swiss chard 0.1 Asparagus 0.1 Green peas 0.1 Mustard green 0.1 Bay leaves 0.1 Green peas 0.1 Pumkins 0.1 Total: 1136 Items Total: 1262 Items Total: 812 Items Total: 950 Items

* Tabular materials taken from: Herman DR, Harrison GG, Jenks E. Choises made by low-income women provided with an economic supplements for fresh fruit and vegetable purchase. J Am Diet Assoc 2006;106:740-744

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The ten most frequently reported Farmers Market Supermarket items were oranges, apples, ba-

7.1% 4.1% nanas, peaches, grapes, tomatoes, 4.9% carrots, lettuce, broccoli, and pota- 8.4% 28.3% 25.4% toes. In the farmers market condi- 15.8% tion, participants purchased 29% more fruits and 25% more vegeta- 13.9% bles although the total number of types of fruits and vegetables did 19.2% 26.5% not differ significantly between the two conditions. However, partici- Apples Oranges Peaches Bananas Apples Oranges pants in both settings purchased a Grapes Strawberries Grapes Pears wide variety of items including blue-berries, pomegranates, arti- Figure 2: Comparison of top five fruits purchased at the farmers market chokes, and mustard greens show- and supermarket sites ing a full range of seasonal varia- tion in purchase patterns (10).

Farmers Market Supermarket Conclusion and policy implications 9.1% 10.4% 14.2% 18.8% Despite much skepticism among

9.8% policymakers and retailers, this 11.5% study showed that low-income consumers can make wise, varied, and

13.2% 15.4% nutritious choices from available 11.7% 14.3% produce when presented with the economic wherewithal. Findings Tomatoes Lettuce Broccoli Carrots Tomatoes Lettuce from a previous study of first-time Carrots Potatoes Broccoli Potatoes WIC participants showed that WIC mothers often regard the purchase of fresh produce as a ‘luxury’ item Figure 3: Comparison of top five vegetables purchased at the farmers market and supermarket sites due to its higher price in comparison with other foodstuffs (11). The high uptake of the economic sup- people in their immediate families (range: 2 – 11 people). Family income plement confirmed that low- was on average $1,233 per month (range: $0 – $3,640 per month) and income families highly value the reflected the income criterion for entry into the WIC program of 185% of ability to purchase and consume a the federal poverty limit. wide variety of fresh produce.

Participant purchases reflected good nutritional choices and a wide With the exception of lettuce and variety of fresh produce grapes, all of the most frequently purchased items were significant In all, $44,000 of vouchers were issued for the supermarket and $44,960 sources of potassium, vitamin C, for the farmers market (10). Redemption rates were 90.7% for the farm- vitamin A, and/or dietary fiber. The ers market and 87.5% for the supermarket (10). Table 1 shows the specif- findings of this study informed ic fruits and vegetables reported as purchased by the participants and their policymakers. These food compo- vouchers. nents were determined to be of high priority in revising WIC food pack- Overall, participants reported purchasing 27 and 26 different fruits and 34 ages by the recent Institute of and 33 different vegetables in the farmer’s market and supermarket out- Medicine study, WIC Food Pack- lets, respectively. Five fruits and vegetables accounted for approximately ages: Time for a Change (8). The 70% of the items reported for each group. variety of choices in this study demonstrated the significant poten-

16 Food vouchers Magazine Issue 1/2007

mination Survey Epidemiologic follow- up study. Am J Clin Nutr 2002;76:93-99. 4. National Cancer Institute. Research/ Formative.html. Available at: www. 5aday.gov. Accessed September 26, 2005. 5. World Health Organization (WHO). WHO Fruit and Vegetable Promotion Initiative – report of the meeting, Geneva, 25-27 August 2003. 6. United States Department of Agri- culture and Economic Research Service. Briefing Room, The WIC Program. Available at: http://www. ers.usda.gov/Briefing/WIC/. Accessed March 16, 2005. 7. Centers for Disease Control and Prevention. 1996. Nutritional status of children participating in the Special Supplemental Nutrition Program for Women, Infants, and Children – United Two girls testing strawberries States, 1988-1991. From the Centers for Disease Control and Prevention. JAMA tial for dietary improvement for undertaken. Given the abundance 275;10:750-752. low-income women and their fami- of scientific evidence available on 8. Institute of Medicine of the National lies when provided with a targeted the relationship of fruit and veg- Academies. WIC Food Packages: Time subsidy that allows free choice etable consumption to prevention for a Change. Washington, DC: National within the fresh produce category. of chronic disease, the time to scale Academy Press; 2005. While the establishment of a simi- up such programs is now. 9. U.S. Government Accountability Office (GAO), WIC Program: More Detailed lar fruit and vegetable promotion Price and Quantity Data Could Enhance initiative in a developing country References Agriculture’s Assessment of WIC may require different community Program Expenditures, GAO-06-664, and governmental partners than 1. World Cancer Research Fund and July 2006. Available at: www.gao. were utilized in this study in the American institute for Cancer Research. gov/new.items/d06664.pdf. 10. Herman DR, Harrison GG, Jenks E. United States, many of the factors Food, Nutrition, and the Prevention of Cancer: a global perspective. Wash- Choices made by low-income women are similar to the ones in the pres- ington, DC: American Institute for provided with an economic supplement ent study. Like so many developing Cancer Research;1997. for fresh fruit and vegetable purchase. J countries, California has a climate 2. International Agency for Research on Am Diet Assoc 2006; 106:740-744. conducive to year-long production, Cancer, World Health Organization. 11. Herman DR, Harrison GG, Afifi AA, there are many benefits for small- IARC Handbooks of Cancer Prevention: Jenks E. The effect of the WIC program Fruits and Vegetables. Lyon, France: on food security status of pregnant, scale farmers, consumers place a IARC Press; 2003. first-time participants. Fam Econ Nutr high benefit-to-health value on 3. Bazanno LA, He J, Ogden LG, et al. Rev 2004;16:21-30. consumption of quality fruits and Fruit and vegetable intake and risk of vegetables but there is also a high cardiovascular disease in US adults: The cost associated with their purchase first National Health and Nutrition Exa- (5). As has been suggested in the WHO 2003 report (5), partners for a fruit and vegetable initiative should include both private and public sectors and should be integrated into national intersectoral food and nutrition policies. These programs also need to be consistent with the predominant stage of the nutrition transition in each country. While only a small-scale study, these findings provide an example Winter squashes of how such initiatives can be

17 SIGHT AND LIFE Nutritional status

The nutritional status of Guatemalan schoolchildren

J. De León Arana Universidad de San Carlos, Guatemala F. Martinez Luzardo Instituto de Ciencias Superiores, Cuba

Correspondence: J. De León Arana Universidad de San Carlos (Edificio T12), Guatemala Email: [email protected]

Introduction The alimentary conduct of each been done for schoolchildren. The child derives from physical, social novelty of this work, therefore, is The age between 6 and 10 years in and psychological characteristics that it establishes a baseline nutri- girls and between 6 and 12 years in (1). tional status for a group of schoolboys is a period of slow, stable children aged 5 to 14 years. These growth in which bodily changes In order to compile the data neces- data may be used as a reference for occur gradually. For this reason, sary to fulfil our aims, we imple- assessing the impact of the this period is referred to as a latent mented a conglomerated sampling Guatemalan School Food Program- growth period (1). procedure involving two stages: mes (Programas de Alimentación first, schools were selected; then Escolar). Up to around the age of 9 or 10 children were selected in each years, a child’s weight and height school. The data were subsequently Materials and methods increase annually, on average, by classified according to the eight around 2.3–2.7 kg and 5 cm, regions into which Guatemala is Population respectively. As children grow, dif- divided (2). ferences between the sexes become The target population was estab- apparent in weight and height Although studies have been con- lished as 2,200,000 children attend- increases, given that girls grow ducted in Guatemala to establish a ing class during 2004 at one of the faster from around the age of 11, baseline nutritional status for chil- 15,226 primary schools in the whereas boys grow faster from dren aged under 5 (e.g. the height Guatemalan public school system. around the age of 13. census of 2001 (3)), this has not Schoolchildren were of both sexes,

Calorie needs vary individually according to the speed of growth, physical activity and body size. Nonetheless, it has been estimated that up to the age of 10, a child needs between 70 and 80 kcal/ kg/day of energy and around 2 g/ kg/day of proteins. Supervision of a child’s nutritional status should be periodic (approximately every six months). The aim is to evaluate weight and height gains and to detect problems of excessive or defective growth or weight gain so as to be able to take the necessary preventative measures. Gardening project in Guatemala

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while taking the second one. The results for the initial measurement of all the children were noted in the corresponding form and set aside until the second set of measurements had been made.

Results

The results of the nutritional evaluation of the group of schoolchildren aged 5 to 14 showed that most individuals evaluated had a nutritional status that was normal or adequate. This confirms the results of the National Health Survey of Mothers and Children (ENSMI (5)) Nutritional education and vitamin A distribution conducted in 2002, which reported a prevalence of acute malnutrition aged between 5 and 14 years, in A form to evaluate healthy schools (weight/height) of 1.6% for the age First to Sixth Grade, and were validated by the Institute of group preceding the age bracket attending morning or evening, Nutrition for Central America and covered by our study (i.e. children urban or rural schools. Panama (INCAP) (4) . aged 5 and under). It can be assumed therefore that an adequate Sample The form for recording anthropo- nutritional status is maintained as metric data was validated using the pre-school children grow and com- A sample size of 3,200 children method of the group mean which mence schooling. This situation is was calculated by taking into typically bases the standardization possibly affected by the nutritional account a non-response rate of process on ten subjects. Each sub- contribution provided by school approximately 10% among the ject was measured twice, but the food programs, and also by the fact selected children. The initial sam- interviewer was not allowed to see that the food available at home – ple was thus 3,600 children. the results of the first measurement even if not necessarily balanced Methodological considerations are described below. Table 1: Healthy and non-healthy aspects of the sampled schools

Variables Characteristic Yes (%) No (%) Healthcare centre 49.4 50.6 Recorded were weight, height and Health campaigns against 36.5 63.5 age for each pupil. Also evaluated diarrhoea, parasites and was the degree to which schools ectoparasites promoted health, vitamin A content Learning difficulties 60.5 39.5 in sugar used to prepare school Children who smoke 9.5 90.5 meals, and iodine content in salt. A microbiological analysis of the Children who use inhalants 4.9 95.1 drinking water used in the sampled Children who drink alcohol 7.4 92.6 schools was performed according Accidents in 2004 32.2 67.8 to the guidelines of Standard 29001 Existence of a first-aid kit 59.3 40.7 of the Guatemalan Standards Com- Bar near the school 15.3 84.7 mission (COGUANOR). Brothel near the school 2.5 97.5 Industrial waste emissions 12.9 87.1 Two data collection forms were Fumigations with pesticides 18.8 81.2 used, as follows: a) A form to Annoying noises 9.4 90.6 record anthropometric data, and b) Traffic accidents 32.9 67.1

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and nutritionally complete – is probably sufficient to In regard to sugar, most of the samples complied with meet the calorie requirements of this group. It would the recommended vitamin A intake (10-20 µg of also explain the percentage of children who show evi- retinyl palmitate/g of sugar). On evaluating sugar sam- dence of overnutrition (obesity). Another factor – indi- ples it was observed that at the national level 30% cated in similar studies in Mexico, Venezuela (1), failed to comply with the recommended vitamin A Cuba (6), Argentina (7) and Panama – may be that if level. The region with the greatest deficit was the these children are stunted, their body proportions will southwest. As for salt, most of the evaluated samples be different to standards for groups with other genetic failed to comply with adequate levels of iodine; 18% characteristics and/or which may not have experienced of samples, moreover, were not fortified. nutritional problems in the past. Thus, weight/height or body mass index (BMI) values may be obtained that Conclusions overestimate the true nutritional status. This would occur principally with children suffering from overnu- 1. The current nutritional status of most schoolgirls trition, since it may not be certain whether the excess aged 5 to 10 years is adequate, although 35.2% weight is fat or muscle. Moreover, if a child has stunt- showed moderate or severe stunting. Likewise, the ed growth, any increase in caloric intake or reduction current nutritional status of most schoolboys of the in activity level is likely to lead to weight gain to the same age is adequate, although 31.3% showed mod- point where he/she becomes overweight or obese. erate or severe stunting.

In regard to past nutritional status or chronic malnutri- 2. Schoolgirls aged over 10 generally had an adequate tion (evaluated using the height/age indicator), it was current nutritional status, although 16% had malnu- determined that both sexes experienced stunted trition problems due to undernutrition or overnutri- growth. This can be explained by the high levels of tion (mainly the former). Schoolboys in the same chronic malnutrition reported for children aged under age group generally had an adequate current nutri- 5 who have reached school-age with their growth tional status, although 15.8% had malnutrition prob- potential already affected. However it is important to lems and were underweight or overweight. note that the most severely affected region in terms of the prevalence of nutritional deficiencies was the 3. None of the schools evaluated satisfied the estab- northwest, which is located among the regions with the lished criteria for healthy school environments. The greatest food insecurity. main unhealthy situations identified were: a lack of drinking water, a lack of hygiene in food prepara- The overall nutritional status (weight/age) for most of tion, and use of sugar and salt (30% and 67.7% of the schoolchildren in this age group was adequate. establishments, respectively) that fail to comply Note that this indicator does not distinguish between with stipulated fortification levels of vitamin A and current nutritional status and past nutritional status, but iodine. merely evaluates weight gain in relation to an individual’s age. Weight may increase and even approach the References expected weight for that age, even though height may be stunted. 1. Casanueva E. et. al. Nutriología Médica. 2da. Ed. México. Editorial Médica Panaméricana, S.A. de C.V., 2001. In regard to as to whether schools were healthy envi- 2. Scheaffer R, Mendenhall W, Ott L. Elementos de Muestreo. Grupo Editorial Iberoamérica. México. p 232-240, 1995. ronments, no school satisfied all the pre-established 3. Ministerio de Educación (MINEDUC). II Censo de Talla criteria. Table 1 lists the different healthy and 2001. Editorial Ministerio de Educación, 2002. unhealthy aspects of the sampled schools. 4. Martorell R. Results and implications of the INCAP follow- up study. J Nutr 1995;S125:1127-38. A total of 88 samples were collected for microbiologi- 5. Instituto Nacional de Estadística (INE). Encuesta de Salud Materno Infantil (ENSMI) 2002. Guatemala, 2002. cal analysis. Aerobic bacteria, total coliform and faecal 6. Chacón, M. Anemias Nutricionales. Nutrición al día 1997; coliform counts were made. A confirmation of the 9:24-32. presence of Escherichia coli was taken as an indicator 7. Díaz, N, Páez, C y Liset Solano. Situación nutricional por of faecal contamination. Of the 88 samples, only 9 estrato social en niños escolarizados venezolanos. Acta (representing 10.2%) satisfied the bacteriology stan- Científica Venezolana. 53(4). Venezuela, 2002. dard for drinking water.

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The 4th World Congress on Developmental Origins of Health and Disease Utrecht, the Netherlands, September 2006

Noël W Solomons Cessiam, 17a Avenida, Zona 11, Guatemala City 01011, Guatemala Email: [email protected]

During the Dutch Hunger Winter of vulnerability for the fetus develop- pregnant mothers and newborn 1944-45, food supplies were cut off ing in the womb. It is, therefore, children should be fed and cared to the populations in the eastern quite appropriate that the 4th for in order to minimize the off- Netherlands’ larger cities. This World Congress on Developmental spring’s later risk of disease. famine provided the setting for the Origins of Health and Disease first serious examination of the (DOHaD) was held in the Dutch The venue was the Educatorium effects of a severe nutritional defi- city of Utrecht. The Congress took building on the campus of the ciency on the pre-conception and place September14–16, 2006. University of Utrecht. The fetal environment. It has since Congress attracted 300 registrants, allowed researchers to distinguish The epidemiological observation falling roughly into four relatively the short-term and long-term published by David Barker and equivalent categories, with one- effects of acute maternal malnutri- Clive Osmond in The Lancet in quarter each from: within the tion during different windows of 1986 rekindled interest in what Netherlands; other parts of Europe; then came to be called the Americas; and Asia and “fetal origins of disease.” Australasia. Notable by its absence They reported that British was any representation from men with lower birth Africa. The meeting featured a total weight had a higher sub- of 22 invited lectures, 16 of them sequent risk of cardiovas- presented within the context of the cular disease. Five years morning plenary sessions. These later, Alan Lucas coined followed a sequential daily pro- the phrase prenatal or gression, from epidemiological evi- fetal “programming,” dence on the first day, to diseases understood to be “either on the second day, to prevention the induction, detection, and intervention on the third day, or impaired development with emphasis on developing coun- of a permanent somatic tries (Table 1). structure or the ‘setting’ of a physiological system The plenary program by an early stimulus or insult operating at a ‘sen- Day 1 plenary: Epidemiological sitive’ period.” From evidence these origins, a relatively new disciplinary perspec- The keynote speech on Day 1 was tive – the “developmental given by Dr Matt Gillman of the origins” view – has been Harvard Medical School. He com- applied to the way in mented on some of the principles of which fertile-age women, the epidemiology of developmental

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Table 1: The plenary session themes and lecture topics in the three-day to the resetting of the axis of hor- morning thematic series mones, especially that related to the glucocorticoid hormones. The Day 1 Session theme: The evidence, epidemiology, human and other mechanism is related to the across species: Evidence, mechanisms and infant period supply of oxygen reaching the • The future of DOHaD epidemiology fetus. In the "natural experiment” • Transgenerational effects of environmental challenges during of high altitude residence, as in the development Andean mountain range of South • Hypoxia and oxidative stress as triggers for early origins of America, the effect of hypoxia on cardiovascular disease birth weight is well known. The • Glucocorticoid programming: Unto the next generation? indigenous descendants of the Inca in Bolivia living in contemporary • Infant feeding and later obesity risk: What is the relationship? La Paz give birth to newborns who • Evolutionary constraints on human infancy: Lessons for DOHaD are of greater weight than those of Day 2 Session theme: The diseases: Cardiovascular disease, type 2 the more affluent, middle-class diabetes, obesity mothers who are largely of Euro- • Early life determinants of cardiovascular disease pean descent. At sea-level altitudes, • Biological mechanisms for programming the fetal heart the reverse relationship is observ- • Diet and vitamins in the prevention of preeclampsia ed. This would seem to represent an • Type 2 diabetes - early growth, genes and lifestyle evolutionary adaptation. • Pathways to obesity Finally on the first morning, we Day 3 Session theme: DOHaD in developing countries: Prevention gathered some insights on the fasci- and intervention nating topic of “evolutionary con- • Emerging issues for clinical practice and public health straints on human infancy” from • The Mumbai Maternal Nutrition Prevention the perspective of a biological • The effects of nutrition in early life on adolescent and adult health anthropologist, Dr Chris Kuzawa • The STRIP study: A prospective atherosclerosis prevention trial in of Northwestern University in the USA. He drew his listeners out on children the topic of how organisms parti- • Poor fetal growth and type 2 diabetes in adult life tion their resources (all of the things available from the environ- origins. Among his recommenda- Koletzko of Munich, who outlined ment). For instance, if a given tions, he suggested that we change the design and objectives of a large species of organism uses resources our approach from focusing on low European collaborative initiative to on growth, it cannot at the same birth weight itself as being the randomize formula-fed children to time direct them to maximal main- cause of later-life problems. He higher or lower protein content in tenance and repair. For humans, emphasized the higher purpose in the diet, and compare them to growth rate and brain size are knowing the particular process exclusively breast-fed babies. The important in this regard. Man is the leading to a child’s poor growth hypothesis is that the one compo- slowest growing mammal of its performance in utero or early life. nent of diet that can be safely mod- size on the planet, and gains weight As cited by Dr Gillman, a consen- ified to moderate early growth is at the slow rate seen in reptilian sus is growing that accelerated protein. species. Moreover, the brain con- growth in early infancy was more sumes 20% of all energy, much relevant to “programming” adverse The first day’s theme was epidemi- more than for any other species. In metabolic responses than small size ological evidence in developmental evolution, the deposition of fat in in itself. If a child is born with low origins. Two presentations present- abdominal stores is seen as a way birth weight, it will be healthier in ed evidence and arguments that to have available a source of meta- the long term if the recovery of size adaptations programmed in one bolically-active fat (as a “ready re- over time is slower. This emphasis generation could act as if they were serve” of energy) to allow carbohy- on moderating the rate of infant “heritable” and pass on into subse- drates to be spared for use by the growth was echoed later in the quent offspring generations. One of brain. The later-life problem be- opening plenary by Prof. Berthold the mechanisms advanced related comes too much accumulation of

