AJCN Cancer Health Disparities Conference
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Purchase Article
Right arrow View Shopping Cart
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Christian, P.
Right arrow Articles by West, K. P
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Christian, P.
Right arrow Articles by West, K. P, Jr
Agricola
Right arrow Articles by Christian, P.
Right arrow Articles by West, K. P
American Journal of Clinical Nutrition, Vol. 83, No. 4, 788-794, April 2006
© 2006 American Society for Nutrition

ORIGINAL RESEARCH COMMUNICATION

Antenatal supplementation with micronutrients and biochemical indicators of status and subclinical infection in rural Nepal1,2,3

Parul Christian, Tianan Jiang, Subarna K Khatry, Steven C LeClerq, Sharada R Shrestha and Keith P West, Jr

1 From the Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (PC, TJ, SCL, and KPW), and the Society for Prevention of Blindness, Tripureswor, Kathmandu, Nepal (SKK and SRS)

2 Supported by the Micronutrients for Health Cooperative Agreement no. HRN-A-00-97-00015-00 and the Global Research Activity Cooperative Agreement no. GHS-A-00-03-00019-00 between the Johns Hopkins University and the Office of Health, Infectious Diseases and Nutrition, US Agency for International Development, Washington, DC; grants from the Bill and Melinda Gates Foundation, Seattle, WA; and the Sight and Life Research Institute, Baltimore, MD.

3 Address reprint requests to P Christian, 615 North Wolfe Street, Room W2041, Baltimore, MD 21205. E-mail: pchristi{at}jhsph.edu.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Previously we showed that women in rural Nepal experience multiple micronutrient deficiencies in early pregnancy.

Objective: This study examined the effects of daily antenatal micronutrient supplementation on changes in the biochemical status of several micronutrients during pregnancy.

Design: In Nepal, we conducted a randomized controlled trial in which 4 combinations of micronutrients (folic acid, folic acid + iron, folic acid + iron + zinc, and a multiple micronutrient supplement containing folic acid, iron, zinc, and 11 other nutrients) plus vitamin A, or vitamin A alone as a control, were given daily during pregnancy. In a subsample of subjects (n = 740), blood was collected both before supplementation and at {approx}32 wk of gestation.

Results: In the control group, serum concentrations of zinc, riboflavin, and vitamins B-12 and B-6 decreased, whereas those of copper and {alpha}-tocopherol increased, from the first to the third trimester. Concentrations of serum folate, 25-hydroxyvitamin D, and undercarboxylated prothrombin remained unchanged. Supplementation with folic acid alone or folic acid + iron decreased folate deficiency. However, the addition of zinc failed to increase serum folate, which suggests a negative inhibition; multiple micronutrient supplementation increased serum folate. Folic acid + iron + zinc failed to improve zinc status but reduced subclinical infection. Multiple micronutrient supplementation decreased the prevalence of serum riboflavin, vitamin B-6, vitamin B-12, folate, and vitamin D deficiencies but had no effect on infection.

Conclusions: In rural Nepal, antenatal supplementation with multiple micronutrients can ameliorate, to some extent, the burden of deficiency. The implications of such biochemical improvements in the absence of functional and health benefits remain unclear.

Key Words: Micronutrients • pregnancy • Nepal • infection • supplementation


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Although it is generally accepted that multiple micronutrient deficiencies during pregnancy are common in developing countries, few studies have examined the changes in serum concentrations of micronutrients over the course of a pregnancy or the effect of antenatal micronutrient supplementation on these concentrations. Pregnancy is a period of numerous physiologic and metabolic changes. Because micronutrients are involved in regulating these processes, it is plausible that micronutrient deficiencies could alter pregnancy outcomes (1-3).

There is growing interest in elucidating the effect of daily antenatal supplementation with multiple micronutrients on pregnancy and newborn outcomes in areas of the world where micronutrient deficiencies are common. We conducted a cluster-randomized, double-masked, controlled trial in rural Nepal in which we observed that an antenatal multiple micronutrient supplement failed to provide any additional benefit above that seen with folic acid and iron for an outcome such as birth weight (4). Furthermore, it failed to show an apparent reduction in infant mortality of {approx}20%, which was observed with folic acid and iron (5), providing little evidence for the use of such an intervention for enhancing pregnancy and infant outcomes in Nepal. Also, iron and hematologic status in our trial (6) and another one in Mexico (7) did not improve with multiple micronutrient supplementation beyond the improvement observed with iron and folic acid alone.

