Development and Determinants of Iron Status and Anemia, and Relationship to Inflammation, in a Cohort of Bolivian Infants Open Access

Burke, Rachel Maria (2016)

Permanent URL:


Iron deficiency is the most common micronutrient deficiency worldwide, and has been associated with preterm birth and cognitive delays in children. However, measurement of iron status can be complicated: biomarkers must be measured in blood, and the effect of inflammation must be accounted for. These considerations underscore the importance of understanding status during early infancy, while adjusting for inflammation. The Nutrición, Inmunología, y Diarrea Infantil (NIDI) study followed 456 healthy mother-infant pairs over the first year of life, collecting several blood samples as well as clinical and sociodemographic data. The study took place in El Alto, Bolivia, where the population is primarily indigenous with low socioeconomic status. In the first aim of this dissertation, we estimated the effects of acute and chronic morbidities and pathogen exposure (represented by water, sanitation, and hygiene [WASH] resources) on the inflammatory biomarkers CRP and AGP over these infants' first year of life. Inflammation was more prevalent in older infants and significantly associated with recent illness. In the second aim, we calculated the prevalence of iron deficiency (ID), anemia, and iron deficiency anemia (IDA) at 3 time points, correcting for the effect of inflammation. Though infants were born with normal iron stores, ID was nearly universal in the cohort by 12 - 15 months. Inflammation correction affected prevalence estimates. In a third aim, we used multiple imputation to account for the uncertainty introduced into models by linear regression correction of ferritin. We found a minimal effect of random error on effect estimates. In the fourth aim, we assessed the effect of infant feeding practices on iron status at 6 - 8 months of age. Although the length of exclusive breastfeeding was significantly negatively associated with iron status, the evidence did not support changes to currently recommended practices of 6 months of exclusive breastfeeding. Taken together, these studies suggest that even healthy, breastfed infants in developing countries are highly vulnerable to early declines in iron status, implying a need for early interventions to improve maternal and infant iron status (e.g., delayed cord clamping, improved maternal nutrition). Further, the importance of measuring and accounting for inflammation is underscored.

Table of Contents

Introduction. 1

Chapter 1: Literature Review. 5

Chapter 2: Prevalence and Predictors of Inflammation. 48

Chapter 3: Prevalence of Iron Deficiency, Iron Deficiency Anemia, and Anemia. 89

Chapter 4: Impact of Random Error in Effect Estimates Using Inflammation-Corrected Iron Levels. 130

Chapter 5: Effect of Feeding Practices on Infant Iron Status at 6 - 8 Months of Age. 138

Chapter 6: Conclusions and Future Directions. 170

Appendix. 173

About this Dissertation

Rights statement
  • Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.
  • English
Research Field
Committee Chair / Thesis Advisor
Committee Members
Last modified

Primary PDF

Supplemental Files