22 DOHaD Magazine Issue 1/2007

fat in abdominal deposits. Dr Kuzawa suggested that this pattern of fat use of multiple vitamin-mineral storage, characteristic of the human metabolic syndrome, may be a conse- supplements (MVMs) among those quence of an evolutionary “trade off.” entered into the VIP study, as well as in a recent observational report Day 2 plenary: Diseases from Pittsburgh, USA, significant inverse association between prior Continuing with the narrative of the plenary program, on Day 2, which exposure to MVMs and lower risk was dedicated to the theme of “diseases and conditions,” we heard presen- of preeclampsia were documented. tations covering vascular, toxemic, metabolic and excess body fat prob- The excessive dosage of the two lems. The insights, seen through the prism of cardiovascular disease, were vitamins, which may bring out their illuminating. The degree of “attributable risk” for later adult cardiovascu- pro-oxidant potential, may be the lar disease that one can lay directly on intra-uterine growth retardation in explanation for the unexpectedly affluent populations was discussed from the epidemiological perspective. adverse results on birth weight in It was concluded that, if all birth weight deficits were normalized, we the UK study. would only reduce 5% of myocardial ischemia episodes. This is probably testimony to the other adverse cardiovascular risk factors in Western The Chairman of DOHaD is Prof. societies. Peter Gluckman of New Zealand. In collaboration with Prof. Mark A dramatic experimental example of adaptive plasticity was outlined by Hanson of Southampton, UK, he Dr Kent Thornburg of the University of Oregon. His research group has provided a reinterpretation and showed that creating anemia in fetal sheep in utero forces such an increase expansion of the original “fetal ori- in blood flow to the cardiac muscle that it literally carves out a massively gins” theory. Throughout the early arborized coronary vasculature that persists throughout the animal’s life- years following the Barker and span. This example of adaptive plasticity was shown to produce a large Osmond Lancet publication, the buffer against myocardial ischemia oxygen availability to the heart mus- classical interpretation of “pro- cle. It is a paradox, however, that such heavily vascularized hearts are sus- gramming” of the metabolism to ceptible to more extensive ischemic damage if infarction actually does avidly retain nutrients was that of a occur. pathological occurrence. In his closing plenary talk of the day, The presentation, entitled Diet and vitamins in the prevention of preeclampsia by Prof. Lucilla Poston of London, addressed the traditional micronutrient focus of readers of the SIGHT AND LIFE Magazine. It helped to illustrate developmental origins in both an obvious and an unanticipated man- ner. Prof. Poston has long been an advocate of the idea that toxemia of pregnancy (a combination of high blood pressure and protein leaking into the urine) is the result of free radicals and oxidation. She and colleagues at 25 different maternity centers in the UK and Europe conducted a randomized study, the Vitamins in Preeclampsia (VIP) trial, to test the Berthold Koletzko of the Dr von Hauner Children's Hos- hypothesis. Some 1,199 mothers were randomly pital at the University of Munich (left) and Gerard Visser assigned to receive 1,000 mg vitamin C and 400 IU of the University Health Centre of Utrecht, the chair of the local organizing committee for DOHaD (right) vitamin E (RRR-α-tocopherol) daily, and 1,205 others allocated to a placebo, from the second trimester of pregnancy until delivery. The rates of preeclampsia, the precursor con- loosely organized around the ob- dition of toxemia, were identical in both groups, as was the incidence of esity epidemic, Prof. Gluckman low birth weight and small size for gestational age. There was, however, clarified and crystallized the a statistically significant 15% greater incidence in low birth weight among Gluckman-Hanson reinterpretation babies born to women who took antioxidant vitamins, as compared to con- of programming as part of a trols. The initial thesis of oxidation and preeclampsia risk may still be process of “predictive adaptation.” valid, however. Within the observational associations made between prior Stated simply, the environment in

23 SIGHT AND LIFE DOHaD

which the mother becomes preg- the world’s two most populous pelvic dimensions of Indian moth- nant would presumably be that in nations, India and China. The ers, an obstetrical crisis of obstruct- which her offspring would grow to chances of a mismatch between the ed delivery would come from any adulthood. They propose that conditions signaled by the mother’s precipitous increase in birth size. mothers can pass signals from their meager subsistence in a rural vil- Dr Sachdev did admit that the surroundings to the fetus in utero, lage and an offspring’s later offer- increased visceral fat of Indian which influence its life-long meta- ing of richer fare after urban migra- infants, the so-called “thin-fat” bolic responses. If scarcity is the tion sets the stage for obesity and babies, is a prelude to excessive environmental condition, being the adverse features of vascular and adiposity even with body mass programmed to conserve nutrients metabolic disorders of the meta- indices well below the cut-off lev- after birth would be adaptive for bolic syndrome. els for overweight of the World success in a harsh ecological situa- Health Organization convention. tion. If nutrients are adequate in the Day 3 plenary: Prevention and in- Poverty automatically creates an mother’s environment, then being tervention image of undernutrition, and food able to dispose of excess nutrients supplementation programs are reg- is a positive state for metabolic The third day was billed as a dis- ularly trotted out by aid agencies well-being over the long run. In his cussion of prevention and interven- and governments in response. As lecture, Dr Gluckman cited recent tion within a DOHaD context, shown in Chile and elsewhere, this experimental animal findings to focusing on developing countries. can fuel childhood obesity. show that mimicking a nutrient- The first three plenary presenta- poor or nutrient-rich environment tions were indeed given by speak- Second on the program, from in the animals’ feed produced the ers born in India; but only 40% of Mumbai came the news of a recent- opposite birth weights to those the morning program was actually ly initiated intervention trial in col- expected. The important insight is based on an experience in a devel- laboration with the University of that continuing the animals on a oping-society. This possibly re- Southampton. It would test two diet of the same nutrient density as flects the scarcity of scientists ori- serial hypotheses. The first is that a that of the mother’s during gesta- ented to the study of developmental combination of micronutrients tion, i.e. to match uterine and post- biology in the low-income areas of from natural sources in vegetables, natal conditions, produced healthy, the world. baked into the traditional samosa normal-weight animals. However, pastry, would increase the birth when the food-availability situation The words of Dr Harshpal Sachdev, weights of babies born to poor of gestation was reversed in either in the first talk, were steeped in his mothers of the Mumbai squatter direction in the post-natal life of the decades of work in New Delhi. settlements, and the second that animals, problems occurred. The From an Indian perspective, his this decrease in fetal malnutrition offspring were unable to cope with considerations regarding either undernutrition in gestation a low-nutrient intake in followed by overnutrition post- infancy were the oppo- Mothers can pass natally, or pregnancy overnutrition site of those cited earlier replaced by postnatal undernutri- from Prof. Koletzko’s signals from their tion. The former situation produced European project. For obesity and metabolic derange- his part, Dr Sachdev was ments; the latter produced uncom- first and foremost con- surrounding to the pensated wasting malnutrition. cerned about young children being too small and fetus in utero The world is currently full of staying too small, such undersized and poorly-fed women that it would decrease their chances would lead to better health out- giving birth to low-weight infants. of survival. As a rule-of-thumb, a comes in childhood. This adapts them to cope with child’s growth should at least nutrient scarcity, but leaves them approximately follow the path of The plenary turned next from inter- ill-prepared to deal with an abun- the reference growth-chart curves. ventions in India to experiences in dance of nutrients in later life. Falling below the growth curve is a Europe, including the lessons Urbanization and nutrition transi- clear signal of dangerously learned in London from a random- tion are two social changes sweep- impaired growth. However, given ized trial in premature infants ing the developing world, including the small stature and concomitant assigned from birth either to a low-

24 DOHaD Magazine Issue 1/2007

density or high-density nutrient mals. With a venue in the Nether- match consequences as anticipated. regimen for four weeks. The chil- lands, the organizers dedicated Experiments with maternal dietary dren are now 17 year old adoles- special attention to the ongoing restriction produced offspring that cents, and their outcomes show a findings from the Dutch famine were lighter in weight at birth, but paradox. In terms of neuromotor study. Adults survived on rations of that were larger, fattier, and had and cognitive development, the 900 kcal per day in the besieged more metabolic abnormalities of enriched formula feeding has pro- cities. Those conceived during or lipids or glucose as adolescent or duced lasting advantages as com- just after those six months of acute adult animals. However, when pared to breast milk or standard food deprivation are now 61 years postnatal “match” was applied, i.e. formula. However, the current pro- old. Many are grandparents. Sever- the same low energy diet fed to the files of insulin resistance, lipid pro- al longitudinal studies have looked mother was fed to the offspring, the files and hormonal regulation of at the fertility and pregnancy out- problems of obesity, hyperlipi- visceral fat are inferior and tend comes of offspring of Dutch moth- demia and insulin resistance were more towards a risk of metabolic ers of that era. As compared to avoided. syndrome in the children who those nurtured in fetal life in the received the early high-density Dutch countryside, without food The majority of the nutritional nutrient feeding. modifications in the experimental models related to total energy The free paper (calorie restriction). A few free program Low birth weight papers, however, related directly to manipulation of micronutrients. A The late-morning coffee predisposes to poor study from Tamil Nadu, India, in- break, lunch hour, and volved maternal deficiency of vita- afternoon periods were metabolic health min E, zinc or copper at 50% of the devoted to the parallel requirement levels for female rats. thematic program for If the deficiencies were induced free papers. A total of in later life before pregnancy there were no 209 abstracts were pro- adverse outcomes for the offspring. grammed either for oral presenta- restriction, the offspring of fam- When induced during pregnancy, tion (in one of the nine platform ished mothers had fewer children. however, all three deficiencies had sessions, three per day over all Both current mental health and equivalent negative effects on the three days) or as a poster (divided cardiovascular response to stress rat offspring in their adult lives. evenly between Days 1 and 2). tests were poorer in those exposed They had poorer cardiac function, Table 2 indicates the free-paper prenatally to undernutrition than in and were hypertensive and insulin thematic areas and the distribution controls who were not exposed. resistant. The individual antioxi- of contributions by topic. For six of Finally, the metabolic syndrome dant systems were consistently the topic areas, a 30-minute invited was marginally more common in down-regulated. lecture by a senior expert led off those affected by the Hungry the platform session. No compre- Winter conditions in utero than in Inquiries into epigenetic mecha- hensive review of the information those spared the crisis during their nisms constituted a large body of from so many presentations can be gestation. the free paper work across the synthesized, but there were a series experimental categories. The larger of highlights of special interest to a With regard to the mechanisms by nutrition community must begin to nutritional readership. which the alterations in anatomical understand the potential of epige- or physiological phenotype charac- netic influences. They provide a Highlights of the free paper pro- teristics are created and main- portal to the adaptive responses of gram tained, the free paper program the fetus and infant to his or her amply explored the validity of prin- surroundings. The underlying me- The positive scientific interactions ciple of the match or mismatch pre- chanism affects the conformation in the DOHaD community involve dictive adaptation hypothesis of of the deoxyribonucleic acid the reinforcing of epidemiological Gluckman and Hanson. Many (DNA) in the genetic materials in observations in human populations young researchers, using rodent the cells, without altering the with confirmation of mechanistic and ovine experimental animal sequence of the genetic code itself. principals from experimental ani- species, documented the mis- This can be achieved by adding

25 SIGHT AND LIFE DOHaD

bonds or linkages that shift the Table 2: The free-paper themes in the platform session and poster shape of the DNA chains or the program nuclear proteins that hold the genes in place when genetic information A: Basic science, regulation of somatic growth and epigenetics (n= 30) is being expressed. We are begin- B: Birth cohort studies (n=34) ning to recognize a series of dietary C: Cardiovascular disease and hypoxia (n=24) influences that can alter the DNA D: (Dutch) Famine studies (n=9) chains or their chromatin protein E: Cancer (n=15) backbones, and determine the syn- F: Stress, neurobehavior, neurodevelopmental outcomes (n=30) thesis of cellular proteins. Among G: Glucocorticoids, medication and toxins (n=15) them are the amounts of folate, H: Maternal and infant nutrition (n=26) choline, betaine and methionine in the diet, as well as the adequacy of J: Diabetes, obesity, metabolic syndrome (n=23) K: Placenta (n=3) vitamins B2 and B12.

Six of the free paper oral sessions and especially to nutritional public of the 5th International Congress on were accompanied by a featured, health. Traditional public health DOHaD, and featured an editorial invited lecture. Dr Karin Michels of sees equity in giving everyone and two comprehensive review the Harvard Medical School gave access to equal amounts of the articles on the overall concepts. an interesting talk on the develop- same collective measures or inter- The next meeting of the mental origins of cancer. She is the ventions; DOHaD emphasizes the International Society for Develop- leader of the Nurses' Mothers’ fact that one size cannot fit all. It mental Origins of Health and Study, in which interviews were emphasizes the variance among Disease will be hosted by the performed with the mothers of the individuals. In public health inter- University of Western Australia in nurses being followed in the ventions one must respect the fact Perth, Australia in November, famous Nurses’ Health Study. She that individuals across the popula- 2007. focused her discussion on the topic tion may be differently adapted. of birth weight. Taller babies are at Similarly, different individuals increased risk of at least three have different requirements and malignant conditions: breast and different tolerances in public health testicular cancer, and leukemia. interventions. However, having a higher body mass index (BMI) as a girl protects Whereas the nutritional science women from breast cancer of pre- community is focusing in on nutri- menopausal onset. While having a tional genomics (looking at nu- high BMI as a girl or an adult wo- trients’ influence on the expression man is protective, in the postmeno- of the genetic map), the orientation pausal period, having a low BMI of developmental origins is towards becomes protective. The insights of what can be called nutritional Dr Michel help us to realize some “phenomics” (looking at nutrients’ of the “trade-offs” involved in the influence on plastic adaptations in developmental origins of disease. the body’s structure or metabolic We cannot have it both ways. Low function). The DOHaD community birth weight predisposes to poor tends to rely more heavily on epi- metabolic health in later life, but is genetic research in relation to nutri- protective against breast and testic- ents and dietary substances than ular cancer. does even the experimental nutritional biology community in gen- Synthesis and looking forward eral.

In a growing number of ways, A special issue of the journal Early however, the developing origins Child Development (2006, Vol 82, outlook represents a challenge to pp 487–574) published abstracts of conventional nutrition science, all invited lectures and free papers

26 SLAN Magazine Issue 1/2007

The 14th Latin American Congress on Nutrition (SLAN) Florianopolis, Brazil, November 2006

Noël W Solomons Cessiam, 17a Avenida, Zona 11, Guatemala City 01011, Guatemala Email: [email protected]

The 14th Latin American Congress tures, 40 symposia, 12 conferences, The Congress' offering of vitamin on Nutrition, the triennial gathering 3 workshops, several special satel- and mineral-related features began of the Latin American Society of lite symposia and 1 memorial trib- in the keynote plenary session. It Nutrition (abbreviated SLAN, in ute. It also allowed for the presen- was entitled Nutrigenomics: The Spanish and Portuguese), was held tation of 1060 free papers, either in road to a better understanding of at a seaside conference center in one of the 39 platform sessions or the nutrient-gene integration and Florianopolis, Brazil, from Novem- as part of the three day long series was presented by Prof. Hannelore ber 12–16, 2006. It was attended by of poster exhibitions. Among the Daniel of the Technical University more than 1700 professionals and varied topics were talks and ses- of Munich. She defined and charac- students, primarily from Latin sions dedicated to obesity, meta- terized various research tools, such America, but also from all across bolic syndrome, chronic diseases, as gene-deleted mice (knock-out the globe and marked Brazil’s Prof. nutrient recommendations and die- mice) and chip-arrays or analytical Helio Vannucchi’s end of tenure as tary guidelines, functional ingredi- systems for gene expression (gen- SLAN president, having organized ents in functional foods, infant omics), protein expression (pro- and presided over the Congress in growth, as well as specific updates teonomics) and metabolite secre- previous years. Prof. Vannucchi on the nutritional situation of indi- tion (metabolomics). inaugurated the event with vidual countries or subregions in an assembly on the evening of Latin America. The Congress Pro- The McCollum International Lec- November 12, which featured gram offered six notable sessions, tureship on Nutrition by the greetings from Brazilian govern- which concentrated on research American Society for Nutrition mental authorities, orchestral findings and the experiences of was awarded to Prof. Jean-Pierre music, and a discourse by Prof. micronutrients in public health as Habicht. He presented his lecture, Ricardo Uauy of Chile, current indicated in the Table. titled Potential to Benefit from president of the International Union of Nutritional Sciences, on the Table: Symposia at the 14th Latin American Congress on Nutrition with topic: The challenge of the new special relevance to micronutrients epidemiological profile for Latin America. A personal tribute was Page 4: Micronutrients and infant development paid to two of the past presidents of Page 12: Nutrition and bone health throughout life SLAN, Dr Jose Eduardo Dutra de Page 16: Nutrition and cancer Oliveira of Brazil and Dr Adolfo Page 22: HarvestPlus: Applied biotechnology and value-added traits in Chávez of Mexico. crop foods Page 27: International and regional guidelines for food fortification: The Congress featured an extensive design, monitoring and evaluation and varied array of themes on the Page 38: Nutrition and physical activity program including 9 plenary lec-