Previously, we also published data from our trial in Nepal, which showed that micronutrient deficiencies in early pregnancy are common and coexist in rural Nepal (8). The deficiencies are exacerbated due to increased metabolic demands as the pregnancy advances. Plasma concentrations of micronutrients can also be modified by the extent of plasma volume expansion, which complicates the interpretation of serum biochemical indicators in pregnancy. Some studies do show that supplementation with micronutrients enhance their circulating concentrations in pregnancy (9, 10).

In this article we compare changes in maternal micronutrient status from the first to the third trimester of pregnancy in the control group, relative to that observed with daily supplementation with 4 combinations of micronutrients that included a multiple micronutrient supplement. Serum indicators of B complex vitamins, copper, zinc, and vitamins D, E, and K are examined. Furthermore, we also present data on the effect of micronutrient supplementation on acute phase markers of subclinical infection during pregnancy. These data provide information regarding the success or failure of such a supplementation strategy for enhancing nutritional status and correcting micronutrient deficiencies during a critical life stage—one of the objectives for considering its implementation in the developing world. It also allows the exploration of nutrient-nutrient interactions that provide plausible pathways for understanding the mechanisms responsible for the lack of beneficial effects and even perhaps adverse effects previously noted (4, 5)


   SUBJECTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Study design and population
This study was carried out in the Southeastern plains District of Sarlahi in Nepal during 1999–2001. Details of the trial are described elsewhere (4, 5). Briefly, the study area consisted of 30 village development communities in the district that were divided into 426 small units, called sectors. Married women of reproductive age who were not already pregnant, menopausal, sterilized, or widowed were enumerated. They were visited every 5 wk, and the amenstrual women were administered a urine-based human chorionic gonadotropin test to identify new pregnancies. Consenting pregnant women were enrolled into a trial of antenatal and postnatal supplementation with alternative combinations of micronutrients to examine the effect on birth weight and infant survival and health. The pregnant women were randomly assigned to receive daily 400 µg folic acid, 60 mg folic acid + iron, 30 mg folic acid + iron + zinc, a multiple micronutrient supplement containing the foregoing nutrients plus 11 other micronutrients (10 µg vitamin D, 10 mg vitamin E, 1.6 mg thiamine, 1.8 mg riboflavin, 20 mg niacin, 2.2 mg vitamin B-6, 2.6 µg vitamin B-12, 100 mg vitamin C, 65 µg vitamin K, 2.0 mg Cu, and 100 mg Mg), or 1000 µg RE vitamin A and vitamin A alone as the control group. At baseline, an assessment of variables reflecting household socioeconomic level, literacy, occupation, previous pregnancy history, morbidity, diet, substance use, and strenuous work activities in the previous 7 d was made. Sector workers delivered supplements twice a week to enrolled pregnant women in their homes. Pregnancy outcome was monitored, and a day-of-birth assessment of the newborn and mother was carried out by trained teams of anthropometrists and interviewers.

In 25% of the sectors, a substudy involving blood collection was carried out to assess the effect of supplementation on the women’s micronutrient status. Venous blood was drawn at home by trained phlebotomists at baseline (before supplementation) and again in the third trimester (scheduled at 32 wk of gestation). Detailed methods of this substudy were described previously (6, 8). Blood was collected into 7-mL trace metal-free vacuum test tubes (Vacutainer; Becton Dickinson Company, Franklin Lakes, NJ), kept on ice, and brought to the project laboratory for centrifugation at 750 x g for 20 min to separate the serum. Aliquots of serum were stored in liquid nitrogen tanks in trace element-free cryotubes (Nalgene Company, Sybron International, New York, NY) and shipped to the Johns Hopkins Bloomberg School of Public Health in Baltimore, MD, where they were stored at –80 °C until analyzed.

Laboratory analyses
Serum was analyzed over the course of 2–2.5 y for 11 different biochemical indicators of micronutrient and infection status. Data on the effect of supplementation on iron-status indicators, including hemoglobin, serum ferritin, iron, and transferrin receptors, were published previously (6) and are not presented here.

