Effect of micronutrient supplement on health and nutritional status of schoolchildren: biochemical status

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    Dande Sreeramulu, Ph.D.b, Palla Suryanarayana, Ph.D.b, Punjal Ravinder, Ph.D.a,







    2006) S

    089doiVeena Shatrugna, M.D.c, Prattipati Ajey Kumar, M.Sc.c, Manchala Raghunath, Ph.D.b,araganti Vikas Rao, M.Sc.a, Nagalla Balakrishna, Ph.D.d, Putcha Uday Kumar, M.D.e, and

    Namala Raghuramulu, Ph.D.ba Division of Biophysics, National Institute of Nutrition (Indian Council of Medical Research), Hyderabad, India

    b Division of Endocrinology and Metabolism, National Institute of Nutrition (Indian Council of Medical Research), Hyderabad, Indiac Division of Maternal and Child Health, National Institute of Nutrition (Indian Council of Medical Research), Hyderabad, India

    d Division of Field Studies, National Institute of Nutrition (Indian Council of Medical Research), Hyderabad, Indiae Division of Pathology, National Institute of Nutrition (Indian Council of Medical Research), Hyderabad, India

    Manuscript received April 6, 2004; accepted July 23, 2005.

    stract Objective: We assessed the effect of a daily intake of a micronutrient-fortified beverage for 14 moon indicators of biochemical status of important micronutrients in schoolchildren.Methods: A double-blind, placebo-controlled, matched-pair, cluster, randomization study design wasused. Biochemical indicators of micronutrient status were evaluated at baseline and at the end of 14mo on a subsample in nine matched pairs. Prevalence (percentage) of subclinical deficiency, mean,and mean increments of each indicator were compared between supplemented and placebo groups.Results: Extent of inadequacy at baseline was more or less 100% for folic acid, 65% for vitaminsB2 and B6, and 55% for vitamins C and A. Prevalence of anemia among subjects was 55%, withinadequacy of vitamin B12 being 40% and that of vitamin D being 30%. No subject had inadequacyof iodine based on urinary iodine. Supplementation of a micronutrient-enriched beverage for 14 mosignificantly improved the status of many of the nutrients. The effect was significant with respect tovitamins A, B2, and B12, folic acid, vitamin D, parathyroid hormone, and thyroid-stimulatinghormone in children who received the supplement compared with those who received only placebo.Hemoglobin status improved only in children who had anemia in the supplemented group.Conclusions: Prevalence of multiple subclinical micronutrient deficiencies are high in middle-income Indian school children. Daily consumption of a micronutrient-enriched beverage hadpositive effects that were confined to those nutrients that were inadequate at baseline. 2006Elsevier Inc. All rights reserved.

    words: Micronutrients; Biochemical status; Nutritional supplementation; Children; Vitamins; Minerals; Subclinicaldeficiency


    Protein, energy, and micronutrient deficiencies affectysical work capacity, body fitness, and mental function

    [13]. In particular, deficiency of micronutrients such asiron, vitamin A, zinc, iodine, and B-complex vitamins havebeen shown to affect growth, maximal work capacity [3],mental function [2,3], visual acuity [4], and psychomotorfunction [5]. Supplementation of malnourished childrenwith iron and B-complex vitamins has been reported toimprove these functions [46]. Supplementation with min-This study was supported by M/S GlaxoSmithKline Consumer Health-

    e, Ltd., India.Effect of micronutrient supplementschoolchildren: b

    Battiprolu Sivakumar, Ph.D.a,*, Kr

    Nutrition 22 (era

    tal* Corresponding author. Tel.: 91-40-2701-8083.E-mail address: dirnin_hyd@yahoo.co.in (B. Sivakumar).

    9-9007/06/$ see front matter 2006 Elsevier Inc. All rights reserved.:10.1016/j.nut.2005.07.012health and nutritional status ofemical status

    apillai Madhavan Nair, Ph.D.a,

    15S25www.elsevier.com/locate/nutls and vitamins has been associated with improved men-function [7] and growth and development of children