27 SIGHT AND LIFE SLAN

Nutrition Interventions: Synergisms which a ‘western’ pattern of gas- Program, in which participants and Antagonisms. This message trointestinal and hormonal malig- were provided with more detailed offered an important series of nancies can be seen to be emerging information on the concept. insights for the planning of micro- in the urban regions of South nutrient intervention programs, and America’s largest nation. Doctors A landmark for public health nutri- the full text will be published in the Ritva Butrum and Ivana Vucenik tion was the formal unveiling to the Journal of Nutrition during the summarized the revision process of public of a new World Health course of 2007. the guidelines for cancer preven- Organization document, the WHO tion which will lead to the release Food Fortification Guidelines. This The symposium on micronutrients of their second report, Food, Nutri- came as part of the symposium on and child development illustrated tion, Physical Activity and Pre- International and regional guide- intervention programs aimed par- vention of Cancer: A Global Per- lines for food fortification: design, ticularly at iron deficiency and ane- spective, to be made public in monitoring and evaluation. Dr mia in early life, as well as other November, 2007. Denise Coitinho, director of the micronutrient problems. For in- Department of Nutrition for Health stance the iron-fortified milk distri- The HarvestPlus Project of the and Development of the WHO in bution program for Chilean school- IFPRI presented a symposium on Geneva chaired the session. It fea- children has reduced anemia rates applied biotechnology and value- tured a talk by Dr Omar Dary, one and improved health now for over a added traits in food crops. The first of the four contributing authors to decade. However, there is a need of the three presentations was high- the consultancy. The 306 pages of for a degree of caution in linking ly informative, in its description of the document were distributed on a micronutrients with energy-rich the efforts of the ILSI to maintain a CD-ROM, given away at the foods in the public health interven- constantly updated register of the conclusion of the session. This tion programs of both Chile and micronutrient Mexico as both have lead to content of agricul- improved micronutrient status on tural crops, since the one hand, but also to a rapid rise varieties also con- in juvenile overweight on the other. stantly rotate and evolve. The other Nutrition and bone health through- two presentations out life was a symposium that truly focused on phytic spanned the life course, beginning acid, the major with nutritional considerations to inhibitor for the improve bone mineralization for absorption of iron, preterm and newborn children, and zinc and other then progressing from infancy trace metal nutri- Three delegates from Chile enjoy Brazilian food on Italian tablecloths through adolescence, and finally ents. One covered also including the special reproduc- the advances in tive states of pregnancy and lacta- the exploration of low-phytate document sets out the principles for tion. The consumption not only of hybrid varieties of grains and the creation of national fortification calcium, but also of macronutrients legumes in field and community programs for staple foods, such as and other micronutrients, which settings. This was complemented salt, sugar, cooking oil and flour. It form the overall dietary pattern, by the discussion on phytate as an includes mathematical formulae were all covered by the three in- antioxidant and its potentially ben- that allow for the use of data from vited speakers. eficial and protective role both for individual settings to determine the plant itself and for human safe and appropriate fortificant An important discussion at the health. Biofortification involves levels. interface of foods and nutrient improving plants – and even live- sources in the diet was the sympo- stock – by increasing the density of Finally, tucked between the nu- sium on nutrition and cancer, spon- micronutrients in the edible tissues. tritional supplements and lipid oxi- sored by the American Institute for This same topic was represented dation themes was a talk in the Cancer Research (AICR). It includ- elsewhere on the program in a con- symposium on nutrition and physi- ed an epidemiological mapping of ference format, Nutrition Research cal activity by Dr Manuel Ramírez- cancer incidence across Brazil, in in the HarvestPlus Biofortification Zea, of INCAP in Guatemala on the

28 SLAN Magazine Issue 1/2007

topic of Interactions of micronutri- Suazo-Romo, a ents, physical activity and physical graduate student and mental development. It focused from the Institute on the early years of the lifespan, of Nutrition and and micronutrients for nervous tis- Food Technology sue growth and development. (INTA) in Chile. Satisfying the micronutrient de- Her contribution, mand for a rapidly growing organ- entitled A search ism so that full genetic growth for molecular bio- potential can be achieved is also a markers for the requisite for early life. evaluation of human copper sta- A view of the Costao do Santinho Resort and Prof. Dutra de Oliveira organized tus, was a truly Conference Center at Florianopolis and chaired a satellite workshop major advance for within the Congress on the topic of the field. It examined the genetic exercise their leadership tools. On using drinking water as a vehicle expression of the copper-dependent the day of inauguration, full-day for adding bioavailable iron to the enzymes system and its regulation pre-Congress update courses were diets of children. Along with sev- as a potential pathway to moving held on the topics of: molecular eral interested participants, he beyond the static nutritional-status biology and nutrition; the use of reviewed the evidence for the effi- indicators for copper, such as circu- informatics in nutrition; methods cacy of this novel and little ex- lating levels of copper or cerulo- for evaluating food intake; and plored approach to enhancing iron plasmin. A second Kellogg Prize nutrition and strategies: analysis intake to control iron-deficiency was awarded at the professional through repeated measures. anemia. Based on the evidence of level. Alceu Afonso Jordão, Jr, a an improvement in the hematologi- physician from the University of The triennial congresses, organized cal status of schoolchildren made Sao Paulo's Ribeirao Preto campus, by SLAN, is just one more of a after fortifying school’s drinking won the award with his paper enti- growing number of recent interna- water with iron fortificants, the tled The effects of carotene supple- tional meetings that found a way to approach can be recommended as mentation on hepatic cells of rats galvanize various sectors to a com- an additional measure to combat receiving ethanol. It distinctly mon cause. Sessions in the Con- iron-deficiency anemia. showed the protective role of gress were sponsored, variously, by carotene in averting hepatic dam- academic organizations such as the Micronutrient topics appeared first age from alcohol in a rodent model. ASN and the Spanish Society for and foremost in the awards compo- A solemn feature of the proceed- Community Nutrition, governmen- nent of the Congress. The student ings was a memorial tribute to the tal and UN agencies, such as the winner of the Kellogg Nutrition life of Dr Rainer Gross. An impor- Bolivian and Argentine Ministries Prize was Ms. Miriam Gloria tant contributor to the development of Health, WHO, FAO and PAHO, and validation of intermittent-day and industrial corporations such as supplementation with iron and Unilever, the Kellogg Company, other micronutrients, Dr Gross had Danone and ILSI/Brazil. Prof. worked in both Brazil and Peru and Eduardo Atalah, of the University had participated in many SLAN of Chile, assumed the presidency of meetings. SLAN for the next three years, and the 15th Congress will be held in The Congress in Florianopolis pro- Santiago in 2009. vided an opportunity to hold a series of related, pre-Congress events in the immediate surroundings. One of the most notable was the 4th Latin American Nutrition Leadership Workshop, which brought 22 young students and pro- Lluis Serra gifts his nutrition textbook to Licda Veronica Molina fessionals from throughout the Latin American region to learn and

29 SIGHT AND LIFE African Forum

The African Forum: An integrated response to the dual epidemics of HIV/AIDS and food insecurity Lusaka, Zambia, May 2006

Gwen E. O’Donnell, Project Concern International, 1140 Connecticut Ave, Suite 500, Washington D.C. 20036, USA Email: [email protected]

exchange experience from almost half of them (6.4 million) “When spiders the perspective of field will need some form of nutritional practitioners. The event in support. Of the 6.6 million also unite, they can Lusaka was organized needing access to antiretroviral with the goal of providing therapy, approximately one million a platform to build rela- will need direct food aid. For those tie down a lion” tionships and enable col- hearing the projections in Lusaka, laborative learning and to this posed a tremendous challenge The spirit and spark of this African improve and expand service deliv- as they were only too fully aware aphorism represents the overall ery at the community and house- that people in countries most spirit of the Africa Forum 2006: An hold level. Thus, the Forum affected by HIV/AIDS also suffer Integrated Response to the Dual allowed and encouraged partici- from hunger. In these countries, the Epidemics of HIV/AIDS and Food pants to share their expertise with sectors of nutrition, food security, Insecurity that took place May one another. It enabled them to dis- and agriculture are often discon- 8–12, 2006, in Lusaka, Zambia. cover practical solutions for nected from one another, not to One of the first events of its kind, improving food and livelihood mention the added fragmentation of the Forum assembled 220 delegates security in their own communities. HIV/AIDS and livelihood interven- from 20 countries for a prac- Over the five days of the confer- tions. The message emphasized titionerled, non-academic conference, moreover, participants identi- during the Forum was that a path- ence. Its purpose was to showcase fied the priorities and changes way toward integration, i.e. focus- new ideas on integrated food and needed at all levels in order to ing on both epidemics, is more nutrition security and HIV/AIDS make the concept of integrated pro- important now than ever before. programs from affected areas of gramming a reality. Readers of the Magazine will Africa. Following the World appreciate how important a quality Health Organization Consultation Food security is a central issue in diet and adequate nourishment are (April 10–13, 2005), and the Inter- Africa and in the fight against for bolstering immune systems. national Food Policy Research HIV/AIDS Strengthening nutrition and health Institute Conference on HIV/AIDS interventions will help to support and Food and Nutrition Security According to World Food Pro- anti-retroviral treatment adherence (April 14–16, 2005), Project Con- gramme projections, 13.8 million and mitigate the impact of the cern International (PCI) became people will need access to HIV/ illness and resultant deaths on aware of the escalating demand to AIDS care by 2008, and of those, families by protecting assets and

30 African Forum Magazine Issue 1/2007

options. In short, the central prin- The round of key note speakers Reflections to set the context of the ciple that the Forum sought to week were presented on the first advance was that through the The week commenced with a wel- day of the event by Dr Stuart Gill- strategic use of resources, food and coming reception and opening espie, co-founder and Director of nutrition security and HIV infec- remarks delivered by Zambia’s RENEWAL (Regional Network on tion can be addressed in ways that Minister of Community Develop- HIV/AIDS, Rural Livelihoods and foster improved health and liveli- ment and Social Services, Mr. Food Security) and Ms. Kate hoods outcomes for those infected Steven Manjata, and U.S. Defense Greenaway, former HIV/AIDS (harboring the virus) and those Attaché, Lt. Col. David Dougherty. Coordinator for C-SAFE (Con- affected (living in the same house- The speakers highlighted the fact sortium for Southern Africa Food hold or communities). that the dual epidemics of HIV/ Security Emergency). Dr Jeffrey AIDS and food and nutrition inse- Sachs, Director of the UN Millen- Participants in the Africa Forum curity are putting entire generations nium Project and Director of the 2006 were a unique group of indi- in Africa at risk. They combine to Earth Institute at Columbia Uni- viduals, coming from diverse disci- impact negatively on the economic, versity, also made an address by plines and vocations: small-scale social, and political development of video conference. “HIV/AIDS, farming, agribusiness, HIV care and many countries in the region. Lt. nutrition and food security,” he treatment, nutrition programs, care Col. Dougherty went on to recog- stated, “are not only interlinked, they are the components of the ‘perfect storm’ that is underway right now in Africa.” These professionals represent the most thorough and innovative thinking in devising policy and program responses to the hunger and food insecurity aspects of the epidemic. The Forum then took off with what participants had come for, namely unique and powerful opportunities for hands- on learning through site visits, skills-building sessions, interactive discussions, presentations, and other activities. Taste and touch session The diversity of formats on the of orphans and vulnerable children, nize the people in attendance as Forum program food security and livelihoods pro- constituting the “front line” in the gramming, and other areas. All of fight against food and nutrition The Forum was not a typical, these relate directly to the themes insecurity in the context of the PowerPoint presentation driven of the Forum. At least half of HIV/AIDS epidemic. He stated: conference. Throughout the week, the participants were women, “You and your colleagues are the participants were expected to be and numerous delegates were, public health experts, the medical both learners and contributors/ themselves, people living with technicians, the agriculture exten- teachers. This meant that each HIV/AIDS (PLHA). “It was a tionists, and the project imple- participant had to present in one diverse group with a common inter- menters who grapple with the enor- form or another. Participants est, using different approaches to mity of these life and death issues learned by getting their hands dirty, address food and nutrition insecurity everyday, under often difficult cir- not only in a figurative, but often in and HIV/AIDS,” one participant de- cumstances and with limited re- a literal sense, for example, by dig- scribed. “Discussing, debating and sources. And yet somehow you and ging gardens. Other activities struggling to answer tough questions your colleagues not only persevere included: visiting nearby communi- with Africans from different coun- – but also manage to perform your ties, dancing with orphans, vulner- tries and organizations,” was identi- life-saving work with conviction, able children and their caretakers, fied as one of the most compelling compassion and humility, day in and learning from widows how to experiences of the Forum. and day out.” grow mushrooms and rear quail to

31 SIGHT AND LIFE African Forum

obtain household food and in- and overall forum activities was, Tell’ session in which delegates creased personal income. “learning how people grow food had the opportunity to present indi- for themselves and others, as well vidual projects. One display fea- Projects and training opportunities as for economic viability.” tured foods, herbs, and plants com- emphasizing cost-effective, repli- mon to East Africa and showed pic- cable interventions that could be Skill-building sessions for staff in tures of various sites implementing tailored for expanded use in various the field permaculture methods, an ecologi- African settings were showcased. cally friendly and self-sustaining An illustrative list of some of the Skill-building sessions emphasized system of agriculture. Each partici- topics covered is shown in the building capacity around integrated pant also took part in a ‘taste and Table. program approaches that have touch’ session where they prepared demonstrated success. These ses- a wide variety of indigenous food In total, 17 presentation slots were sions were tailor-made for the field recipes to diversify diet and filled during the five-day Forum, staff. The organizers realized that increase nutrient availability for consisting of two presenters per field workers are people of action, PLHA. A variety of unique and session, and a facilitated audience who require dynamic, practical and creative opportunities for self- discussion. Fifteen panel sessions skills-oriented learning approaches. expression were provided to engage participants and facilitate Table: Selected topics related to food security programming for the interaction, such as collective participants of the African Forum painting of a mural depicting an African market scene abundant • Never-ending food with permaculture with healthy food and livestock. • Junior farmer field schools • Soybean processing and utilization Each participant was asked to pre- • Infant and young child feeding in the context of HIV/AIDS pare an individual action plan, • PLHA self-help to improve nutrition and livelihoods describing how he or she would • Strengthening antiretroviral therapy adherence through nutritional apply what they learned at the support Forum to their own work. • Keyhole garden: A quiet revolution in homestead gardening Participants were also asked to • Mainstreaming and holistic approaches to integrated programming describe how they would support • Orphans and vulnerable children and food security the ‘call to action’ that had been developed during the week. The PLHA: People living with HIV/Aids Africa Forum 2006 Declaration describes changes that need to hap- also took place, using a ‘talk show’ Peer learning and active engage- pen in order to make integrating format to engage the audience in ment of health practitioners were food and nutrition security and an exploration of topics across featured as ways for those in atten- HIV/AIDS programming a reality. methodologies, programs, and dance to build upon what they countries. already knew. “During the skills Examining the role of research building sessions,” explained one The participants particularly en- participant, “I received hands-on The Africa Forum 2006 demon- joyed the nine site visits that training on how to improve nutri- strated that much is currently going offered them an opportunity to gain tion and food security through on as implementers grapple with an enhanced first-hand understand- bio-agriculture. I learned new live- the dual epidemics, trying to ing about integrating food and lihood interventions, and how to integrate food security efforts and nutrition security with the other improve food security and HIV/ the response to HIV/AIDS. Practi- concerns of the Forum. Site visit AIDS mainstreaming into my orga- tioners have a lot to share about the facilitators were encouraged to cre- nization’s programs and policies.” specific challenges they face in try- ate lively and interactive outings, ing to make integrated program- allowing participants to observe Participatory responsibilities of ming a reality. They also have a lot and experience project activities, in the participants to share about interventions that addition to discussing and exchang- show promise and need further ing ideas. As one participant The week’s poster session exhibit research and investment. Like the described, one of the best site visits evolved into a popular ‘Show-and- old adage that asks, “If a tree falls

32 African Forum Magazine Issue 1/2007

in a forest and nobody is around to hear it fall, does it make a sound?” Implementers also face the thorny question of how much time and financial resources can be dedicated to research efforts to improve practices, thus rephrasing the adage, “Does innovation on the ground exist if there is no docu- mentation or research to prove it?” Clearly, in an ideal world, action and study need to be combined for maximum quality and impact, and to provide the evidence needed for collective advocacy and fund rais- Site visit to OVC center ing purposes. However, it escaped no one at the Forum that resources for investigation are somewhat of a revered by all 220 in attendance. served as a living metaphor that luxury. Combining jokes, aphorisms, and while problems may be large, they even song, he spoke to the assem- can ultimately be resolved. A visit from a former President bled and deepened their fortitude in of Zambia the tough battle against the dual Epilogue epidemics. Dr Kaunda personifies No matter from what part of Africa several struggles in securing the The African Forum was not an end, (or of the world for that matter), a independence of a nation and gov- but a beginning. Since the event, delegate to the Africa Forum 2006 erning it into a cohesive state. As we have remained in touch with the was from, the thrill and excitement founder of the Kenneth Kaunda delegates and are gauging the long- of the visit of Dr Kenneth Kaunda Children of Africa Foundation, fur- term impact these five days in to deliver the closing remarks was thermore, Dr Kaunda is, “commit- Zambia may have had. In 2007, palpable. To the Zambians, Dr ted to practical involvement and in PCI will begin producing periodic Kaunda is known as “Father” and working with all institutions, Briefing Notes of case studies from founder of their nation. Still spry, organizations, and individuals to these advancements, demonstrating lucid and wise in his 82nd year, the bring relief to the suffering, while how participants have applied ex-President of the nation of offering the children what they learning and the ripple effects that Zambia, who guided his country need most: hope for a better tomor- this has had. It is clear from the sto- out of the era of colonialism, was row.” His presence at the Forum ries and comments that participants felt empowered to improve their own programming. As one delegate revealed, “The conference has empowered me to improve the care of those patients with whom I work at the AIDS clinic in Kenya. I will be a better and more holistic provider due to this experience.”

Building a keyhole garden

33 SIGHT AND LIFE Education

From farming to human nutrition The journey of a Beninese man: Philippe Bani Mora

Anne-Catherine Frey, SIGHT AND LIFE, PO Box 2116, 4002 Basel, Switzerland Email: [email protected]

This article is a continuation of the one appearing on pages 45 and 46 of the SIGHT AND LIFE Newsletter number 3/2005. Philippe Bani Mora’s story is exemplary: thanks to a scholarship granted by SIGHT AND LIFE, he has been able to complete his studies in nutrition. He achieved an excellent diploma and is now ready to assist the malnourished people of Benin (editor).

Childhood care of a minister and was able to sary to calculate the prevalence of work in the hospital and in its clin- night blindness among the popula- Philippe Bani Mora was born in ics, providing him with the means tion studied and to formulate rec- Parakou, Benin, in 1974. He was to earn a living. ommendations to reduce this. the son of a farmer and a housewife who had four other children. He He went on to study for the BTS, a Situation alternated between schoolwork and vocational training certificate, in work in the fields in order to Public Health, with an option in The village of Foulan Koira is part purchase school materials for the Human Nutrition. At that time, he of the urban community of Niamey family. Following several failed became aware of nutritional sur- and is Fula in origin. It has a popu- attempts at the BEPC, the school- veys, quality control in microbiol- lation of 22,509 inhabitants, 22% of leaving exams, he entered the ogy laboratories, the development whom are women of childbearing Bembéréké Hospital’s training of questionnaires, the prescription age and 21% children under five. school for auxiliary nurses. This of diets, etc. During his placements, The vast majority of the population internal qualification gave him the he worked with MSF, Medécins lives beneath the poverty threshold, opportunity to earn a living while Sans Frontières, the Red Cross and believed to be below $1 (US) a day. continuing his training. After two other NGOs looking after malnour- Hygiene is poor in this village. In years, he passed his BEPC, ished people. During a placement at fact, there is just one public latrine enabling him to continue his studies the Regional Department for Health and used water is not removed. to become a nurse. He then went to in Zinder, Niger, he developed a Niamey in Niger, to the National program on the planning of commu- School of Public Health, the result nity nutrition and of a contract agreed with his hospi- wrote a paper entitled tal. “Causes and prevalence of night blind- His early career ness among children and pregnant women On his return to the country, he in Foulan Koira.” became aware of the presence of malnutrition in cases observed Final year project at while on duty, and so decided to Foulan Koira study to become a nutritionist. He made contact with SIGHT AND Having identified the LIFE who, after examining his case, causes of night blind- decided to grant him a scholarship ness and appraised the to the Niamey Public Health nutritional state of the Philippe Bani Mora riding a donkey Institute. He was placed under the children, it was neces-

34 Education Magazine Issue 1/2007

• Encourage breastfeeding. • Raise awareness of nutritional education. • Pursue the activities of the broad- ened vaccination program. • Use health centers in case of illness. • Develop home gardening. • Develop an improved use of existing nutritional resources.