Details of the analytic methods are provided elsewhere (8). Briefly, serum zinc and copper concentrations were analyzed by atomic absorption spectrometry (AAnalyst 600; Perkin-Elmer, Wellesley, MA). Serum folate was measured with a microbiological assay with the use of a chloramphenicol-resistant strain of Lactobacillus rhamnosus (NCIMB 10463) (11). Homocysteine was analyzed with a microtiter plate assay (Calbiotech Inc, Spring Valley, CA), which is similar to an enzyme immunoassay and uses a genetically engineered homocysteine binding protein as the capturing agent. Serum vitamin B-12 was determined with a microbiological assay that uses a colistin sulfate-resistant strain of Lactobacillus lactis (NCIMB 12519) (12, 13). Serum 25-hydroxyvitamin D [25(OH)D] was determined by immunoassay (Nichols Institute, San Juan Capistrano, CA). Serum retinol and {alpha}-tocopherol were determined simultaneously by reversed-phase HPLC (Beckman, System Gold, Columbia, MD) attached with an autosampler (717 Plus AS; Waters Corp, Milford, MA) by using a procedure described by Yamini et al (14) with modifications. Serum riboflavin concentrations were measured as a surrogate for vitamin B-2 with the use of reversed-phase HPLC (model 1100; Agilent Technologies, Foster City, CA) with a fluorescence detector (model FP-1520; Jasco Corp, Easton, MD). The serum concentration of pyridoxal 5-phosphate, the active form of vitamin B-6, was measured by using HPLC. Serum (100 µL) was deproteinized by the addition of perchloric acid. Precolumn derivatization was performed with potassium cyanide. The fluorescent cyanide derivatives were detected by fluorometry. Undercarboxylated prothrombin (proteins induced by vitamin K absence; PIVKA-II) were assessed with a commercial enzyme-linked immunoassay (ELISA) kit (Asserachrom PIVKA II; Diagnostica Stago, Parsippany, NJ).

Markers of inflammation that were examined included {alpha}1-acid glycoprotein (AGP) and C-reactive protein (CRP). CRP was measured by ELISA with a commercial kit from ADI (San Antonio, TX), and serum AGP was measured with a radial immunodiffusion assay with commercially available kits (Kent Laboratories, Bellingham, WA).

Statistical analysis
Statistical analyses were based on an intention-to-treat basis. The baseline biochemical status of pregnant women was compared across treatment groups. The mean relative difference (defined as the difference in the change in serum concentrations of various analytes from baseline to follow-up for each supplementation group compared with that in the control group) and 95% confidence limits (CLs) were estimated by using generalized estimating equations linear regression models with an identity link and exchangeable correlation to account for randomization of sectors rather than individuals to treatment groups (15). Each model was adjusted for the baseline concentration of the analyte of interest. We used published cutoff values for defining deficient concentrations of micronutrients. Prevalence ratios (and 95% CLs) for micronutrient deficiencies and subclinical infection, on the basis of a serum AGP concentration >1 g/L and a CRP concentration >5g/L in the third trimester, were estimated by using a generalized estimating equations binomial regression model with a log link and exchangeable correlation, with the control (vitamin A alone) group as the reference category (15). Data were analyzed by using SAS version 8.1 (SAS Institute Inc, Cary, NC).

Informed consent was obtained from all participants before enrollment in the study. The study received ethical approval by the Committee on Human Research of the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, and the Nepal Health Research Council, Kathmandu, Nepal.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Of 1361 pregnant women in the substudy area, 1165 (85.6%) agreed to have their blood drawn at baseline and 779 (59.2%) agreed to having their blood drawn during the third trimester (Figure 1Go). A total of 740 women contributed both a baseline and a follow-up blood sample. A smaller number of women had both baseline and follow-up blood samples collected because women were eligible to contribute blood at the follow-up visit even if they had not at baseline. The mean (±SD) gestational age at baseline and at follow-up was 10.2 ± 4.1 and 32.6 ± 3.9 wk, respectively. The high nonresponse at the third trimester was due to 1) women having gone to their parental home for delivery, 2) early pregnancy loss, 3) migration, and 4) refusal; the nonresponse rates did not differ significantly by treatment group (Figure 1Go).


Figure 1
View larger version (20K):
[in this window]
[in a new window]
  		FIGURE 1. Study participation and follow-up by supplementation group. R, randomization.

 
The baseline mean (±SD) concentrations of micronutrients and CRP and AGP did not differ by treatment group (Table 1Go). In control subjects, serum concentrations of water-soluble vitamins (including riboflavin and vitamins B-12 and B-6) decreased significantly by 32–48% from early to late gestation (data not shown). Serum concentrations of fat-soluble vitamin E ({alpha}-tocopherol) increased by 69%, but vitamins D and K (indicated by PIVKA-II) remained unchanged. Trace mineral concentrations did not exhibit a consistent pattern of change, serum zinc concentrations decreased, and serum copper concentrations increased.