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    S16 B. Sivakumar et al. / Nutrition 22 (2006) S15S2511]. It has been reported that the benefit of micronutrientplementation is optimal only when multiple micronutri-

    ts are provided [10,1214] and the effect is pronounced ifre is a basal micronutrient deficiency [1517].During the past 25 y, a large database has been accumu-ed on the diet and nutritional status of the rural populationdifferent states of India [18]. These surveys indicate thatdiets of the rural population are inadequate and deficientmost nutrients. However, there have been no studieswing the effect of micronutrient supplementation in chil-n with adequate dietary intake and no apparent clinical

    ficiency of macronutrients. It is worthwhile to examineh a situation because inadequate concentrations of mi-nutrients in the body may be responsible for suboptimalwth and development. To test this hypothesis, we carried

    t a double-blind, placebo-controlled, cluster, randomized,tched-pair study in residential schoolchildren and com-

    red their micronutrient status before and after supplemen-ion.

    aterials and methods

    The details of the study design, composition, and admin-ration of the micronutrient-enriched beverage and othertical issues related to the methodology of the study arevided in a separate report [19]. Briefly, we have adopted

    double-blind, placebo-controlled, matched-pair, cluster,domization design. The children were 6 to 18 y of age

    d in grades 1 to 10 from a middle-income residentialool near Hyderabad, India. Effect on biochemical statuss assessed in a randomly selected subsample of a mini-m of 4 to a maximum of 19 from each pair. There weree matched pairs available for biochemical status assess-nt at the end of 14 mo of supplementation.Various biochemical parameters such as hemoglobin,ritin, calcium, phosphorus, parathyroid hormone (PTH),nary iodine, triiodothyronine (T3), thyroid-stimulatingrmone (TSH), albumin, zinc, vitamins A, C, D, B1, B2,, and B12, and folic acid were measured at baseline ander 14 mo.Blood samples after an overnight fast or random urineples were used for estimation. Hemoglobin was esti-

    ted by the cyanmethemoglobin method [20]; plasma lev-of ferritin by enzyme-linked immunosorbent assay [21];

    amin A by high-performance liquid chromatography]; folic acid, vitamin B12 and PTH (Diagnostic Productsrporation, Los Angeles, CA, USA), and T3 (BRIT, Mum-i, India) by radioimmunoassay kits; TSH by immunora-metric assay (BRIT, Mumbai, India); vitamin C [23],nary iodine [24], and phosphorus by colorimetry [25];sma calcium [26] and zinc [27] by atomic absorptionctrometry; vitamin D by protein binding assay [28];um albumin by dye binding [29]; vitamins B1, B2, andby enzyme activation coefficient assays in erythrocyteate [30]; and urinary riboflavin (B2) concentration was smasured fluorometrically [31]. Because analysis of vitamincould not be performed immediately, the sample at base-e was smaller but was more than adequate for all otherrameters. For vitamin B6 the number was smaller atseline due to some technical problems.For convenience in comparison, different biochemicalicators were broadly categorized according to their func-nal association with an important nutrient:

    1. Measurements related to hemopoiesis (hemoglobin,ferritin, vitamin C, folic acid, vitamin B12, and vita-min A)

    2. Measurements related to bone health (calcium, phos-phorus, vitamin D, PTH, zinc, and albumin)

    3. Measurements related to iodine status (T3, TSH, andurinary iodine)

    4. Measurements related to status of psychomotor vita-mins (vitamins B1, B2, and B6)

    tistical analysis

    The percentage of inadequacy of micronutrient status atseline in these schoolchildren was computed from cutofflues derived from the literature [3236]. The effect ofplementation on indicators of micronutrient status was

    aluated in cohort samples from the differences betweenal and baseline values. Whenever baseline differencestween groups differed (vitamin D), these differences wererrected by a regression model before testing the finalans between the supplement and placebo groups. Anal-s was also done to test whether the supplement had anyect in improving hemoglobin in children who were ini-lly anemic by t test. SPSS 11.5 (SPSS, Inc., Chicago, IL,A) was used for computation and statistical analysis.



    Subclinical deficiency or the proportion of children withdequate micronutrient status is presented in Table 1. At

    seline, there were no significant differences in subclinicalficiency in any biochemical indicator between the supple-nted and placebo groups; except for vitamin D. All chil-n in both groups had inadequate red blood cell (RBC)ate status. More than 50% of children had anemia andre deficient in vitamin C at the beginning. About 40% ofildren had vitamin A and B12 inadequacies at baseline.The proportion of children who had poor calcium and PTHtus at baseline was low (7%) except for vitamin D, whichs high and values were significantly different between theplement (30.3%) and placebo (21.6%) groups. The propor-

    n with inadequacy of plasma zinc (30 mol/L) was very

    all and those with inadequate vitamin B2 and B6 were

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    S17B. Sivakumar et al. / Nutrition 22 (2006) S15S25despread because more than 6


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