This paper, along with the brilliant results obtained during three years of training, has enabled Philippe Bani Mora to obtain his diploma Women listening to a speech on vitamin A nutrition and healthy eyes with distinction. He is now able to embark on higher education. Rubbish dumps adjoin the dwellings and the market in which food provi- sions are sold. The most common illnesses are malaria, respiratory tract Conclusion infections, malnutrition and diarrhea. It is noteworthy that the number of staff at the Health Centre meets WHO guidelines, but that social workers Philippe Bani Mora’s journey has are woefully lacking. taken him from the rural world to that of health care professional. Survey Thanks to his dual skills as nurse and nutrition technician, he can During the survey of 84 people (42 pregnant women and 42 mothers) now devote his professional life to carried out in the beginning of March 2006, it appeared that: his fellow citizens to improve their nutritional state and manage in the • 31% of children are in poor health, as are 12% of pregnant women. best possible way the recurrent • 17% of children and 5% of pregnant women have suffered from night crises of famine or food shortages blindness. in the Sahel. This has been made • The children affected are on average between 20 and 29 months old, possible by the permanent support more are female and they often belong to families of more than of SIGHT AND LIFE: financial 8 people. support by way of a scholarship, • 80% of pregnant women and mothers are housewives and have no edu- practical support through the grant- cation. They all know of this illness but are unaware of the causes and ing of books and educational mate- treatment. rial, and moral support by maintain- • 24% of pregnant women had suffered from this illness during previous ing correspondence. pregnancies. • 80% of those surveyed had eaten at least twice during the day. • 80% of fathers had no paid employment and 83% had no education.

Recommendations for improving the situation

• Develop the production of foodstuffs rich in vitamin A, by way of irrigation. • Fortify the most widely consumed local foodstuffs. • Supplement vulnerable groups every 4 to 6 months, following the vitamin A administration strategy in tandem with national vaccination days. Philippe among a group from the Red Cross • Systematically deworm target groups. in Niger • Prevent infectious diseases through mass vaccination.

35 SIGHT AND LIFE ANLP

The fifth African Nutrition Leadership Programme (ANLP)

Mohamed Rguibi Training and Research Unit on Food Sciences, Laboratory of Physiology Applied to Nutrition and Feeding, Chouaib Doukkali University, School of Sciences, El Jadida 24000, Morocco. Email: [email protected]

The African Nutrition Leadership which includes role-playing, pre- leader requires some change. The Programme (ANLP) was held from sentations, and discussion groups. activities provide useful informa- October 31 to November 10, 2006 tion on how to develop the self- in Potchefstroom, South Africa, The first part of the seminar focus- confidence, relationships, emo- under the Directorship of Johann es on team building, leadership and tional intelligence, vision, wisdom, Jerling (North-West University, communication. The activities and motivational impact, and delivery South Africa) and Kombi exercises provide an opportunity to skills that the most effective leaders Mbhenyane (University of Venda, understand how to build a team have. Another important lesson of South Africa). The 30 participants whose members work together the course is that to be an effective at the program were selected from effectively and positively, and communicator, you must under- final year PhD students, post- stand what your message is, doctoral fellows, the food what audience you are send- industry, or government and Leaders are ing it to, and how it will be are interested and active in perceived. You must also food, nutrition and health at not only found in consider the circumstances large. They are mainly from surrounding your communica- Africa (15 African countries: tions, such as the situational Benin, Botswana, Burkina top positions with and cultural context. During Faso, Gambia, Ghana, Kenya, this part of the course, there Lesotho, Morocco, Mozam- big titles was an interesting communi- bique, Nigeria, Sierra Leone, cation session, where each South Africa, Sudan, Tanzania, show the importance of the participant had the opportunity to Zimbabwe, and one European rewards, respect, and personal present a scientific communication. country: Norway). The 10 day growth that come with effective All participants took part in discus- course is designed to assist partici- leadership. Participants also come sions and feedback was positively pants in identifying and developing to realize that the biggest difference received. The presenters covered a their own leadership skills and style between managers and leaders is variety of topics and the most valu- by focusing on the core skills of the way they motivate the people able lesson of this important ses- leadership, team building, network- who work for or follow them. They sion was to see that everyone has a ing, communication, and the role of have learned that leaders are not variety of strengths and weakness- nutrition and science in society. found in top positions with big es, and therefore one must be aware This is achieved through a varied titles, but at all levels of an organi- of some characteristics of good pre- and highly interactive program, zation. To be a highly effective sentations as well as possible mis-

36 ANLP Magazine Issue 1/2007

takes. Also, the participants took part in an exercise of breathing and voice training and Fifth African Nutrition Leadership Programme had the opportunity to use the skills at din- Declaration ner or lunch when they had to share for seven minutes something about their coun- We, the ANLP 2006 graduates, declare that we are try. committed to improving the nutrition of people in Africa by using evidence-based nutrition principles. The second part of the ANLP focused on a variety of issues related to leadership in nutrition in Africa. It encouraged us to have We will strive to provide effective leaderships and an insight into what actually happens in real build sustainable partnerships based on mutual life when negotiations have to be carried respect and honesty. out between various stakeholders. Participants took part in a case study that We will advocate and lobby for a nutrition agenda to represented a meeting of ‘science, govern- empower and uplift our communities. ment and industry.’ The contents of the procedure, the negotiation process, the strengths and weaknesses were experienced November 2006 and discussed. It enabled participants to realize that the process of getting various stakeholders society and had round table discussions on many sub- to work together is not an easy one, involving negotia- jects related to poverty - Poverty: Real or imaginary? tion, patience and flexibility. Corruption and poverty: Partners in crime and Corruption and poverty: The way out. The concepts of advocacy and lobbying were well articulated and participants were fully involved In addition, during the ANLP program, many activities through the discussion, exercises, and case studies. were held outdoors - climbing over poles, walking in This course has provided me with an opportunity to the bush. The objective of the session on teamwork - understand how to acquire skills to be able to persuade lessons from nature, was to allow interaction with the others; to become a good nutrition advocate and how environment, to show that success is never an accident, to run a campaign with a clearly defined objective and and it helped consolidate all the concepts related to strategy. communication, leadership and teamwork.

In addition, an interesting session of this part of ANLP As health and nutrition problems are essentially the was a symposium on poverty and corruption. The par- same throughout Africa, participants are committed ticipants presented a drama to depict corruption in and encouraged to position themselves as leaders in solving or addressing these challenges, facilitating networking and sharing information amongst all (see ANLP Declaration).

Acknowledgement

The participation in the ANLP courses was made possible by the support of SIGHT AND LIFE who provided me with a grant for travel to South Africa and by the ANLP organization which provided me with a grant for registration including tuition fee, course materials, full board and lodging at the Raaswater Resort in the North West Province Mohamed Rguibi with Klaus Kraemer (from left) of South Africa.

37 SIGHT AND LIFE ANLP

Interview with Prof. Johann over 100 participants from 27 Jerling, North-West University, countries throughout Africa have Potchefstroom, initiator of the had a chance to experience per- African Nutrition Leadership sonal growth and form lasting net- Programme (ANLP). works. Relationships are built on a The questions were asked by Jane deep, personal level, not just on a Badham, [email protected]. work or professional basis. These za on behalf of SIGHT AND LIFE. are, I believe, the strongest of relationships. A huge level of trust is What made you initiate ANLP? built between people from varied The organizers of the European backgrounds and this is a unique Nutrition Leadership Programme offering of ANLP and could act as (ENLP) wanted to expand the pro- the catalyst to change the way we gram and invited me to attend the have done things and the way we Johann Jerling ENLP and experience it. I immedi- think about and approach Africa's ately realized that this was an nutrition challenges. incredibly worthwhile program that I would want sponsors to become had the potential to change nutri- Where to from here for ANLP? involved by maybe also contribut- tion in Africa. As long as we have dedicated funding their expertise. Most important ing partners, ANLP will continue of all I think sponsors must believe How could ANLP change nutri- to be an annual event. The vision is in the value of building a network tion in Africa? for the ANLP network to translate of people in Africa, be passionate ANLP invests in people and effects into actions that positively impact about Africa and become involved change on a personal level - it is a on nutrition in Africa and that see in nurturing that network and help real, not transient change that then the participants being active leaders it to reach its full potential together has a potential ripple effect. It is wherever they find themselves. with Africans who can and want to difficult to predict exactly what the Each year, a declaration written by deliver the goods. ripple effect will be, but from my the participants gives an indication personal experience and the experi- of the passion and commitment that For more information on the ANLP ence of many ANLP and ENLP exists to improve the lives of the visit: alumni, it has certainly changed the people of Africa. www.africanutritionleadership.org way I think, act and respond and that has changed the environment Do you have special expectations around me and influenced the peo- from ANLP sponsors such as ple I work with and their thinking SIGHT AND LIFE for the and behavior. future? Oh yes, ideally it would be great to What has been the highlight of have sponsors who are committed organizing and running ANLP? for periods of 3-5 years. In addition To see people learn things about themselves that they were never aware of before. There are unfor- gettable moments where people have done things that they themselves never thought possible. That has to change you.

What has ANLP done for nutrition in Africa? The ANLP itself can only create an environment for individuals to be empowered to make a difference in Africa. Since its inception in 2002, Team building activity of ANLP 2006 participants

38 A Life in the Day Magazine Issue 1/2007

A Life in the Day of Parul Christian Parul Christian is Associate Professor at the Department of International Health within the Center for Human Nutrition at Johns Hopkins Bloom- berg School of Public Health, Baltimore, USA. In the first of our new series, “A Life in the Day”, Parul describes her working day and what lies behind it.

dence that will influence policy- ommended dietary allowance of makers, who will in turn influence vitamin A reduced the incidence of the shape of micronutrient support night blindness by approximately programs. 67%.

SAL: It sounds as if the evidential SAL: Significant figures! How basis for your work is very impor- long does it take to develop such tant… evidence? PC: Very much so. Science influ- PC: The link between vitamin A ences policy, policy influences pro- deficiency and night blindness was grams – and programs themselves already known, of course. It took Parul Christian take time to exert an influence on three and a half years to develop the ground. At Hopkins we engage this evidence for pregnant women, in research that is primarily however. Our next step was to dis- SIGHT AND LIFE (SAL): Parul designed to do this. cuss nutritional health policy with Christian (PC), what is the prime the Nepalese government, groups focus of your work at Johns SAL: You have published widely such as the International Vitamin A Hopkins? on the relationship between micro- Consultative Group (now known as Parul Christian: My work here nutrient intake and health. Which the Micronutrient Forum) organiza- falls into three main areas. The first of your papers is most important to tions such as UNICEF and WHO, involves conducting applied re- you? and the scientific community at search among underserved commu- PC: I think I would have to say large. The prevention and treatment nities of the world with the aim of “Night blindness during pregnancy of night blindness is now a part of improving public health. The sec- and subsequent mortality among government health policy in Nepal ond involves training future public women in Nepal”*. This was a – but the entire process from the health professionals through teach- study into the effects of vitamin A commencement of data collection ing, advising, and mentorship. The and β-carotene supplementation on to the policy change took seven or third part of my job involves serv- pregnant women. Night blindness – eight years. This piece of work is ice. Through the provision of tech- a failure of the vision to adapt to very important to me, because it nical expertise and consultation, I dim illumination – is attributable to succeeded in changing the way serve the wider scientific commu- a lack of vitamin A and β-carotene. people thought about maternal nity. Maternal night blindness is wide- night blindness – which is anything spread among pregnant women in but an innocuous condition. SAL: So it’s not actual hands-on rural populations in South Asia. support that you provide? Our study revealed that night-blind SAL: The initiative SIGHT AND PC: No, I tend not to be engaged in women are five times more likely LIFE has recently refocused its programs on the ground; rather, I to die from infections than women efforts on the benefits of a broad advise on the research base for not suffering from this condition – range of micronutrients, rather than interventions and programs de- demonstrating that night blindness just vitamin A. What does SIGHT signed to serve the public in the during pregnancy is a significant AND LIFE mean to you in the con- less developed countries. My task risk factor. Supplementing women text of the global fight against mal- is to generate the scientific evi- throughout pregnancy with a rec- nutrition?

*Published in the American Journal of Epidemiology, Vol. 152. No. 6

39 SIGHT AND LIFE A Life in the Day

PC: SIGHT AND LIFE is very have to build trust, working hard at law. I think that they value our useful to researchers such as the outset and then continuing to work, even though they are actual- myself. It helps us to create connec- work hard to maintain it – and our ly neglected in the framework of tions with the audiences who mat- local colleagues and collaborating what we do. This is a question of ter for our work. It also assists in institutions are key in making this funding, of course. Both additional the dissemination of important happen. From a personal stand- time and resources would be neces- information to a very wide reader- point, I speak many of the lan- sary in order to extend the scope of ship around the globe. Last but not guages of South Asia – my native our activity to include men and the least, it gives important practical Gujarati, Hindi, Nepalese, some elderly – another candidate group support to projects aimed at com- Bangla and some Urdu – and I for our support. bating micronutrient deficiency. dress in the local way and take care not to offend local sensibilities. SAL: How did you come to be SAL: What about the Magazine Most of the time I’m working with involved in nutrition research? Is it itself? It is of value to you? women and children, taking an something you always wanted to PC: I think it does a very good job interest in their health. They gener- do? of bringing together program activ- ally appreciate what I’m trying to PC: In India, where I received ity and research – programmers and achieve. training in nutrition at the Maharaja scientists, in other words. I love the Sayajirao University of Baroda, I pictures, which really capture the SAL: And where do you feel that was fortunate in having excellent work we are engaged in. I also like you belong now? mentors and role models – brilliant the Magazine’s length and its PC: I was born and raised in India women who had dedicated their glossy new look. and came to the USA in 1989, so I lives to the field of nutrition. You like to feel that I belong to both could say that I simply followed in SAL: The title of our new regular worlds. I enjoy living and working their footsteps. After getting my feature is “A Life in the Day”. Is in America, but I still feel totally at Master’s degree, I became involved there actually such a thing as a nor- home when I return to South Asia. in a major nutrition project that mal working day for you? Maybe it’s because I’m a Gemini – took me to villages of Gujarat, PC: There are actually two normal I’ve certainly never experienced an where I interviewed the mothers working days, depending on identity crisis! and conducted anthropometric whether I’m in Baltimore or at measurements on their children. I project sites in South Asia. At SAL: Is it easier for someone with became involved in public health Hopkins I answer e-mails (my least your background to carry out the nutrition at a very early stage in my favorite part of the job!), participate work you do than it might be for, life, and was then very fortunate to in committee meetings, meet with say, a Caucasian American male? be able to come to Johns Hopkins, students, teach, write grants, ana- PC: In some ways, yes. I can blend where I took my doctorate and ben- lyze data and write papers – my in and am not perceived as foreign. efited from the expertise of an out- favorite part. When in the field (in On the other hand, men tend to pre- standing group of individuals, Nepal, Bangladesh or Pakistan) I dominate in the leadership of the many of whom have been great have a very different working day. organizations with which I must mentors and colleagues to me along It’s always very exciting – meeting talk, and it can be hard for me to the way. and getting updates from our proj- establish my status vis-à-vis South ect colleagues and staff, visiting the Asian men. SAL: We’ve talked exclusively communities in which we do about your professional life so far, research, observing ongoing data SAL: Your work to date focuses on but what about your private life? collection, and providing and par- the health of women and young What do you do when you’re not ticipating in training when needed. children. How do men respond to working? It brings me close to what’s really your activities in the countries PC: My professional life very happening on the ground. where programs are running? much drives my private life. PC: They’re generally very sup- Sometimes it’s difficult to sustain SAL: As an academic who has portive, and may sometimes wish networks of personal friends when worked for years in the USA, how to ‘give permission’ for our work in you travel as much as I do. That do you gain the trust of the people certain instances – for example, said, I’m very happy and frequent- with whom you work in the field? when we ask for blood samples ly enjoy evenings out with friends PC: It takes time, of course. You from their wives or daughters-in- and extended family who live on

40 A Life in the Day Magazine Issue 1/2007

the East Coast. I love my work, as travel for pleasure, including treks to Bangladesh, I arranged to have you can probably tell, and I’m con- or visits to the beach, and I also use the latest Harry Potter delivered to stantly trying to achieve a better them to help stay in touch with my me in the field – on the very day of work/life balance. I’m a firm family in India. I’m also a passion- publication! So it’s not all work believer in mixing business with ate and voracious reader – “Crime and no play. pleasure, in fact. I love traveling. I and Punishment” is my favorite try to combine my field trips with book ... Once when I was on a visit Interview by Jonathan Steffen

Erratum 90 Before

Potential of red palm oil for the control of vitamin 80 After 2 years A deficiency in sub-Saharan Africa. Five years of 70 research in Burkina Faso. Delisle H. SIGHT AND 60 LIFE Magazine Issue 3/2006, pp 22–27. 50 Unfortunately, what should have been Figure 1 40 was actually Figure 5 of the previous paper 30 (p 21), although the caption was correct. The 20 omitted Figure 1 should have appeared at the bot- 10 P tom of p 25. We apologize for any inconvenience e r c

e 0 this may have caused. n t Children Mothers

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Figures 1: Proportion of low serum retinol values in mothers e r u and children before and after 2 years of social m

e marketing for RPO consumption t i n o l

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0 . 7

µ m

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41 SIGHT AND LIFE Recent literature

From vitamin A to multiple micronutrients

David I Thurnham University of Ulster, Northern Ireland Centre for Food and Health (NICHE) Cromore Road, Coleraine Northern Ireland, BT52 1SA, UK Email: [email protected]