View this table:
[in this window]
[in a new window]
  		TABLE 1 Serum concentrations of micronutrients and markers of subclinical infection at baseline by supplementation group1

 
Serum folate concentrations increased significantly, by {approx}25 nmol/L, in the groups receiving folic acid or folic acid + iron or the multiple micronutrient supplement (Table 2Go). The combination of folic acid + iron + zinc failed to increase serum folate as indicated by an increment of {approx}10 µmol/L with CLs that did not overlap those in the other folic acid groups or in the multiple micronutrient group. Change in serum homocysteine was not significantly different across supplementation groups. Zinc concentrations did not increase in response to supplementation with zinc in combination with folic acid and iron relative to the control, but did so with multiple micronutrient supplementation (0.5; 95% CL: 0.1, 0.99 µmol/L) (Table 2Go). Serum concentrations of most micronutrients included in the multiple micronutrient supplements increased in that group relative to the control but did not change in the other 3 supplementation groups. The exceptions were {alpha}-tocopherol and PIVKA-II, which remained unchanged with supplementation. There was a significant increase in the concentration of 25(OH)D in the women who received folic acid alone, which did not occur in response to folic acid given with zinc or iron (Table 2Go).


View this table:
[in this window]
[in a new window]
  		TABLE 2 Change in serum concentrations of micronutrients and markers of subclinical infection from the first (baseline) to the third trimester and differences between the supplementation groups and the control subjects1

 
Folate deficiency decreased by 75–86% in the 4 groups who received folic acid (Table 3Go). This effect was not accompanied by a reduction in the prevalence of high homocysteine concentrations. Zinc deficiency, defined as a serum zinc concentration <7.6µmol/L, did not decrease with the folic acid + iron + zinc or the multiple micronutrient supplement, which contained zinc. Deficiencies of vitamins B-12, B-6, riboflavin, and 25(OH)D were 35–77% lower in the multiple micronutrient group than in the control group. Relative to the control group, the prevalence of a PIVKA-II concentration >2.7 ng/mL was lower in the folic acid + iron + zinc group, but not in the multiple micronutrient group, which received a supplement that provided an RDA of vitamin K.


View this table:
[in this window]
[in a new window]
  		TABLE 3 Prevalence ratios of deficiency and subclinical infection in the third trimester in the supplementation groups relative to the control group1

 
Serum AGP concentrations decreased in the control group (Table 2Go). Relative to this decrease, serum AGP decreased significantly more in response to folic acid alone or folic acid with zinc with or without iron (P < 0.05). Supplementation with multiple micronutrients failed to influence serum AGP concentrations relative to the control supplement. Unlike AGP, CRP increased during pregnancy in all groups, and the decrement relative to the control group was statistically significant only in the folic acid + iron + zinc group (0.57 g/L; P < 0.05), although the trend was evident with the other 2 groups who received folic acid. The frequencies of third-trimester concentrations of AGP and CRP above the thresholds considered to reflect infection (>1 and >5 g/L, respectively) were lower in the folic acid + iron + zinc group than in the control group, but the 95% CL for AGP did not exclude 1.0 (Table 3Go). Supplementation with multiple micronutrients failed to affect either of these indexes of infection.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Our community-based study provides data on changes occurring in circulating concentrations of vitamins and minerals and the biological response to daily supplementation with 4 different combinations of micronutrients among rural pregnant Nepali women living with chronic dietary deficits. The trial that generated these data showed no benefit of a multiple micronutrient supplement over folic acid + iron in improving birth weight (4) and perhaps even an adverse effect on infant survival (5). Thus, the biochemical data need to be interpreted in light of these previous findings.

Change in micronutrient status during pregnancy
In the present study, concentrations of most water-soluble vitamins decreased by 20–50% from early to late gestation, a finding that has also been recorded in healthy populations (24). Concentration of homocysteine did not decrease, unlike the decreases that have been described due to pregnancy-related endocrinologic changes (25). Fat-soluble vitamins E and K transported by plasma lipoproteins are known to increase during pregnancy, parallel to the increases in serum concentrations of lipids and triacylglycerols (24, 26). An increase in vitamin D, acting as a calciotropic hormone, is crucial for meeting the increased need for calcium during pregnancy (27-29). In our study, unlike vitamin E, concentrations of vitamins D and K did not increase during pregnancy. With regard to the 2 minerals, their change was expectedly in the opposite direction; serum zinc concentrations decreased in contrast with significant increases in copper, as shown before (30).

Effects of supplementation on status
Improvements in maternal biochemical status during pregnancy associated with micronutrient supplementation may primarily be due to correction of underlying deficiency. Another mechanism may be related to the effect on subclinical infection known to lower circulating concentrations of micronutrients caused by an acute phase response. A lack of response in a measured indicator may, perhaps, be masked by the plasma volume expansion of pregnancy that may in turn have been influenced by micronutrient status (3), or changes in endocrine regulations of pregnancy may facilitate channeling of nutrients to the fetus without altering maternal status. Other reasons for a nonresponse could be related to an inadequate dose or an inhibitory effect of one or more nutrients when provided simultaneously.