From its inception SIGHT AND LIFE has focused its lar. My specific focus has been micronutrients and attention on vitamin A, but the international commun- what started initially as an attempt to tackle problems ity is increasingly realizing that vitamin A deficiency in ‘marginal malnutrition,’ became ‘sub-clinical mal- does not occur on its own. In the late 1970s, Dr Mejia nutrition’ which now addresses the wide range of showed that vitamin A nutrition improved or influ- nutritional issues associated with inflammation. The enced the iron status in rats1 and children2, and many reality in the developing world is a high prevalence of workers have confirmed these findings since then. disease and malnutrition. There is a two-way interac- While the mechanism by which vitamin A improves tion between these two conditions. Malnutrition can iron status still eludes us, it is now widely accepted exacerbate disease but disease can also lead to exag- that there is a metabolic interaction between these and gerated claims of malnutrition. I have been asked to other micronutrients, which means that nutrition work- both abstract and comment on these matters, so I hope ers can no longer justify the luxury of just addressing that authors will not be too upset if some of my com- one nutrient in their work. For this reason SIGHT ments are critical. In fact we would welcome discus- AND LIFE has also decided to adjust to developments sion and healthy debate in the correspondence columns and the literature digest will now cover all micronutri- so if you do not agree with what is said, tell us why. ents accordingly. Lastly, I am sure that all SIGHT AND LIFE readers In these columns we hope to broaden the nutritional will want to join me in thanking Dr Donald McLaren discussions to include the wider issue of multiple who has so ably managed the digest for many years micronutrient deficiencies and address health issues in and I look forward to carrying on his good work. the developing world. This section will therefore bring you abstracts of all the current literature on the subject. 1. Mejia LA, Hodges RE, Rucker RB. Role of vitamin A in The field of micronutrients is enormous; so how will absorption, retention and distribution of iron in the rat. J Nutr this be done, I can see you asking? For just vitamin A 1979;109:129-37 2. Mejia LA, Arroyave G. The effect of vitamin A fortification of alone, I noticed in one of the recent issues of the sugar on iron metabolism in preschool children in Guatemala. Am SIGHT AND LIFE Magazine, there were more than 40 J Clin Nutr 1982;36: 87-93 abstracts. That number will now have to address the entire field and obviously a selection will have to be made. It is my objective to make just such a selection Dietary intake and use of dietary supplements in relation to demographic variables among pregnant based on the level of general interest and relevance to Finnish women. Arkkola T, Uusitalo U, Pietikainen M international nutrition, to mechanisms of action and to et al. Br J Nutr 2006;96:913–20. (Department of interactions with other micronutrients. Of course my Paediatrics, University of Oulu, Oulu 90014, Finland. own biases will creep into the selection, so for those of Email: [email protected]) you who do not know me, I should perhaps give you a In a study to examine food choices, nutrient intake and short résumé of my background so that you will hope- dietary supplement use of pregnant Finnish women in fully excuse the odd abstract creeping into the digest association with demographic variables, 1075 families that addresses inflammation. were invited to a birth cohort study during 1998–9. Mothers of 797 newborns completed a validated 181- I was trained as a biochemist but apart from a short item food-frequency questionnaire from which the food spell working on malaria toxins, my interests have and nutrient intakes were calculated and information been in nutrition and international nutrition in particu- about supplement use was collected for the whole of

42 Recent literature Magazine Issue 1/2007

pregnancy. Healthy food choices were found to be com- removed from plasma and concentrated in the liver. VA mon among pregnant Finnish women and were posi- deficiency did not prevent the oxidative metabolism of tively correlated with age and education, but there was RA. Nevertheless, the quantity of [3H]-RA metabolites inappropriate nutrient supplementation. Nutrient sup- in plasma and the ratio of total [3H]-polar metabolites to plements were used by 85% of the women and 31% unmetabolized [3H]-RA in liver varied directly with consumed vitamin A-containing supplements, although VA status (VA-adequate > VA-marginal > VA- it is not recommended during pregnancy. However, deficient, P <0.05), and the RP-supplemented rats even taking food and supplementation into account, the behaved like VA-adequate ones. Authors suggest that intake of vitamin D and folate did not meet the dietary measuring plasma retinoid metabolites after a dose of recommendations. RA may provide insight into the metabolism of this bioactive retinoid by visceral organs. All-trans-retinoic acid distribution and metabolism in vitamin A-marginal rats. Cifelli CJ, Ross AC. Am Carotenoid content and flesh color of selected J Physiol Gastrointest Liver Physiol 2006;291: banana cultivars growing in Australia. Englberger L, G195–G202. (Department of Nutritional Sciences, Wills RB, Blades B et al. Food Nutr Bull 2006; Pennsylvania State University, PA 16802, USA.) 27:281–91. (Island Food Community of Pohnpei, Retinoids, including all-trans-retinoic acid (RA), are Kolonia, Pohnpei, Federated States of Micronesia. considered to have anti-inflammatory properties and are Email: [email protected]) used therapeutically for diseases of the skin and certain The authors’ objective was to identify further banana cancers. The present study was conducted to better cultivars that may improve vitamin A status in understand the effects of exogenous RA, both in the Micronesia. Ripe fruit of 10 banana cultivars growing in absence and presence of inflammation, on the distribu- Australia (mostly field research collections) with yel- tion and metabolism of a dose of tritium-labelled [3H] low or yellow/orange flesh colour were compared with RA. Rats fed a low vitamin A diet were pre-treated with two cream-fleshed cultivars marketed worldwide. RA (po), a low dose of lipopolysaccharide (LPS, ip), or Carotenoid content was analyzed by HPLC and flesh their combination. Twelve hours later, albumin-bound colour by HunterLab colorimetry. There was a positive [3H]RA was injected intravenously and tissue metabo- correlation between carotenoid content and deeper yel- lites were measured at 10 and 30 min. LPS-induced low/orange coloration with Asupina (a Fe'i banana) inflammation significantly reduced plasma retinol by containing the highest level (1,412 µg/100 g) of trans ß- 47%, increased total 3H in plasma at 10 min, and carotene and more than 20 times higher than that of the reduced total 3H in liver at both times. In contrast, RA cream-coloured variety. All 10 yellow or pre-treatment did not affect plasma retinol, significant- yellow/orange-fleshed cultivars (Asupina, Kirkirnan, ly increased total 3H in plasma at both times, did not Pisang Raja, Horn Plantain, Pacific Plantain, Kluai Khai affect liver total 3H and, by 30 min, had significantly Bonng, Wain, Red Dacca, Lakatan, and Sucrier) had increased metabolism of [3H]RA in plasma, liver, lung, significant carotenoid levels, potentially meeting half or and small intestine. The authors conclude that, although all of the estimated vitamin A requirements for a non- LPS-induced inflammation affects the organ distribu- pregnant, non-lactating adult woman within normal tion of RA, the ability of RA to induce its own catabo- consumption patterns. All were acceptable for taste and lism is maintained during inflammation. other attributes.

Chronic vitamin A status and acute repletion with Vitamin A potentiates CpG-mediated memory B cell retinyl palmitate are determinants of the distribu- proliferation and differentiation: Involvement of tion and catabolism of all-trans-retinoic acid in rats. early activation of p38MAPK. Ertesvag A, Aasheim Cifelli CJ, Ross AC. J Nutr 2007;137:63–70. HC, Naderi S et al. Blood 2007; January 5 [Epub ahead (Department of Nutritional Sciences, Pennsylvania of print]. (Department of Biochemistry, Institute of State University, PA 16802, USA.) Basic Medical Sciences, University of Oslo, Oslo, Vitamin A (VA)-deficient, marginal and adequate rats, Norway.) and a group of deficient rats fed retinal palmitate 20 h Foreign CpG-DNA from viruses and bacteria can previously, were injected with a dose of tritium-labelled activate memory B cells through binding to toll-like [3H]-retinoic acid (RA) and the distribution of the [3H] receptor 9, and this pathway has been hypothesized to was measured after 30 min. Plasma and several tissues be involved in the continuous activation of memory B were analysed 30 min after [3H]-RA, for unmetabolized cells ensuring life-long humoral immunity. In this [3H]-RA, organic and aqueous phase [3H]-labelled study, the authors demonstrate that retinoic acid (RA) is metabolites. In all groups, [3H]-RA was rapidly a potent co-activator of this pathway in human B cells.

43 SIGHT AND LIFE Recent literature

RA enhanced the CpG-mediated proliferation of prevalence differed significantly across the regions, CD27+ memory B cells, and the proliferative response with highest prevalence in the Northern Mountainous was accompanied by increased immunoglobulin (Ig) areas for VAD and in the Northern Mountainous area secretion indicative of plasma cell formation. By using and Mekong River Delta for anemia. It is concluded that specific inhibitors to identify all RA-mediated events, sub clinical vitamin A deficiency and anemia are still the authors propose that RA can strengthen humoral important public health problems in Vietnam. immunity by activation of the signalling molecule (Comment from DIT: Inflammation has a strong influ- p38MAPK, resulting in increased proliferation and dif- ence on both VAD and anemia in this age group, and ferentiation to Ig-secreting plasma cells. needs assessing in order to interpret these data fully.)

Model-based compartmental analysis indicates a Evaluation of vitamin A supplementation regimens reduced mobilization of hepatic vitamin A during in Ghanaian postpartum mothers with the use of the inflammation in rats. Gieng SH, Green MH, Green JB, modified-relative-dose-response test. Tchum SK, Rosales FJ. J Lipid Res 2007; January 18 [Epub ahead Tanumihardjo SA, Newton S et al. Am J Clin Nutr of print]. (Department of Nutritional Sciences, 2006;84:1344–9. (Kintampo Health Research Centre, Pennsylvania State University, University Park, PA, Health Research Unit, Ghana Health Service, Accra, USA.) Ghana.) Vitamin A (VA) kinetics was studied in rats with mar- The objective of this study was to determine the length ginal hepatic VA stores before, during, and after inflam- of time mothers are protected postpartum against vita- mation-induced hyporetinolemia. Rats received an oral min A depletion after receiving either 400,000 IU vita- dose of [3H]VA (d 0), and inflammation was induced min A in two divided doses or 200,000 IU as a single on d 21 with lipopolysaccharide (LPS) for 3 d (n=5) or dose plus a placebo 24 h apart. 168 mothers were recombinant human interleukin-6 (rhIL-6) for 7 d recruited by trained fieldworkers 7–10 d after delivery. (n=5); PBS was similarly given to controls (n=4). Serial Modified-relative-dose-response (MRDR) tests were plasma samples collected from 2 h to 54 d after [3H]VA performed at baseline in 167 women, and vitamin A indicated that both the fraction of [3H]VA and retinol was administered within 6 wk after delivery. At base- concentrations in plasma were significantly reduced by line mean serum retinol concentration was 1.4 µmol/L LPS and rhIL-6. Of the four potential mechanisms and did not change after treatment. MRDR at baseline investigated: Modeling results indicated that a 79% indicated marginal deficiency and both treatments reduction in mobilization of hepatic retinol (from 4.3 to significantly improved liver reserves even at 5 mo. 0.9 nmol/h) by 15 h after LPS administration best accounted for observed changes in plasma VA kinetics. Vitamin E rhIL-6 caused a similar but earlier reduction (75% by 5.6 h lasting for up to 8 d). The modelling predicted Higher baseline serum concentrations of vitamin E that, after inflammation, hepatic retinol mobilization are associated with lower total and cause-specific would return to control values by 10 d. mortality in the α-Tocopherol, β-Carotene Cancer Prevention Study. Wright ME Lawson KA, Weinstein Sub clinical vitamin A deficiency and anemia among SJ et al. Am J Clin Nutr 2006;84:1200–7. (NCI, Vietnamese children less than five years of age. Khan Division of Cancer Epidemiology and Genetics, NIH, NC, Ninh NX, Nhien NV et al. Asia Pac J Clin Nutr 6120 Executive Blvd, EPS 3048, Bethesda, MD 20892, 2007;16:152–7. (National Institute of Nutrition, 48B USA. Email: [email protected]) Tang Bat Ho, Hanoi, Vietnam. Little is known about the relation between mortality and Email: [email protected]) circulating concentrations of vitamin E resulting from A cross-sectional survey was conducted in 40 villages dietary intake, low-dose supplementation, or both. In (clusters) of four ecological regions in Vietnam during the prospective cohort study of 29,092 Finnish male April–May 2001. 1657 children less than 5 years old smokers aged 50–69 y who participated in the were recruited and the prevalence of sub clinical vita- α-Tocopherol, β-Carotene Cancer Prevention (ATBC) min A deficiency (VAD, serum retinol <0.70 µmol/L) Study, authors examined whether baseline serum α- was 12.0% and the prevalence of anemia (hemoglobin tocopherol concentrations was associated with total and <110 g/L) was 28.4%. In children under 6 mo the preva- cause-specific mortality. Only 10% of participants lence of VAD was 35.1% whereas the prevalence of reported vitamin E supplement use at baseline, and thus anemia was 61.7%. The prevalence of children with baseline serum concentrations of vitamin E mainly both VAD and anemia was 6.1%. VAD and anemia reflected dietary intake and other host factors. During

44 Recent literature Magazine Issue 1/2007

up to 19 y of follow-up, 13,380 deaths (including 4,518 endothelial cells. It now appears that the classic VDR, and 5,776 due to cancer and cardiovascular disease, long known to reside in the cell nucleus, in some cells respectively) were identified. Men in the higher quin- is also associated with caveolae present in the plasma tiles of serum α-tocopherol had 12, 21 and 30% lower membrane. risks of total and cause-specific mortality, total mortality and deaths due to cancer, cardiovascular disease, and The 25-hydroxyvitamin D threshold for better other causes respectively than did those in the lowest health. Bischoff-Ferrari HA. J Steroid Biochem Mol quintile. Further analysis showed increasing risk reduc- Biol 2007; January 13 [e-pub ahead of print]. tions up to serum α-tocopherol values of 13–14 mg/L (Department of Rheumatology and Institute of Physical (30–32 µmol/L), after which no further benefit was Medicine, University Hospital Zurich, Gloriastrasse 25, noted. 8091 Zurich, Switzerland.) The author reviews available evidence supporting a Vitamin E: maternal concentrations are associated threshold plasma concentration of 25-OH-vitamin D of with fetal growth. Scholl TO, Chen X, Sims M, Stein 75 nmol/L, adherence of patients to vitamin D treatment TP. Am J Clin Nutr 2006;84:1442–8. (Department of in fracture trials in regard to achieved anti-fracture effi- Obstetrics and Gynecology, University of Medicine and cacy, and finally, discusses current recommendations Dentistry of New Jersey School of Osteopathic for vitamin D intake. Medicine, Stratford, NJ 08104, USA. Email: [email protected]) Vitamin D receptor polymorphism among rickets Authors measured maternal plasma concentrations of children in Mongolia. Kaneko A, Urnaa V, Nakamura α- and γ-tocopherols to determine their relation with K et al. J Epidemiol 2007;17:25–9. (Health Promotion, measures of fetal growth and the relation of diet and Division of Public Health, Graduate School of Tokyo supplement use to tocopherol concentrations at week 28 Medical and Dental University.) of gestation. 1,231 gravid women from Camden, NJ, It was reported that 32% of children under five years old were studied from ~16 wk gestation and plasma toco- in Mongolia had symptoms of rickets. Authors investi- pherol concentrations were measured at entry and at gated whether vitamin D receptor (VDR) gene poly- week 28. Plasma concentrations of α-tocopherol at morphisms were related to the high prevalence of rick- entry and at week 28 were positively related to fetal ets in Mongolia and to bone properties measured by growth (birth weight for gestation), a decreased risk of age-standardised mid-tibial cortical speed of sound. The small-for-gestational-age births, and an increased risk study was done in Ulaanbaatar in 80 children aged 7–10 of large-for-gestational-age births. Concentration of years with a history of rickets and 72 children with no α-tocopherol at week 28 was positively related to use of history of rickets. VDR polymorphisms and bone prop- prenatal multivitamins and dietary intake of vitamin E. erties did not differ between the cases and controls, and polymorphisms do not play a major role in the develop- Vitamin D ment of rickets in Mongolia.

Mini-review: vitamin D receptor: New assignments Early-life supplementation of vitamins A and D, in for an already busy receptor. Norman AW. Endo- water-soluble form or in peanut oil, and allergic dis- crinology 2006;147:5542–8. (Department of eases during childhood. Kull I, Bergstrom A, Melen E Biochemistry, University of California Riverside, et al. J Allergy Clin Immunol 2006;118:1299–304. Riverside, CA 92506, USA. (Department of Occupational and Environmental Email: [email protected]) Health, Stockholm County Council, Stockholm, The author reviews the history of vitamin D from its Sweden. Email: [email protected]) discovery in 1920 to the mid 1980s and beyond, when a The authors studied the association between early-life new world of 1α,25(OH)(2)D-3-mediated rapid supplementation of vitamins A and D in water-soluble responses (RR) was discovered. These were responses form or in peanut oil and allergic diseases up to four that occurred too rapidly (minutes to an hour) to be years of age, using data from repeated parental ques- explained as the simple consequence of the nuclear vita- tionnaires providing information on exposure and min D receptor (VDR) regulating gene transcription. health of a prospective birth cohort of 4,089 newborn Some RR examples include the rapid intestinal absorp- infants. At four years, the response rate was 90%, and tion of calcium (transcaltachia), secretion of insulin by allergen-specific IgE levels to food and airborne pancreatic β-cells, opening of voltage-gated Ca2+ and allergens were measured in 2,614 of the participating Cl-channels in osteoblasts, and the rapid migration of children. Vitamins A and D were given to 98% of the

45 SIGHT AND LIFE Recent literature

children in infancy, and vitamins based in peanut oil P <0.001) but in multiple regression analysis, dietary dominated (90%). It was found that children supple- K1 only explained 8% of the variance. mented with vitamins A and D in water-soluble form during the first year of life had an almost twofold greater risk of asthma, food hypersensitivity and sensi- Vitamin C tization to common food and airborne allergens at four years, compared with those receiving vitamins in peanut Rationale and impact of vitamin C in clinical nutri- oil. No higher risk of IgE antibodies to peanuts was seen tion. McGregor GP, Biesalski HK. Curr Opin Clin Nutr in children receiving vitamins in peanut oil. Metabol Care 2006;9:697–703. (Department of Biological Chemistry and Nutrition, University of Vitamin D deficiency in a healthy group of mothers Hohenheim, Garbenstrasse 30, D-70599 Stuttgart, and newborn infants. Lee JM, Smith JR, Philipp BL et Germany. Email: [email protected]) al. Clin Pediatr (Phila) 2007;46:42–4. (Division of The authors reviewed recent evidence of the clinical Pediatric Endocrinology, Child Health Evaluation and benefit and underlying effects of parenteral vitamin C in Research Unit, University of Michigan, Ann Arbor, conditions of oxidative stress. Usually the impact of Michigan 48109, USA. vitamin C on oxidative stress-related diseases is moder- Email: [email protected]) ate because of its limited oral bioavailability and rapid Plasma 25-hydroxyvitamin D was measured in 40 clearance. Recent findings in critically ill patients after healthy, mostly Black, mother-infant pairs. Although a severe burns suggest that parenteral administration of majority of mothers received a daily prenatal multivita- vitamin C rapidly restores depleted ascorbate levels and min, vitamin D deficiency (25-OHD <30 nmol/L), was may reduce circulatory shock, fluid requirements and found in 50% of mothers and 65% of their newborn oedema. Ascorbate is particularly effective in protecting infants, with a positive correlation between maternal the vascular endothelium, which is especially vulnera- and infant plasma 25-hydroxyvitamin D concentrations. ble to oxidative stress. Supraphysiological levels of Maternal vitamin D deficiency may represent an impor- ascorbate, which can only be achieved by parenteral and tant risk factor for the development of rickets in chil- not by the oral administration of vitamin C, may facili- dren in some parts of the USA. tate the restoration of vascular function in the critically ill patient. Vitamin K Uric acid restores endothelial function in patients Plasma phylloquinone (vitamin K1) concentration with type 1 diabetes and regular smokers. Waring and its relationship to intake in British adults aged WS, McKnight JA, Webb DJ, Maxwell SR. Diabetes 19–64 years. Thane CW, Wang LY, Coward WA. Br J 2006;55:3127–32. (Clinical Pharmacology Unit, Nutr 2006;96:1116–24. (MRC Human Nutrition University of Edinburgh, Queen’s Medical Research Research, Elsie Widdowson Laboratory, Fulbourn Institute, 3rd Floor E, Room E3-22,47 Little France Road, Cambridge CB1 9NL, UK.) Crescent, Edinburgh EH16 4TJ, Midlothian, Scotland. Plasma phylloquinone (vitamin K1) concentration from Email: [email protected]) non-fasted blood samples was examined by season, The urate molecule has antioxidant properties, which smoking status, socio-demographic factors and vitamin could influence endothelial function. The impact of K1 intake in a nationally representative sample of 1,154 acutely raising uric acid concentrations on endothelial British individuals aged 19–64 years from the 2000–1 function was studied in eight men with type 1 diabetes, National Diet and Nutrition Survey. Geometric mean eight healthy regular smokers, and eight age-matched plasma vitamin K1 concentration was 0.94 (95% CI healthy control subjects in a randomized, four-way, 0.88, 1.00) nmol/L, with 95% of values in the range double-blind, placebo-controlled study. Subjects 0.10–8.72 nmol/L. Plasma vitamin K1 concentrations of received 1,000 mg uric acid i.v. in vehicle, 1,000 mg 530 men were significantly higher than those of 624 vitamin C as a control antioxidant, vehicle alone, or women (1.13 v. 0.81 nmol/L; P <0.001) and independ- 0.9% saline on separate occasions over 1 h. Forearm ent of other factors. In women, plasma vitamin K1 con- blood flow responses to intrabrachial acetylcholine and centration was lower in younger than older women and sodium nitroprusside were assessed using venous occlu- was lower during summer compared with winter and sion plethysmography. Responses to acetylcholine, but spring (each P <0.01). Plasma vitamin K1 concentra- not sodium nitroprusside, were impaired in patients tions were positively correlated with vitamin K1 intake with diabetes (P <0.001) and in smokers (P <0.005) in men and women (r=0.26 and 0.32 respectively; each compared with control subjects. Administration of uric

46 Recent literature Magazine Issue 1/2007

acid and vitamin C selectively improved acetylcholine fortification. Authors investigated the changes in serum responses in patients with type 1 diabetes (P <0.01) and folate, RBC folate, and total homocysteine (tHcy) con- in regular smokers (P <0.05). Uric acid administration centrations utilizing data from National Health and improved endothelial function in the forearm vascular Nutrition Examination Surveys (NHANES) before and bed of patients with type 1 diabetes and smokers, sug- after food folate fortifiation. The current study included gesting that high uric acid concentrations in vivo might 17,144, 17,213, and 11,415 measurements for serum serve a protective role in these and other conditions folate, RBC folate, and tHcy, respectively. Overall, geo- associated with increased cardiovascular risk. metric mean serum folate concentrations were 149.6 and 129.8% higher in 1999–2000 and 2001–2002, Ascorbic acid attenuates aspirin-induced gastric respectively, than in 1988–1994 (P <0.0001). Sex-, age, damage: role of inducible nitric oxide synthase. and race-ethnicity-adjusted serum folate was signifi- Konturek PC, Kania J, Hahn EG, Konturek JW. J cantly lower in 2001–2002 than in 1999–2000 (10.4%, Physiol Pharmacol 2006;57(Suppl 5):125–36. (First P <0.0002). The prevalence of low serum folate Department of Medicine, University Erlangen- decreased from 18.4% in 1988–1994 to 0.8% in Nuremberg, Germany. Email: [email protected]) 1999–2000 and to 0.2% in 2001–2002 (P <0.0001). Aspirin (ASA) represents an important risk factor for RBC folate increased from 391 nmol/L in 1988–1994 to gastric mucosal injury. Recently, vitamin C releasing 618 nmol/L in 1999–2000, and to 611 nmol/L in aspirin (ASA-VitC) has been shown to reduce gastric 2001–2002. Consequently, the prevalence of low RBC toxicity of ASA in an animal model of gastric injury. In folate decreased from 45.8% in 1988–1994 to 7.3% in the present study the effect of ASA and ASA-VitC was 1999–2000 and to 7.1% in 2001–2002 (P <0.0001). compared on gastric mucosal damage before and after Although RBC folate status improved after folic acid Helicobacter pylori (Hp) eradication in 10 young fortification in all race-ethnicities, the prevalence of low healthy Hp-positive volunteers. Endoscopic examina- RBC folate (~20.5%) continues to be high in non- tion showed treatment with ASA-VitC (both before and Hispanic blacks. Age-, sex-, and race-ethnicity-adjusted after Hp treatment) induced significantly less gastric tHcy declined from 9.5 µmol/L in 1988–1994 to mucosal lesions than plain ASA. 7.6 µmol/L in 1999–2000 and to 7.9 µmol/L in In vitro experiments were also performed on a gastric 2001–2002. mucosal cell line (MKN-45 cells) incubated with ASA or ASA-VitC alone or in combination with Hp. The Population reference values for plasma total homo- studies demonstrated a significant increase in inducible cysteine concentrations in US adults after the fortifi- nitric oxide synthase (iNOS) expression in MKN-45 cation of cereals with folic acid. Ganji V, Kafai MR. cells incubated with Hp, and this was aggravated by the Am J Clin Nutr 2006;84:989–4. (Department of Human addition of ASA, but not ASA-VitC. The authors con- Nutrition, College of Applied Health Sciences, clude that the addition of vitamin C to the ASA induces University of Illinois, 1919 W. Taylor St., Room 650, less gastric mucosal damage, possibly due to its Chicago, IL 60612, USA. Email: [email protected]) inhibitory effect on iNOS expression. Folic acid fortification has resulted in a dramatic (Comment by DIT: There are good grounds that the increase in folate intake in the United States. Folate addition of vitamin C would be beneficial in this treat- intake is inversely associated with circulating total ment, since workers have previously shown that gastric homocysteine (tHcy), which is directly associated with vitamin C concentrations were ~four times higher than cardiovascular disease risk. The authors used data from those in plasma but were destroyed by Hp infection.) two nationally representative sample surveys (NHANES 1999–2001 and 2001–2002), conducted B-group vitamins since folic acid fortification was implemented, to study tHcy distribution by age, sex, and race-ethnicity in Trends in serum folate, RBC folate, and circulating 9,196 persons. Plasma concentrations of tHcy were total homocysteine concentrations in the United higher in men than in women and in older persons than States: analysis of data from National Health and in younger persons. In general, the plasma tHcy data Nutrition Examination Surveys, 1988–1994, reflect the effects of folic acid fortification. Sex, age, 1999–2000 and 2001–2002. Ganji V, Kafai MR. J Nutr and race-ethnicity differences persist in plasma tHcy 2006;136:153–8. (Department of Human Nutrition, concentrations. College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA. Oral vitamin B12 supplementation reduces plasma Email: [email protected]) total homocysteine concentration in women in India. Folate intakes increased dramatically after folic acid Yajnik CS, Lubree HG, Thuse NV et al. Asia Pac J Clin

47 SIGHT AND LIFE Recent literature

Nutr 2007;16:103–9. (Director, Diabetes Unit, King pregnancy through the eighth month of pregnancy, Edward Memorial Hospital, Moodliar Road, Pune, using data from 22,500 women in the Norwegian India. Email: [email protected]) Mother and Child Cohort Study with deliveries record- The authors studied the effect of oral vitamin B12 (500 ed in 2000–2003. Folic acid supplement use increased µg) and/or 100 g cooked green leafy vegetables (GLV) from 11.8% at 2 mo before pregnancy to 46.9% at ges- every alternate day in a 2x2 factorial design over a 6 wk tational month 3, but decreased to 26.0% at gestational period. Non-pregnant vegetarian women (n=42, age month 8. Of 16,116 women (71.6%) who had taken 20–50 y) were randomly allocated to four study groups. folic acid supplements at some time before or during Clinical measurements were made at the beginning and pregnancy, 72.4% had started use after becoming preg- at the end of the study, and blood samples were col- nant. The women (10%) who used supplements regular- lected before, and at 2 and 6 wk. Forty women complet- ly from 1 mo before pregnancy throughout the first ed the trial. Twenty-six women had low vitamin B12 sta- trimester, generally reported higher maternal and pater- tus (<150 pmol/L) and 24 had hyperhomocysteinemia nal education, planned pregnancies, infertility treat- (>15 µmol/L). GLV supplementation did not alter ments, or chronic diseases. They were also more likely plasma folate or tHcy. High-dose per oral vitamin B12 to be older, married, and non-smokers and to have high- supplementation significantly reduced plasma tHcy er income and lower parity. More effective intervention within 2 wk, but did not achieve normal plasma tHcy programs to improve periconceptional intakes of folic concentration even after 6 wk. acid are needed and should consider both demographic and socioeconomic factors. Folate and arsenic metabolism: a double-blind, placebo-controlled folic acid-supplementation trial Vitamin B6, B12, and folic acid supplementation and in Bangladesh. Gamble, MV; Liu, XH; Ahsan, H et al. cognitive function: a systematic review of random- Am J Clin Nutr 2006;84:1093–101. (Department of ized trials. Balk EM, Raman G, Tatsioni A et al. Arch Environmental Health Sciences, Mailman School of Intern Med 2007;167:21–30. (Tufts-New England Public Health, Columbia University, 60 Haven Ave. Medical Center Evidence-based Practice Center, B1, New York, NY 10032, USA. Institute for Clinical Research and Health Policy Email: [email protected]) Studies, Boston, MA 02111, USA. Inorganic arsenic in drinking water can be methylated to Email: [email protected]) monomethylarsonic acid (MMA) and dimethylarsinic Despite their important role in cognitive function, the acid (DMA) via folate-dependent one-carbon metabo- value of B vitamin supplementation is unknown. A sys- lism. Impaired methylation is associated with adverse tematic review of the effect of vitamins B6, B12 and health outcomes. Authors investigated the hypothesis folic acid supplementation on cognitive function was that folic acid supplementation of arsenic-exposed performed. Fourteen trials met their criteria; most were adults would increase arsenic methylation. Two hun- of low quality and limited applicability. Approximately dred adults in a rural region of Bangladesh, previously 50 different cognitive function tests were assessed. The found to have low plasma concentrations of folate (Յ9 authors concluded that as yet the evidence does not nmol/L) were enrolled in a randomized, double-blind, support an effect of vitamin B6 or B12 or folic acid placebo-controlled folic acid-supplementation trial. supplementation, alone or in combination, on cognitive After 12 wk of supplementation with folic acid at a dose function testing in people with either normal or of 400 µg/d or placebo, there was a small but significant impaired cognitive function. increase in the excretion of DMA and other changes that indicate that folic acid supplementation to participants Association of cognitive impairment with plasma with low plasma folate enhances arsenic methylation. levels of folate, vitamin B12 and homocysteine in the elderly. Dimopoulos N, Piperi C, Salonicioti A et al. In Patterns and predictors of folic acid supplement use Vivo 2006;20:895–9. (Department of Biological among pregnant women: the Norwegian Mother and Chemistry, Medical School of Athens University 75 M. Child Cohort Study. Nilsen RM, Vollset SE, Gjessing Asias St., Athens, Greece. Email: [email protected]) HK, Magnus P et al. Am J Clin Nutr 2006;84:1134–41. The authors investigated the relationship between plas- (Department of Public Health and Primary Health Care, ma folate, vitamin B12 and homocysteine and cognitive Section Epidemiology and Medical Statistics, function in persons over 60 years of age living in the University of Bergen, Kalfarveien 31, N-5018 Bergen, community. Screening with the Mini Mental State Norway. Email: [email protected]) Examination identified 37 subjects with dementia and The authors examined the patterns and predictors of 33 healthy controls. Results showed that there were maternal folic acid supplement use from 2 mo before lower levels of plasma folate and/or vitamin B12 and

48 Recent literature Magazine Issue 1/2007

higher levels of plasma homocysteine associated with trient group were heavier by 98 g and measured 0.80 cm cognitive impairment in elderly individuals. longer and 0.20 cm larger in midarm circumference compared with the placebo group. There were 79% Homocysteine, folate, and vitamin B12 and cognitive fewer low birth weight infants and 58% less early performance in older Chinese adults: findings from neonatal morbidity with MM supplementation. the Singapore Longitudinal Ageing Study. Feng L, Ng TP, Chuah L et al. Am J Clin Nutr 2006;84: Micronutrient status during lactation in HIV-infect- 1506–12. (Gerontological Research Programme, ed and HIV-uninfected South African women dur- Faculty of Medicine, National University of Singapore, ing the first 6 mo after delivery. Papathakis PC, Singapore.) Rollins NC, Chantry CJ et al. Am J Clin Nutr The relations of elevated homocysteine, low folate, and 2007;85:182–92. (Africa Centre for Health and vitamin B12 with cognitive performance in non- Population Studies, Somekele, South Africa. Email: demented elderly are not well established. The [email protected]) researchers recruited 451 Chinese aged Ն55 y with The authors compared the protein and micronutrient Mini Mental State Examination scores Ն24 and who status of breastfeeding women by HIV status. Serum were considered fully independent based on Activities albumin, prealbumin, vitamin B12, folate, retinol, of Daily Living score, and measured fasting homocys- α-tocopherol, hemoglobin, ferritin, and zinc concentra- teine, folate, and vitamin B12 concentrations. Cognitive tions were compared between 92 HIV-positive and 52 functions were assessed by a battery of neuropsycho- HIV-uninfected mothers 6, 14, and 24 wk after delivery. logical tests. Authors found elevated homocysteine was C-reactive protein and α-1-acid glycoprotein were used associated with deficits in constructional ability and as proxy indicators of an inflammatory process. Mean processing speed and folate deficiency was associated albumin and prealbumin were significantly lower in with measures of episodic memory and language. The HIV-positive mothers, and a higher proportion of HIV- results provide support for differential effects of homo- positive mothers had low albumin concentrations (<35 cysteine and folate on specific cognitive functions. g/L). Deficiencies in vitamins B12, folate, α-tocopherol, ferritin and zinc were common in the breastfeeding Multiple micronutrients mothers. HIV-positive mothers had lower mean serum concentrations of albumin, prealbumin, folate, and Multimicronutrient supplementation for under- hemoglobin than did HIV-negative mothers and also in nourished pregnant women and the birth size of retinol and zinc, even after correction for inflammation.. their offspring: a double-blind, randomized, placebo-controlled trial. Gupta P, Ray M, Dua T et al. Arch Monitoring micronutrients in cigarette smokers. Pediatr Adolesc Med 2007;161:58–64. (Department of Northrop-Clewes CA, Thurnham DI. Clin Chim Acta Pediatrics, University College of Medical Sciences, 2007;377:14–38. (Center for Disease Control and Block R-6A, Dilshad Garden, Delhi 110095, India. Prevention, Atlanta, GA 30341, USA. Email: [email protected]) Email: [email protected]) The effect of multimicronutrient (MM) supplementa- Smoking is associated with oxidative stress and tion for undernourished pregnant women on the birth increased risks of many chronic diseases that both short- size of their offspring, incidence of low-birth-weight en life and impair its quality. Low plasma concentra- infants (<2500 g), and early neonatal morbidity was tions of several micronutrients, especially the antioxi- examined in a randomized, double-blind, placebo-con- dants vitamin C and β-carotene, are associated with trolled trial in a tertiary-care hospital. From 13,465 smoking, and there has been much interest in determin- pregnant women, 200 were recruited with a body mass ing whether deficiencies in micronutrients are involved index (weight kg)/(ht m)2 of less than 18.5 and/or a etiologically in smoking-related diseases. The micronu- hemoglobin level of 70–90 g/L at 24–32 weeks of ges- trients discussed are vitamins A, E, and C; the tation. 146 neonates (73.0%) were available for analysis carotenoids; some of the B-vitamin group; and the min- of birth size and 170 (85.0%) for analysis of morbidity erals selenium, zinc, copper, and iron. This review in the seven days after delivery. The MM group (n=99) assembles data on diet, biochemical markers and results received a supplement containing 29 vitamins and min- of intervention studies to assess the relative contribu- erals once a day, from enrolment until delivery. The tions of dietary intakes and the oxidative stress of smok- comparison group (n=101) received placebo. All sub- ing on biochemical markers of micronutrient status in jects also received supplements of 60 mg/d of elemental smokers. It was concluded that smoking influences iron, and 500 µg/d of folic acid. Infants in the micronu- plasma nutrient concentrations both by its influence on

49 SIGHT AND LIFE Recent literature

foods consumed and in some cases through inflamma- Park, PA 16802, USA. Email: [email protected]) tory effects. Nutritional surveys use acute phase protein (APP) biomarkers such as C-reactive protein (CRP) and α-1-acid Minerals glycoprotein (AGP) to identify the influence of inflammation on the distribution of iron status biomarkers. In Iodine deficiency persists in the Zanzibar Islands of this paper, the authors explore the relations between Tanzania. Assey VD, Greiner T, Mzee RK et al. Food APP and iron-status biomarkers in African American Nutr Bull 2006;27:292–9. (Tanzania Food and Nutrition infants (n=351) and Guatemalan school-age children Centre, Dar es Salaam, Tanzania. (n=375) to determine which biomarker better identifies Email: [email protected]) persons with spurious elevations in iron status markers. In this study, the prevalence of goitre was assessed by The overall prevalence of either inflammation or iron palpation of 11,967 schoolchildren, urinary iodine con- deficiency was <10% in both samples and the authors centration was measured in a sub-sample and the avail- concluded that (1) the low prevalence of inflammation ability of iodated salt was assessed at the household and has little influence on the distribution of ferritin; and (2) retail levels. The mean total goitre prevalence was the two common indicators of inflammation do not per- 21.3% for Unguja and 32.0% for Pemba, and median form equally well in identifying persons who may have urinary iodine concentrations were 185.7 µg/L and 53.4 elevations in ferritin due to inflammation. µg/L respectively (P <0.01). Likewise, the household availability of iodated salt was 63.5% in Unguja and Provitamin A carotenoids 1.0% in Pemba. The inadequate intake of iodine found in the Zanzibar Islands belies the common assumption Provitamin A carotenoids and ascorbic acid contents that an island population with access to seafood is not at of the different types of orange juices marketed in risk for iodine-deficiency disorders. Spain. Melendez-Martinez AJ, Vicario IM, Heredia FJ. Food Chem 2007;101:177–84. (Department of High dose zinc increases hospital admissions due to Nutrition and Food Science, Faculty of Pharmacy, genitourinary complications. Johnson AR, Munoz A, University of Seville, E-41012 Seville, Spain. Gottlieb JL, Jarrard DF. J Urol 2007;177:639–43. Email: [email protected]) (Department of Surgery, Urology Division, University The vitamin C and provitamin A carotenoids content of of Wisconsin School of Medicine and Public Health, 25 commercially available Spanish orange juices were Madison, Wisconsin 53792, USA.) studied. Large differences in the levels of these com- In a further analysis of the recent Age-related Eye pounds were found. On average, ultra-frozen orange Disease Study (AREDS), authors examined the data juices (UFOJ) and orange juices from ecological agri- pool for primary International Classification of culture showed the highest vitamin C content (518 and Diseases, 9th revision codes given for hospital admis- 412 mg/L, respectively). The major provitamin A sions related to urological problems. The AREDS carotenoids in most samples was β-cryptoxanthin, but randomized 3,640 patients with age related macular this was exceeded in two samples where unusually high degeneration to one of four study arms, two of which contents of β-carotene (>0.5 mg/L) were present. provided 80 mg zinc. Authors found significantly more Mandarin orange juice analyzed showed the highest hospital admissions due to genitourinary causes in provitamin A activity (359.3 µg retinol activity equiva- patients on zinc v. non-zinc formulations (11.1% v. lents (RAE)/L) while the concentration in the other 7.6%, P=0.0003) with a 26% greater relative risk orange juices surveyed ranged from 22.4–78.5 µg (P=0.008) in men. In the 343 patients requiring hospital RAE/L. admission the most common conditions were benign prostatic hyperplasia/urinary retention, urinary tract Bioequivalence of β-carotene and retinol. Thurnham infection, urinary lithiasis and renal failure. There was DI. J Sci Food Agric 2007;87:13–39. (Northern Ireland no increase in prostate or other cancers with zinc Centre for Food and Health, University of Ulster, supplementation. Coleraine, UK. Email: [email protected]) Recently, the bioequivalence of β-carotene was raised Interpretation of serum ferritin concentrations as from 6 to 12 mg β-carotene equal to 1 mg retinol. This indicators of total-body iron stores in survey popula- review re-examines the data used to support the new tions: the role of biomarkers for the acute phase equivalence ratio, especially since some of these data response. Beard JL, Murray-Kolb LE, Rosales FJ et al. were obtained in developing countries where exposure Am J Clin Nutr 2006;84:1498–505. (Department of to gut parasites and other infections is common, yet the Nutritional Sciences, Penn State University, University influence of inflammation on plasma carotenoid and

50 Recent literature Magazine Issue 1/2007

retinol concentrations is frequently ignored. Bioequi- Lutein and zeaxanthin accumulate in the macular pig- valence studies examined in this review include those ment of the retina, and are reported to be associated done in developing and developed countries, depletion with a reduced incidence of age-related macular degen- and repletion studies, feeding with vegetable sources of eration. The yolk of chicken eggs was investigated as a β-carotene or pure supplements, influence of helminths, source of lutein and zeaxanthin in a randomized cross- carotenoid interactions and matrix effects and studies over design trial in which 33 men and women (>60 yr) using stable isotopes (SI). SI studies show the bioeffi- participated in an 18 wk study during which there were cacy of β-carotene conversion to retinol is generally two 5 wk interventions with either 1 egg or egg substi- poor even for pure β-carotene, unless the dose is small tute/d. Serum lutein 26% (P <0.001) and zeaxanthin and fed regularly until equilibration is reached. Retinol 38% (P <0.001) concentrations increased after 5 wk of formation appears to be inversely influenced by previ- 1 egg/d compared with the phase prior to consuming ous vitamin A intake, the amount of material given and eggs, without elevating serum lipids and lipoprotein current vitamin A status. In spite of technical complex- cholesterol concentrations. ities, more SI studies where liver reserves of vitamin A are determined pre and post intervention are needed Xanthophylls in commercial egg yolks: quantifica- to evaluate the β-carotene bioefficacy of different tion and identification by HPLC and LC-(APCI)MS vegetable sources. using a C30 phase. Schlatterer J, Breithaupt DE. J Agric Food Chem 2006;54:2267–73. (Institute of Food Non-provitamin A carotenoids Chemistry, University of Hohenheim, Garbenstrasse 28, 70599 Stuttgart, Germany. 12-wk egg intervention increases serum zeaxanthin Email: [email protected]) and macular pigment optical density in women. The xanthophylls lutein and zeaxanthin may prevent Wenzel AJ, Gerweck C, Barbato D et al. J Nutr adult macular degeneration (AMD). Although egg yolks 2006;136:2568–73. (Clinical Laboratory and Nutri- serve as an important dietary source of lutein and zeax- tional Sciences, University of Massachusetts, Lowell, anthin, data on xanthophyll concentrations in commer- MA 01854, USA. Email: [email protected]) cial egg yolks are not available. Detailed knowledge Two carotenoids found in egg yolk, lutein and zeaxan- about the xanthophyll amounts in eggs is indispensable thin, accumulate in the macular retina where they may to calculate the human uptake. Egg yolks of four types reduce photo-stress. Adult females (eight per group) of husbandry (seven batches each) were examined. consumed six eggs/week for 12 wk of low or high- Lutein (1274–2478 µg/100g yolk) and zeaxanthin carotenoid containing eggs. Workers reported that (775–1288 µg/100g yolk) concentrations in ‘ecological’ serum zeaxanthin, but not serum lutein, increased in eggs (class 0) were greater than those found in eggs of both the EGG 1 (P=0.04) and EGG 2 (P=0.01) groups. all other classes (P <0.01). Mean concentrations of syn- Likewise, MPOD increased in both the EGG 1 thetic xanthophylls in eggs of classes 1 (free range), 2 (P=0.001) and EGG 2 (P=0.049) groups. Although the (barn), and 3 (cage) were as follows: canthaxanthin, 707 aggregate concentration of carotenoid in one egg yolk +/- 284 µg/100 g; β-apo-8'-carotenoic acid ethyl ester, may be modest relative to other sources, such as 639 +/- 391 µg/100 g; and citranaxanthin, 560 +/- 231 spinach, the increase in MPOD indicates their bioavail- µg/100 g. Experiments with boiled eggs proved that β- ability to the retina appears to be high. (Comment DIT: apo-8'-carotenoic acid ethyl ester was the xanthophyll It is interesting to note that both in this study and that of with the highest stability, whereas lutein was degraded Goodrow et al. (2006), the plasma response to the egg to the largest extent (loss of 19%). intervention is two to five times greater/mg/day than comparable studies with food sources or pure supple- Nutrition and the eye, a practical approach. Eperjesi ments.) F, Beatty, S, eds. Edinburgh: Elsevier, 2006. IBSN 0- 7506-8816-5. Consumption of one egg per day increases serum A soft-backed book aimed at “eye-care practitioners” lutein and zeaxanthin concentrations in older adults providing the fundamentals of a healthy diet and much without altering serum lipid and lipoprotein choles- information on the mainly unsuccessful nutritional stud- terol concentrations. Goodrow EF, Wilson TA, Houde ies done to delay onset as well as provide relief from SC et al. J Nutr 2006;136:2519–24. (Department of various eye diseases. Includes some useful descriptive Community Health and Sustainability, University of chapters on morphology and physiological functions of Massachusetts, Lowell, MA 01854, USA. Email: the eye, as well as pathological features of common eye [email protected]) disease in the elderly

51 SIGHT AND LIFE Letters to the editor

Letters to the editor

Dear Sir major prevalence of iron-deficien- Peruvian colleagues, the foodLET cy anemia in all age and gender distribution program was scaled-up A tribute to the micronutrient groups. Teaming with Dr Werner at one of the locations of the origi- animus of Dr Rainer Gross, Schultink and graduate students in nal IRIS study, Chiclayo, Peru, for 1945-2006 the SEAMEO-Tropmed Regional the weekly delivery to children Community Nutrition Program, he between the ages of 6 months to 4 As noted in the Obituary note by demonstrated the general equiva- years old. In addition, a multimi- Tim Ledwith on page 48 of SIGHT lency of impact on anemia recovery cronutrient formulation in capsule AND LIFE MAGAZINE 2006, and iron reserves with the either form, tailored to the needs of ado- issue 3, Dr Rainer Gross, the daily, semi-weekly, or even weekly lescent girls and adult women, was Director of the Nutrition Section at administration of oral iron, in a added to make this a major compo- the UNICEF headquarters in New series of seminal publications nent of the Regional Integrated York, passed away on September throughout the 1990s. Food Security Project. The results, 30, 2006, in his native Germany, findings, conclusions and lessons after a long illness. He was noted The theoretical concern that heavy learned from 4 years of initial for multiple contributions in the supplementation with one nutrient implementation, from 1998 field of public health nutrition, (iron) could induce an imbalanced through to 2001, have just been including leadership and innova- metabolism of other micronutrients published in the December, 2006 tion in research on micronutrients. led him to look for a format and a special Supplement of the Food and Dr Gross had received doctorates in measure of efficacy and effective- Nutrition Bulletin. both human nutrition (1974) and ness for an intermittent-day admin- agricultural plant sciences (1982) istration of a multivitamin supple- Rainer Gross’ assuming of the from the University of Giessen. ment preparation. A series of brain- leadership of the Nutrition Section Most of his professional career was storming and planning meetings in of UNICEF in April 2002, provid- spent within the German Agency of New York, Singapore, Rio de ed him with a more programmatic International Cooperation (GTZ), Janeiro, Cape Town and Lima forum, from which to implement where he implemented collabora- between 1998 and 2001, created the innovations based on his global tive, university-based community justification, conceptualization, experience and creative vision. His nutrition training programs in Rio design and field evaluation of the pursuit of these goals was curtailed de Janeiro, Brazil (1980s), Jakarta, "foodLET," multiple micronutri- all too soon, however, by his illness Indonesia (1990s) and Lima, Peru ents in a chewable or crushable, and untimely demise. The world of (2000s). sweet-tasting edible delivery sys- micronutrient intervention policy tem. It was something of a hybrid and program public health nutrition Perhaps not fully appreciated is the cross between a type of food and a owes a debt of gratitude for the degree to which Dr Gross was an tablet. The foodLET's ability to vision, energy and initiative that Dr innovator and pioneer in two correct nutrient deficiencies of iron Rainer Gross shared with us over important innovations in public and other micronutrients was tested three decades of inquiry and serv- health nutrition with respect to in a 4-nation multicentric field trial ice. micronutrients. These included: 1. with a common protocol in infants the efficacy and safety of intermit- and toddlers in Peru, South Africa, Noël W Solomons tent-day administration of iron sup- Vietnam and Indonesia, under the Guatemala City, Guatemala plements and other micronutrients; International Research on Infant and 2. the conceptualization and Supplementation (IRIS) trial Hector Cori exploration of the use of the financed by UNICEF. The multi- Santiago, Chile foodLET format of multiple micro- centric findings were presented in a nutrient supplements. While work- Supplement Issue of the Journal of Klaus Schümann ing in Jakarta, Indonesia, his own Nutrition in March, 2005. With the Munich, Germany group's studies demonstrated a leadership of Rainer and his

52 Letters to the editor Magazine Issue 1/2007

Dear Sir mon cause worldwide in young tional community. Through its spe- children at the time. Both editors cialist articles and busy correspon- A short history of the worked throughout without any dence columns the Bulletin played Xerophthalmia Club Bulletin remuneration, receiving only their a vital, and I must say greatly out-of-pocket expenses. In the missed, role for the thrashing out of The concept of a regular publica- early years these were paid by highly important and controversial tion dedicated to the cause of the Sight Savers (British Common- issues of the times. I know of noth- control of xerophthalmia was first wealth Society for the Blind) ing quite like it or since it; and brought to public attention at the whose director, Sir John Wilson, when there was a move to get rid of Jerusalem Seminar on Prevention was immensely influential in start- the word "club" by some who rea- of Blindness convened in Jeru- ing the Bulletin and remained sonably suggested it was nothing salem, Israel in August 1971. Dr strongly supportive throughout. like a real club, there was an outcry Antoinette (Tony) Pirie, director of Later on the costs, about £1,000 per from some leaders in the field who the Nuffield Laboratory of issue, were borne equally by Sight maintained that because of its Ophthalmology, Oxford, UK was Savers and IVACG (International informality it really was a kind of appointed editor. She served in this Vitamin A Consultative Group club. In these days of worldwide capacity for the first 31 issues until 1975-2006). From the start the web communication the concept of 1985. I took over with the 32nd "members" grew rapidly in num- a club would accommodate the issue and served until the Bulletin bers, soon reaching over 1,000 in Bulletin very comfortably. ceased with the 72nd issue in Tony's time and topping 3,000 December 1999. It was superseded towards the end. Now IVACG (and INACG) have by SIGHT AND LIFE Newsletter, gone and have been replaced by edited by Dr Martin Frigg until The Xero Bulletin usually came out The Micronutrient Forum. Old 2005 and by Dr Klaus Kraemer three times per year, with only the timers like me will await with inter- thereafter (the SIGHT AND LIFE occasional black and white table, est the unfoldings of the future. The Magazine in its new design also graph or photograph to keep objective has now become much incorporates the Xerophthalmia expenses to the minimum. Its eight more diffuse and complex, there is Club Bulletin; editor). I contributed pages were packed with all kinds of very little basic scientific knowl- a Literature Digest on vitamin A information about health and nutri- edge to go on, and one will search for each issue until the end of 2006 tion in developing countries with, in vain for a spirit like that which when I handed it over. of course, the overwhelming inspired the few enthusiasts of the emphasis on xerophthalmia. Dur- old days to enter what was a kind of Throughout, the Xero Club ing these years before the internet, vocation to preserve the sight and Bulletin, as it was known, was very information and travel to confer- life of millions. much an informal affair and one ences were rare and in this field, might say a "hobby horse" for the until IVACG came along, the Donald S McLaren editors and other enthusiasts in the Bulletin was the only regular Worthing, UK cause of controlling this terrible means of keeping together and form of blindness; the most com- helping the growth of the interna-

Dear Sir Demographic and Health Survey tive age by, for example, establish- 2000/2001, vitamin A deficiency ing ‘child days’ twice a year in all In Uganda, many children under occurs in three out of every 10 56 districts, in order to deliver a five years die from preventable dis- children and five out of every 10 package of preventive services eases and conditions such as ane- mothers. designed to improve child survival. mia, malaria, measles, diarrhea and These include: vitamin A supple- tetanus. It is currently known that The Ministry of Health has made mentation nutrition promotion and five out of every 10 deaths among tremendous efforts to improve the counseling, routine and catch-up under-fives have underlying mal- immunization coverage among immunization against measles for nutrition. According to the Uganda children and women of reproduc- children under 1 year of age and

53 SIGHT AND LIFE Letters to the editor

that multivitamin/mineral mixes are lacking and sourcing is very difficult. In addition I counsel mothers on infant feeding options (also in the context of HIV/AIDS). We also carry out community outreaches for school health education, screening for under- nourishment, micronutrient deficiencies and nutrition education. Immunization and vitamin A supplementation are carried out daily, when sufficient supplies are available.

Despite all the effort, a lot still Training in villages needs to be done. Nutritional education materials are difficult to obtain, as is transportation to and against tetanus for pregnant moth- tinely conducted at least once a from the community for referrals ers, and deworming are all carried week, as part of antenatal care; and follow-up consultations with out on these days. vitamin A is given to all malnour- my clients. ished children in-patients following Fort Portal Hospital, where I work, national guidelines; children and My thanks to SIGHT AND LIFE is a remote public hospital, located other patients at nutritional risk are for adding me to the mailing list for over 300 km from the Ugandan identified and therapy provided. your educational Magazine. capital, Kampala. I perform many Locally available cows’ milk is for- activities in child and maternal tified in the hospital; however I still Joab Tusaasire health but nutrition is my main face the challenge of inadequate Nutritionist chapter. Nutritional education ses- milk supplies due to the large num- Fort Portal Referral Hospital, sions for pregnant mothers are rou- bers of children, as well as the fact Uganda

Dear Sir of vitamin A supplementation and provide regular vaccination cam- reached 1170 children. paigns and mobile vaccination Over the past fiscal year (October units has increased. FH staff assist- 2005 to September 2006) Food for Food for the Hungry Mozambique ed with the vaccination campaign the Hungry (FH) Mozambique has works in coordination with the of 2006, providing vehicles, fuel, distributed vitamin A supplements Mozambique Ministry of Health, and trained personnel. provided by SIGHT AND LIFE to and FH staff administers vitamin A 12,587 children in the Sofala capsules only after verifying that Due to increasing vaccination cov- province. The majority of these the child has not received a dose of erage of the Ministry of Health, FH children received the supplements vitamin A within the last six month. foresees a day when regular vita- through our bi-annual supplemen- Dosages administered by FH staff min A campaigns will not be need- tation campaign. A smaller portion are recorded on child health cards ed. To date, vaccination campaigns received supplements after being provided by the Ministry of Health are not carried out with sufficient identified as moderately malnour- and the information becomes part regularity or coverage to eliminate ished and prior to entering our of the child’s permanent record. the need for FH’s supplementation community based nutritional reha- efforts. bilitation program. Total coverage with vitamin A capsules amounted to above 95%. Due to promotion of orange fleshed By September 2006 our newly Vitamin A coverage has been sweet potato and other vitamin A started Child Survival program increasing in the Sofala province as rich foods in the area like pumpkin, began identifying children in need the Ministry of Health’s capacity to green leaves, papaya, and mango

54 Letters to the editor Magazine Issue 1/2007

91% of children are receiving a months the consumption of vitamin up that targeted orphans and consistent supply of Vitamin A. It A rich foods drops. vulnerable children 1% of all is suspected that during the dry During our annual medical check- children reported night-blindness and 1% were given a diagnosis of cataracts, revealing a continued need for vitamin A supplementation and education regarding the consumption of vitamin A rich food.

Carolyn Wetzel Health Program Manager Food for the Hungry, Mozambique

Vitamin A capsules distribution campaign

Dear Sir

Please kindly receive my thanks for the books you sent to me. These will be important for the community work which I do as a nutritionist.

I’m currently screening for malnutrition and assessing nutritional status in the hospital as well as in the community. If necessary I give out foodstuffs as well as vitamins and minerals.

Education on healthy nutrition and practical work on how to grow vegetables in kitchen gardens or other available plots are both activities of vital importance. There are also projects on keeping small animals such as chickens or rabbits.

In cases of severe malnutrition assistance is provided directly and then followed up as necessary.

Please send any educational resources that would be of help to me. Jim Kamotho working in the maize field Many thanks, Jim

James Maing Kamotho Nutrition Officer Loitokitok Hospital Loitokitok, Kenya

55 SIGHT AND LIFE Publications

Publications

SIGHT AND LIFE presents recent publications which may be of particular interest to our readers. However, no publications other than SIGHT AND LIFE publications are available from us, nor do we have any priviledged access to them (editor).

The definitive summary of nutri- various purposes, such as designing two volumes. The first volume con- ent reference values for healthy nutrition education programs, tains detailed chapters on the nutri- people assessing and planning diets for ents and the second volume individuals and groups, establish- contains chapters on nutrition and ing standards for food assistance the life cycle, chronic disease, programs and nutrition labeling, issues of public health, and interna- developing new products for indus- tional nutrition. The new two try, and evaluating the adequacy of volume edition is tangible evidence food supplies in meeting national of the growing scope and challenge nutritional needs-applications that of nutrition as a field. Present require accurate, practical, up-to- Knowledge in Nutrition (PKN) has date information. been published continuously for over 50 years and has been used as More information on the DRIs are a key reference for instructing available from the Institute of nutritional professionals. The book Medicine of the US National continues to be a favored reference Academies www.iom.edu/CMS/ for nutritionists and is intended to 3788/29985/37065.asp be used as a constant companion on the professional bookshelf that is 9th Edition of Present often turned to first when questions Knowledge in Nutrition on nutrition arise.