Folic acid singly or in combination with iron resulted in an increase in serum folate concentrations. A significant attenuation of this effect was apparent in combination with zinc, which points to a negative interaction between zinc and folate. Old in vitro and in vivo studies have shown that a mutual inhibition exists at the site of intestinal transport (31, 32). Folic acid supplements have shown to increase zinc excretion in men with mild zinc deficiency (33), although one study of short term folic acid supplementation found no adverse effects on zinc status (34). The same study also showed that folic acid utilization was not influenced by zinc intake (34), which is contrary to our study findings. We found no published evidence that zinc supplementation per se (alone or in combination with folic acid or iron) affects folate metabolism. In the present study, however, multiple micronutrients, which also contained zinc, completely reversed the negative effect of zinc on serum folate, although which one or more micronutrients in this mixture could have alleviated this inhibition remains unclear.

Multiple micronutrients succeeded in enhancing the status of B vitamins as indicated by their circulating concentrations. With the exception of folate, this has not been demonstrated to our knowledge for other vitamins in pregnancy. Daily supplementation with the Recommended Dietary Allowance (RDA) of these vitamins, however, was insufficient to lower deficiency for some by much. For example, the prevalence of vitamin B-6 and B-12 deficiencies was reduced by only 30–35% in late gestation. Homocysteine did not decrease with folic acid or in combination with vitamins B-6 and B-12 supplementation. Unlike these findings, changes in homocysteine were previously noted with folic acid supplementation and fortification in the United States and other countries (35-37), although deficiencies of both vitamin B-12 and vitamin B-6 may also affect homocysteine concentrations (38, 39). Persisting deficiencies of these vitamins, despite supplementation, may provide an explanation for the lack of effect on homocysteine in our study.

Concentrations of 25(OH)D increased in the group that received an RDA of vitamin D. This increase was also observed with folic acid supplementation alone. We found no previously described evidence linking folate status with either the synthesis of vitamin D in the skin, the synthesis of the vitamin D-binding protein, or the hydroxylation of vitamin D, which suggests that the mechanism remains to be elucidated.

Zinc concentrations were not responsive to supplementation, which has been shown before in pregnancy (40). It is likely that the bioavailability of zinc was compromised by the presence of iron and folic acid (33, 41, 42). Zinc, in combination with other micronutrients, did increase serum zinc concentrations by 0.5 µmol/L.

The combination of folic acid + iron + zinc reduced the risk of PIVKA-II > 2.7 ng/mL, which suggests that zinc promotes vitamin K status. Previously, an in vitro study showed that zinc sulfate caused a dose-dependent prolongation of prothrombin and partial thromboplastin times as well as shortened thrombin clotting time (43). A rat experiment of the effect of vitamin K2 (menaquinone-7) on bone metabolism showed an enhancement with zinc (44). In patients with alcoholic cirrhosis, zinc supplementation increased plasma prothrombin and serum alkaline phosphatase concentrations (45).

Copper supplementation did not change plasma concentrations of copper, which increased significantly during pregnancy. Previously, copper supplementation in pregnant ewes, mares, or cows resulted in increases in liver copper concentrations without altering plasma concentrations (46-48). Even long-term exposure to a high copper index in men showed no changes in plasma concentration of copper, although other indicators, such as urinary copper, ceruloplasmin activity, benzylamine oxidase, and superoxide dismutase, were significantly elevated (49). Our study showed no evidence of copper status being affected by zinc supplementation at 30 mg/d. Neither was there evidence that copper supplementation affects zinc status because serum zinc response was the highest in the multiple micronutrient group, who received 2 mg Cu. Recently, zinc supplementation was found not to affect plasma copper concentrations in infants (50) or extracellular superoxide dismutase activity in healthy pregnant women (51).

Effect of supplementation on subclinical infection
Micronutrient status, such as that of vitamin A or zinc, is known to modulate the immune system. We found that folic acid alone or in combination with iron, with or without zinc, decreased mean concentrations of AGP and in combination with iron and zinc decreased CRP during pregnancy. This suggests that folic acid and zinc may ameliorate the inflammatory process in pregnancy, which has implications for reproductive health outcomes. However, the multiple micronutrient supplements, which included the above nutrients, failed to show this reduction, which suggests an inhibitory interaction with the other nutrients present in the supplement.

Conclusion
In addition to dietary interventions, supplementation may be a reasonable approach for addressing the problem of micronutrient deficiencies in pregnancy. The data presented in our article support this conclusion, although several considerations are necessary before such an approach is adopted broadly. First, if the goal of such a strategy were just to alleviate deficiency (on the basis of known indicators of status), then the formulation tested in our study achieved this goal for some nutrients (folate, riboflavin, and vitamin D), but had only a modest effect on others (vitamins B-6 and B-12) and even failed to affect it for some (zinc, copper, and vitamin K). Second, both negative and positive nutrient-nutrient interactions may occur. Knowledge of these interactions is critical in creating combinations that will work best together and perhaps even synergize each other. Finally, the usefulness of biochemical indicators for assessing benefits of supplementation is limited. Instead, functional outcomes as true indicators of the effect are needed and should be assessed as endpoints in studies. Methods for the safe delivery of micronutrients to correct the high levels of deficiency that are clearly apparent among women in South Asia are urgently needed. Testing different combinations and doses of micronutrients and alternative delivery mechanisms (food fortification, sprinkles) on both short- and long-term health and functional outcomes in the mothers and their infants should receive priority.


   ACKNOWLEDGMENTS
 
Apart from the authors, several members of the Nepal study team helped in the successful implementation of the study and laboratory analysis, including the field managers, supervisors, and phlebotomy team. Tracey Wagner conducted the laboratory analyses, Joanne Katz was a co-investigator, Kerry Schulze performed the PIVKA-II analysis and provided comments on the paper, Elizabeth K Pradhan and Gwendolyn Clemens were responsible for computer programming and data management, and Lee Wu provided statistical support.