Responding to the expansion of sci- The ninth edition of Present The authors of the chapters in entific knowledge about the roles Knowledge in Nutrition has recent- PKN9 were selected for their of nutrients in human health, the ly been pub- expert knowledge, experience, and Food and Nutrition Board of the lished by the ability to transmit knowledge Institute of Medicine developed a effectively. Each chapter set of nutrient reference values for presents fresh perspec- healthy people, termed Dietary tives as research has Reference Intakes (DRIs). These moved beyond simply replace and expand upon the old understanding the role of Recommended Dietary Allowances inadequate nutrient intakes (RDAs) in the United States and and deficiency to the role of the Recommended Nutrient Intakes nutrition and diet in chronic (RNIs) in Canada. disease prevention, including the consequences of overnutri- The DRIs are recognized by tion. Most chapters in PKN9 Americans and Canadians in the conclude with a discussion of food and health fields as the accept- future directions, including ed source on nutrient reference val- research needs, to challenge and ues for the maintenance of good International Life Science Institute, prepare the reader with interest in health. The DRIs may be used for and for the first time it comes in nutrition for developments coming

56 Publications Magazine Issue 1/2007

in the years ahead. For example, SIGHT AND LIFE usually pres- stroke and cancer: the leading caus- Volume II concludes with a section ents publications here in English or es of death in Europe and the on emerging issues in nutrition, other languages used in developing United States. Links also have been covering the following topics: countries. SIGHT AND LIFE has made between nutritional factors foodborne illness and food safety, supported the translation and print- and the risks of suffering from food biotechnology and bioengi- ing of many publications in region- obesity, diabetes, osteoporosis, neering, the human genome and al languages. The one you have cataracts, and dementia. The ways nutrition, dietary supplements and here was initially a publication in in which diet and disease are relat- functional foods. German, our own “regional” lan- ed are being totally redefined. We guage. It is a very interesting publi- are continuing to gain a better Historically, Present Knowledge in cation which may be of service to understanding of how nutrients Nutrition has had an incredibly many professionals and people work, both at the biochemical level diverse readership. And in turn, we preparing to work in developing and at the genomic level, and we editors were challenged by the countries. As we understand it, a are also becoming increasingly broad use of the book in the field. French version is in preparation more aware of the complex interac- Readership includes undergradu- and an English one may follow tions between food components ates, graduate students, and post- (editor). that until recently were not general- graduates in nutrition, public ly considered nutrients (e.g., fiber, health, medicine and related fields; Checklist on Nutrition carotenoids, flavonoids, etc.). dieticians, physicians and other health professions; and academic, It is imperative, therefore, that industrial and government re- practicing physicians and other searchers. Thus, the readers of health practitioners have a basic PKN9 will range from food scien- understanding of nutrition in order tists and technologists to regula- to communicate with their patients. tors, policy makers and members of Sound nutritional advice for the wider public. patients can only be given by health practitioners who have a working We hope PKN9 will become a stan- knowledge of nutrients and diets. dard text and an authoritative refer- This book should enable physicians ence work in classrooms, libraries, to provide well-grounded recom- laboratories, clinics, and offices mendations to their patients to help around the world. Speaking on them follow a healthy diet and to behalf of the editors (Barbara ensure adequate nutrient intakes Bowman and myself), we believe throughout their life. The book also we have achieved a highly read- covers nutrient toxicities, which is able, well-organized, comprehen- a growing problem in many seg- sive, and timely tome on contem- ments of the population. As we porary nutritional science. shall see, in the case of nutrients, simply acquiring more of them is Barbara E Bowman This new volume on nutrition com- not necessarily a good thing. Robert M Russel pliments the "Checklist Series" for Editors health practitioners. Nutritional sci- For more informatiom see ence has come of age, and this is www.thieme.de/detailseiten/ More information can be obtained truly an exciting time to be 9783131182623.html from International Life Sciences involved in the fields of nutrition Institute www.ilsi.org/ Publica- and health sciences. The general tions/Present+Knowledge+in+ public’s interest in nutrition is at its Nutrition/ highest level ever, since scientists have begun learning that nutrition has a major impact on the rate of the onset of degenerative diseases such as cardiovascular disease,

57 SIGHT AND LIFE Publications

Nutritional Anemia

Every year hunger and undernutrition claim more than 10 million lives – more than the deaths from AIDS, malaria and tuberculosis combined. Many of these people are affected by "hidden hunger", a lack of essential vitamins and minerals, known as micronutrient deficiencies, which do not necessarily result in the swollen bellies and stick-like limbs many associate with serious malnutrition. The control of nutritional anemia, as part of micronutrient deficiencies, is one of the global Development Goals to be achieved in the early years of this new millennium.

It is increasingly clear that effective control of anemia requires integrated solutions that are tailored to the particular needs and opportunities. Components of such approaches include food fortification, micronutrient supplementation of vulnerable groups (particularly children and women of childbearing age), education, dietary diversification, as well as control of diseases such as malaria, worm infections, and other chronic endemic infections. While each of these can help reduce the burden of anemia, none is capable of doing the job on its own.

The chapters of this book offer essential information to needs of program managers, details on programmatic achieve these goals. The topics include an overview approaches, as well as safety and technical aspects of of the global burden of anemia, the economic interventions. implications and functional consequences and the significance of these factors for policy makers, basic The book can be received from SIGHT AND LIFE, scientific informationon on iron metabolism, inter- www.sightandlife.org actions with macronutrients and micronutrients, the role of infections in fostering anemia, the information

WHO/FAO Guidelines on Food Fortification with Micronutrients Geneva, 2006

Interest in micronutrient malnutrition has increased greatly over the past few years. One of the main reasons for this has been the growing realization that micronutrient malnutrition contributes substantially to the global burden of disease. Furthermore, although micronutrient malnutrition is more frequent and severe in the developing world and among disadvan- taged populations, it also represents a public health problem in some industrialized countries. Measures to correct micronutrient deficiencies aim at ensuring consumption of a balanced diet that is adequate in every nutrient. Unfortunately, in many places this is far from being achieved since it requires universal access to adequate food and appropriate dietary habits. Food fortification has the dual advantage of being able to deliver nutrients to large segments of the population without requiring radical changes in food consumption patterns.

58 Publications Magazine Issue 1/2007

In order to assist countries in the They are primarily intended for to fortify foods, and reviews prior design and implementation of nutrition–related public health pro- experiences of their use in specific appropriate food fortification program managers, but should also be food vehicles. Part IV describes the grams, WHO and FAO took the ini- useful to all those working to con- key steps involved in designing, tiative to develop these guidelines trol micronutrient malnutrition, implementing, and sustaining forti- on food fortification. Drawing on including the food industry. fication programs. Starting with a several recent high quality publica- determination of the amount of tions and program experience on The document is organized into nutrients to be added to foods, this micronutrients, information on four complementary sections. Part I process continues with the imple- food fortification has been critical- introduces the concept of food for- mentation of monitoring and evalu- ly analysed and then translated into tification as a potential strategy for ating systems (including quality scientifically sound guidelines for the control of micronutrient malnu- control/quality assurance proce- application in the field. These trition. Part II summarizes the dures), followed by an estimation guidelines are intended to be a prevalence, causes, and conse- of cost-effectiveness and cost- resource for governments and quences of micronutrient deficien- benefit ratios. The importance of, agencies that are currently imple- cies, and the public health benefits and strategies for, regulation and menting or considering food fortifi- of micronutrient malnutrition con- international harmonization, com- cation, as well as a source of infor- trol. It lays the groundwork for munication, advocacy, consumer mation for scientists, technologists public health personnel to assess marketing and public education are and the food industry. The guide- the magnitude of the problem and also explained in some detail. lines are written from a nutrition the potential benefits of fortifica- and public health perspective to tion in their particular situation. Lindsay Allen, Bruno de Benoist, provide practical guidance on how Part III provides technical informa- Omar Dary, Richard Hurrell food fortification should be imple- tion on the various chemical forms Editors mented, monitored and evaluated. of micronutrients that can be used

Healthy Eyes Activity Book (HEAB), updated 2nd edition

Readers of SIGHT AND LIFE are probably well familiar with the HEAB, as it has featured on several occasions since its first appearance in the 4/2000 Newsletter. In the 2/2004 Newsletter, for example, the use of the HEAB in Tibet and China was presented, where the versions printed in local languages proved to be a unique and very effective tool for training and education. There have been numerous further examples of HEAB in use as well as SIGHT AND LIFE supporting many educational projects across the world using this book; with many grants being awarded for the translation and printing of the information into different languages, as is mentioned in the preface to the updated second edition, available now. Again, this second edition with adaptations made for a more international use, was made possible through the initiative and by resources from SIGHT AND LIFE.

A handy PDF file is featured on the SIGHT AND LIFE website. For copies please contact the ICEH ([email protected]) or SIGHT AND LIFE, www.sightandlife.org

59 SIGHT AND LIFE News

News

Building bridges to combat malnutrition

SIGHT AND LIFE presented the book Nutritional Anemia at BioVision 2007.

SIGHT AND LIFE, the humanitarian initiative of DSM – the leading manufacturer for nutritional ingredients – presented the book Nutritional Anemia at BioVision 2007. The book aims to help fight the dev- astating health burden of nutritional anemia throughout the world. The proud editors Michael B Zimmermann and Kul C Gautam (Deputy Executive Director, UNICEF), Klaus Kraemer (from left) Michael Stayton (Deputy Executive Director, United Nations World Food Programme) and Hugo Siblesz the developing world – with approximately one mil- (Dutch Ambassador to France) received the book from lion dying of anemia every year. Up to 200 million SIGHT AND LIFE at a special session on March 11, children are not reaching their full mental and physical 2007 at BioVision, the World Life Sciences Forum, in potential due to this and other forms of malnutrition. Lyon, France. The loss in gross domestic product is estimated to amount to USD 50 billion per year. Unfortunately, Editors Klaus Kraemer (SIGHT AND LIFE, Basel) there has been little documented progress in the global and Michael B Zimmermann (Swiss Federal Institute fight against this public health scourge over the last of Technology, Zurich) worked with leading scientists decades. from academia and international organizations in com- piling the latest research on nutritional anemia. The Klaus Kraemer explained: "With this book, which book will point the way forward in controlling this specifies for the first time all the critical factors of major global health problem. nutritional anemia, we want to make it clear that we recognize our responsibility and are determined to More than two billion people are affected by anemia point the way forward in combating this public health around the world – especially mothers and children in problem. What we still need to do is to build bridges between science and technology, and between service providers and political as well as economic deci- sion makers. The eradication of nutritional anemia will be a big step forward in reaching the United Nations Millennium Development Goals concerning the malnutrition, morbidity and mortality of children and mothers and will have major benefits for the social and economic development of the countries affected."

Michael Stayton, Kul C Gautam, Klaus Kraemer and Hugo Siblesz (from left) with the new Nutritional Anemia book

60 News Magazine Issue 1/2007

BioVision, the World Life Sciences Forum, in Lyon

Hunger, disease and environmental damage – these are the major problems affecting the world. And it was exactly these topics that were addressed at the 5th BioVision, the World Life Sciences Forum, which took place from March 11–14, 2007 in Lyon, France. Leading international experts from science, politics and industry came together with civil society representatives to discuss and agree on actions for change in health, nutrition and environmental issues.

This year’s event focused solely on the contribution of Life Sciences to the United Nations Millennium Development Goals. At the beginning of the millennium all members of the UN agreed on these goals, (to reduce hunger in the world’s population by half, for instance, or to reduce the mortality rate among children under five by two thirds and to reduce maternal mortality by three quarters by 2015). However, there Feike Sijbesma (President SIGHT AND LIFE, are still more than 850 million hungry people in the incoming CEO of DSM) with Michael Stayton world. Hunger is the number one threat to health in the (Deputy Executive Director, United Nations World world, with more than 10 million people dying each Food Programme) (from left) year of hunger-related causes – that is more than AIDS, malaria and tuberculosis combined. The partnership will focus on improving and increasing nutritious food for people in poor countries and The time for action is now. The primary goal of during humanitarian crises. DSM/SIGHT AND LIFE BioVision, the World Life Sciences Forum is to de- will provide WFP with expertise and high-nutrient velop concrete recommendations and proposals, lead- products as well as financial assistance. “We are ing to constructive action whenever possible. thrilled about the partnership with DSM,” sayed WFP Executive Director James Morris. “Every four sec- Global partnership with World Food Programme onds, a person dies of hunger and its related diseases. If we can ensure better nutrition for the millions of “The life science industry is able to make a major con- people we serve, then we are not only saving lives, but tribution to fighting global malnutrition and hunger,” also better ensuring healthy and productive futures.” stated Feike Sijbesma (President of SIGHT AND LIFE and incoming CEO of DSM) at a special session of the BioVision conference in Lyon. He announced a global humanitarian partnership with the United Nations World Food Programme (WFP), the largest provider of food aid to the world's hungry. “Solving malnutrition and hunger are critical to achieving the United Nations Millennium Development Goals, which aim to halve hunger and poverty by 2015. Companies, in the life sciences sector, amongst others, with their expertise and leadership can serve as a driving force to Food distribution by the United Nations World Food Programme tackle these problems.”

61 SIGHT AND LIFE News

tional agencies and non-governmental organizations can work together to decrease rates of nutritional anemia worldwide,” explains James T Morris, Executive Di- rector of the World Food Pro- gramme in his foreword, describing the book as key to reducing overall hunger and malnutrition rates.

“This book is an important contribution reminding us that in order to reduce anemia, we need to recognize that no single intervention will solve the problem, but that the solu- tion requires an integrated strategy Jeffrey Sachs (UN Millennium Project) speaking at BioVision Forum of complementary interventions,” said Kul C Gautam, Deputy Exe- cutive Director of UNICEF at the But even if people have enough problem, its economic and func- DSM – SIGHT AND LIFE special food to survive, this food can vary tional consequences, basic scientif- session at BioVision, in Lyon. in its nutritional value. This means ic information on iron metabolism, that even if there is sufficient the role of infections, detailed pro- And it was with exactly this in caloric intake, there could still be a grammatic approaches and an mind that SIGHT AND LIFE lack of certain key nutrients. This overview of the safety and techni- presented the first copies of the type of undernutrition is generally cal aspects of interventions. The book to Kul C Gautam (Deputy referred to as ‘hidden hunger’ – book Nutritional Anemia provides Executive Director, UNICEF), malnutrition resulting from vitamin an account of the information that Michael Stayton (Deputy Exe- and mineral deficiencies with the was presented and comprehensive- cutive Director, UN World Food known consequences of morbidity ly discussed at the workshop in Programme) and Hugo Siblesz and mortality. Barcelona. (Dutch Ambassador to France) who welcomed receiving this road map Workshop on nutritional anemia Building bridges to combat nutri- in the global fight against nutrition- tional anemia al anemia, hunger and malnutrition. In September 2006 SIGHT AND LIFE hosted a workshop with sci- This book also contains some good Nutritional Anemia shall be instru- entists from leading academic insti- news: the realization that anemia is mental in helping to reach the tutions and global organizations, not simply iron deficiency allows United Nations Millennium Goals including the WHO, UNICEF, us scope for it to be effectively concerning malnutrition and mor- FAO, World Bank, World Food reduced by building bridges tality. In the future DSM and Programme, International Nutrition between science and technology, SIGHT AND LIFE will continue to Foundation and the Micronutrient and between service providers and work closely with partners such as Initiative to develop solutions in political as well as economic deci- the World Food Programme and the fight against nutritional anemia. sion makers. UNICEF as well as other international organizations and play a vital The workshop included an update “This textbook also serves as a role in the global battle against on the magnitude of the anemia guide for how government, interna- nutritional anemia.

Outstanding Health Research Award

The Food Fortification Study Group of the Food and Nutrition Center of the Philippines has won the 2006 Outstanding Health Research Award (OHRA) in the health services research category. This award is presented by the Philippine Council for Health Research and Development, a section of the Philippine Department of

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Science and Technology, and the Health Policy Development and Planning Bureau of the Department of Health. The OHRA is awarded to an individual or study group which has been able to demonstrate the link between research and practice through the adoption or utilization of the research project in the health delivery system.

The picture was taken during the awarding ceremonies held last 29 September 2006.

Dr Solon also convey- ed thanks to SIGHT AND LIFE for its continuing support to his institution. The Food Fortification Study Group of the Food and Nutrition Center of the Philippines headed by Dr Florentino S Solon receiving the 2006 Outstanding Health Research Award presented during the 7th Health Research for Action National Forum held on 29 September 2006 at the Pan Pacific Manila Hotel

Healthy Eyes We are enormously glad that the authors Victoria Francis and Activity Book Baoteng Wiafe have agreed to con- (HEAB), updated tinue their work on this book. Like nd the first edition, this second edition 2 edition encourages users to adapt the book to their local setting. We also know Readers of SIGHT AND LIFE are now that the book has a much probably well familiar with the broader international appeal than HEAB, as it has featured on several initially expected, and the authors occasions since its first appearance have tried to reflect this accordingly in the 4/2000 Newsletter. In the by making modest adjustments at 2/2004 Newsletter, for example, the ‘internationalizing’ it. Furthermore, use of the HEAB in Tibet and China this second edition expands on some was presented, where the versions areas that were not covered in great printed in local languages proved to detail in the first; there is a chapter be a unique and very effective tool devoted to nutrition and a chapter for training and education. There devoted to refractive errors. The have been numerous further exam- section on ‘How to adapt and trans- proof of a very successful partner- ples of HEAB in use as well as late this book’ has been expanded to ship and synergy between the SIGHT AND LIFE supporting promote the adaptation of the mate- International Centre for Eye Health many educational projects across rial still further, so that the stories and SIGHT AND LIFE. We hope the world using this book; with reflect the day-to-day reality of chil- that this second edition will also be many grants being awarded for the drens’ lives, and also gives details widely used and similarly translated translation and printing of the infor- of SIGHT AND LIFE’s experiences into many languages. mation into different languages, as in overseeing the translations of the is mentioned in the preface to the book. Children in Bangladesh and A handy PDF file is featured on the updated second edition, available the UK have both contributed addi- SIGHT AND LIFE website. For now. Again, this second edition tional drawings to the second edi- copies please contact the ICEH with adaptations made for a more tion. ([email protected]) or international use, was made possible SIGHT AND LIFE, through the initiative and by The wide use of the HEAB and the www.sightandlife.org resources from SIGHT AND LIFE. realization of this second edition are

63 Photo credits Cover page; page 61, bottom: Marcus Prior/WFP

Versandletter: Credit: Marcus Prior/WFP

Colophon

SIGHT AND LIFE Magazine Printer: Burger Druck, SIGHT AND LIFE Incorporating the Xerophthalmia Waldkirch Dr Klaus Kraemer Club Bulletin Graphic: graphic art studio, Secretary General Grenzach-Wyhlen PO Box 2116 Publisher: SIGHT AND LIFE 4002 Basel, Switzerland Editor: Klaus Kraemer Opinions, compilations and figures Phone: +41 61 688 7494 Editorial team: Anne-Catherine contained in the signed articles do Fax: +41 61 688 1910 Frey, Martin Frigg, Svenia Sayer- not necessarily represent the point Email: Ruehmann of view of SIGHT AND LIFE and [email protected] Translation and language: are solely the responsibility of the www.sightandlife.org transparent - translation & text authors. services, Berlin ISBN 3-906412-34-2