PC was the principal investigator and analyzed and wrote the paper. TJ was the laboratory director, oversaw all the biochemical analyses, and provided edits for the manuscript. SKK was country director and implemented the study. SCL participated in the procedure development, study design, and edits to the article. SRS supervised the field work and data collection. KPW assisted in the development of the research idea, study design, protocol, and manuscript preparation. None of the authors had a personal or financial interest to declare.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Allen LH. Multiple micronutrients in pregnancy and lactation: an overview. Am J Clin Nutr 2005;81(suppl):1206S–12S.
  2. Keen CL, Clegg MS, Hanna LA, et al. The plausibility of micronutrient deficiencies being a significant contributing factor to the occurrence of pregnancy complications. J Nutr 2003;133:1597S–605S.
  3. Neggers Y, Goldenberg RL. Some thoughts on body mass index, micronutrient intakes and pregnancy outcome. J Nutr 2003;133:1737S–40S.
  4. Christian P, Khatry SK, Katz J, et al. Effects of alternative maternal micronutrient supplements on low birth weight in rural Nepal. A double-masked randomized community trial. BMJ 2003;326:571–6.
  5. Christian P, West KP Jr, Khatry SK, et al. Effects of maternal micronutrient supplementation on fetal loss and infant mortality: a cluster-randomized trial in Nepal. Am J Clin Nutr 2003;78:1194–202.
  6. Christian P, Shrestha J, LeClerq SC, et al. Supplementation with micronutrients in addition to iron and folic acid does not further improve the hematologic status of pregnant women in rural Nepal. J Nutr 2003;133:3492–8.
  7. Ramakrishnan U, Neufeld LM, Gonzalez-Cossio T, et al. Multiple micronutrient supplements during pregnancy do not reduce anemia or improve iron status compared to iron-only supplements in Semirural Mexico. J Nutr 2004;134:898–903.
  8. Jiang T, Christian P, Khatry SK, Wu L, West KP Jr. Prevalence and seasonal variation of multiple micronutrient deficiencies among pregnant women in rural Nepal. J Nutr 2005;135:1106–12.
  9. Hininger I, Favier M, Arnaud J, et al. Effects of a combined micronutrient supplementation on maternal biological status and newborn anthropometric measurements: a randomized double-blind, placebo-controlled trial in apparently healthy pregnant women. Eur J Clin Nutr 2004;58:52–9.
  10. Latham MC, Ash DM, Makola D, Tatala SR, Ndossi GD, Mehansho H. Efficacy trials of a micronutrient dietary supplement in schoolchildren and pregnant women in Tanzania. Food Nutr Bull 2003;4:S120–8.
  11. Molloy AM, Scott JM. Microbiological assay for serum, plasma, and red cell folate using cryopreserved, microtiter plate method. Methods Enzymol 1997;281:43–53.
  12. Kellenher BP, O’Broin SD. Microbiological assay for vitamin B-12 in 96-well microtiter plates. J Clin Pathol 1991;44:592–5.
  13. Kellenher BP, Scott JM, O’Broin SD. Cryo-preservation of Lactobacillus leichmannii for vitamin B-12 microbiological assay. Med Lab Sci 1990;47:90–6.
  14. Yamini S, West KP Jr, Wu L, Dreyfuss ML, Yang D-X, Khatry SK. Circulating levels of retinol, tocopherol and carotenoid in Nepali pregnant and postpartum women following long term ß-carotene and vitamin A supplementation. Eur J Clin Nutr 2001;55:252–9.
  15. Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika 1986;73:13–22.
  16. Sauberlich HE. Laboratory tests for the assessment of nutritional status. 2nd ed. Boca Raton, FL: CRC Press, 1999.
  17. Bondevik GT, Schneede J, Refsum H, Lie RT, Ulstein M, Kvale G. Homocysteine and methylmalonic acid levels in pregnant Nepali women. Should cobalamin supplementation be considered? Eur J Clin Nutr 2001;55:856–64.
  18. Brussaard JH, Lowik MRH, van den Berg H, Brants HAM, Kistemaker C. Micronutrient status, with special reference to vitamin B6. Eur J Clin Nutr 1997;51:S32–8.
  19. Lopez-Anaya A, Mayersohn M. Quantification of riboflavin, riboflavin 5-phosphate and flavin adenine dinucleotide in plasma and urine by high-performance liquid chromatography. J Chromatogr 1987;423:105–13.
  20. Underwood BA, Vitamin A in human nutrition: public health considerations. In: Sporn MB, Roberts AB, Goodman DS, eds. The retinoids. New York, NY: Raven Press, 1994:211–27.
  21. Islam MZ, Lamberg-Allardt C, Karkkainen M, Outila T, Salamatullah Q, Shamim AA. Vitamin D deficiency: a concern in premenopausal Bangladeshi women of two socio-economic groups in rural and urban region. Eur J Clin Nutr 2002;56:51–6.
  22. Hotz C, Peerson JM, Brown KH. Suggested lower cutoffs of serum zinc concentrations for assessing zinc status: reanalysis of the second National Health and Nutrition Examination Survey data (1976–1980). Am J Clin Nutr 2003;78:756–64.
  23. Preziosi P, Galan P, Herbeth B. Effects of supplementation with a combination of antioxidant vitamins and trace elements, at nutritional doses, on biochemical indicators and markers of the antioxidant system in adult subjects. J Am Coll Nutr 1998;17:244–9.
  24. Worthington-Roberts BS, Williams RD. Nutrition in pregnancy and lactation. 6th ed. Boston, MA: WCB McGraw Hill, 1997.
  25. Murphy MM, Scott JM, McPartlin JM, Fernandez-Ballart JD. The pregnancy-related decrease in fasting plasma homocysteine is not explained by folic acid supplementation, hemodilution, or a decrease in albumin in a longitudinal study. Am J Clin Nutr 2002;76:614–9.
  26. Herrera E, Ortega H, Alvino G, Giovannini N, Amusquivar E, Cetin I. Relationship between plasma fatty acid profile and antioxidant vitamins during normal pregnancy. Eur J Clin Nutr 2004;58:1231–8.
  27. Oliveri B, Parisi MS, Zeni S, Mautalen C. Mineral and bone mass changes during pregnancy and lactation. Nutrition 2004;2:235–40.
  28. Kovacs C, Kronenberg HM. Maternal-fetal calcium and bone metabolism during pregnancy, puerperium and lactation. Endocr Rev 1997;18:832–72.
  29. Prentice A. Micronutrients and the bone mineral content of the mother, fetus and the newborn. J Nutr 2003;133:1693S–9S.
  30. Institute of Medicine. Nutrition during pregnancy. Washington, DC: National Academy Press, 1990.
  31. Gishan FK, Said HM, Wilson PC, Murrell JE, Green HL. Intestinal transport of zinc and folic acid: a mutual inhibitory effect. Am J Clin Nutr 1986;43:258–62.
  32. Tamura T. Nutrient interactions between folate and zinc or copper: their possible implications to pregnancy outcome. In: Massaro EJ, Rogers JM, eds. Folate and human development. Totowa, NJ: Humana Press Inc, 2002:219–40.
  33. Milne DB, Canfield WK, Mahalko JR, Sandstead HH. Effect of oral folic acid supplements on zinc, copper, and iron absorption and excretion. Am J Clin Nutr 1984;39:535–9.
  34. Kauwell GP, Bailey LB, Gregory JF III, Bowling DW, Cousins RJ. Zinc status is not adversely affected by folic acid supplementation and zinc intake does not impair folate utilization in human subjects. J Nutr 1995;125:66–72.
  35. Holmes VA, Wallace JM, Alexander HD, et al. Homocysteine is lower in the third trimester of pregnancy in women with enhanced folate status from continued folic acid supplementation. Clin Chem 2005;51:629–34.
  36. Rockel JE, Venn BJ, Skeaff CM, Green TJ. Folic acid fortified milk increases red blood cell folate concentration in women of childbearing age. Asia Pac J Clin Nutr 2004;13:S84.
  37. Ellison J, Clark P, Walker ID, Greer IA. Effect of supplementation with folic acid throughout pregnancy on plasma homocysteine concentration. Thrombosis Res 2004;114:25–7.
  38. Lewerin C, Nilsson-Ehle H, Matousek M, Lindstedt G, Steen B. Reduction of plasma homocysteine and serum methylmalonate concentrations in apparently healthy elderly subjects after treatment with folic acid, vitamin B12 and vitamin B6: a randomized trial. Eur J Clin Nutr 2003;57:1426–36.
  39. Strain JJ, Dowey J, Ward M, Pentieva K, McNulty H. B-vitamins, homocysteine metabolism and CV. Proc Nutr Soc 2004;63:597–603.
  40. Osendarp SJM, West CE, Black RE, Maternal Zinc Supplementation Study Group. The need for maternal zinc supplementation in developing countries: an unresolved issue. J Nutr 2003;133:817S–27S.
  41. Solomons NW, Jacob RA. Studies on the bioavailability of zinc in humans: effects of heme and nonheme iron on the absorption of zinc. Am J Clin Nutr 1981;34:475–82.
  42. O’Brien KO, Zavaleta N, Caulfield LE, Wen J, Abrams SA. Prenatal iron supplements impair zinc absorption in pregnant Peruvian women. J Nutr 2000;130:2251–5.
  43. Abou Shady EA, Farrag HE, el-Damarawy NA, Mohammed FA, Kamel AM, Massoud AA. In vitro effects of trace elements on blood clotting and platelet function. B–Zinc and magnesium. J Egypt Public Health Assoc 1991;66:49–72.
  44. Ehara Y, Takahashi H, Hanahisa Y, Yamaguchi M. Effect of vitamin K2 (menaquinone-7) on bone metabolism in the femoral-metaphyseal tissues of normal and skeletal-unloaded rats: enhancement with zinc. Res Exp Med (Berl) 1996;196:171–8.
  45. Weismann K, Christensen E, Dreyer V. Zinc supplementation in alcoholic cirrhosis. A double-blind clinical trial. Acta Med Scand 1979;205:361–6.
  46. Grace ND, Knowles SO, West DM, Lee J. Copper oxide needles administered during early pregnancy improves the copper status of ewes and their lambs. N Z Vet J 2004;52:189–92.
  47. Pearce SG, Grace ND, Wichtel JJ, Firth EC, Fennessy PF. Effect of copper supplementation on copper status of pregnant mares and foals. Equine Vet J 1998;30:200–3.
  48. Ahola JK, Baker DS, Burns PD, et al. Effect of copper, zinc, and manganese supplementation and source on reproduction, mineral status, and performance in grazing beef cattle over a two-year period. J Anim Sci 2004;82:2375–83.
  49. Turnlund JR, Jacob RA, Keen CL. Long term high copper intake: effects of indexes of copper status, antioxidant status, and immune function in young men. Am J Clin Nutr 2004;79:1037–44.
  50. Sazawal S, Malik P, Jalla S, Krebs N, Bhan MK, Black RE. Zinc supplementation for four months does not affect plasma copper concentration in infants. Acta Paediatr 2004;93:599–602.
  51. Tamura T, Olin KL, Goldenberg RL, Johnston KE, Dubard MB, Keen CL. Plasma extracellular superoxide dismutase activity in healthy pregnant women is not influenced by zinc supplementation. Biol Trace Elem Res 2001;80:107–13.
Received for publication June 27, 2005. Accepted for publication December 15, 2005.




This article has been cited by other articles:


Home page
 Cancer Epidemiol. Biomarkers Prev.Home page
J. M. Faupel-Badger, C.-C. Hsieh, R. Troisi, P. Lagiou, and N. Potischman
Plasma Volume Expansion in Pregnancy: Implications for Biomarkers in Population Studies
Cancer Epidemiol. Biomarkers Prev., September 1, 2007; 16(9): 1720 - 1723.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Clin. Nutr.Home page
J. M Graham, M. J Haskell, P. Pandey, R. K Shrestha, K. H Brown, and L. H Allen
Supplementation with iron and riboflavin enhances dark adaptation response to vitamin A-fortified rice in iron-deficient, pregnant, nightblind Nepali women
Am. J. Clinical Nutrition, May 1, 2007; 85(5): 1375 - 1384.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Purchase Article
Right arrow View Shopping Cart
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Christian, P.
Right arrow Articles by West, K. P
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Christian, P.
Right arrow Articles by West, K. P, Jr
Agricola
Right arrow Articles by Christian, P.
Right arrow Articles by West, K. P

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS