The Assessment of Iron Status of Kenyan Preschool Children in Rural Western Kenya Open Access

Grant, Frederick Kobina Ebo (2011)

Permanent URL: https://etd.library.emory.edu/concern/etds/f7623c63w?locale=en
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Abstract

ABSTRACT
The Assessment of Iron Status of Kenyan Preschool Children in Rural Western Kenya
By
Frederick Kobina Ebo Grant
The assessment of the true burden of iron deficiency (ID) has been plagued by
influence of infection, especially in developing countries. Common and recurrent
infections, such as malaria and human immunodeficiency virus (HIV) infection may
impact the evaluation of iron status of the population. This makes ID monitoring in
these areas difficult, as inflammation influences hemoglobin (Hb), ferritin (SF), zinc
protoporphyrin (ZP), and to some extent soluble transferrin receptors (TfR). Further, in
the absence of a non-invasive or feasible gold standard, the stages of ID are best
characterized by use of multiple-indices. However, the choice of an appropriate single
iron biomarker to replace the multiple-criteria model (use of ≥3 tests of iron status) for
screening for ID at population level in resource poor and remote field settings
continues to be a critical need.
Diarrhea and respiratory illnesses are leading causes of death in children less than
5 years. Sprinkles have been shown to be effective against diarrhea and febrile
illnesses. However, issues surrounding the use of sprinkles in resource poor settings
include the need for daily supplementation.
Our study suggests that subclinical inflammation (indicated by C-reactive
protein/CRP and alpha-1-acid-glycoprotein/AGP) affects TfR, ZP and SF and not

correcting for such inflammation alters the measures of ID. In the absence of a gold

standard for iron status indicator the multiple-criteria model can be used to assess iron
deficiency, and that TfR was as accurate as the multiple-criteria model in assessing the
prevalence of ID in preschool children. Additionally, when multiple-
micronutrient powder, Sprinkles, is distributed under non-experimental conditions it helps reduce the incidence of both diarrhea and fever in
preschool children.
Studies aimed at assessing the iron status of children in resource poor, high
inflammation settings should include both CRP and AGP as inflammatory biomarkers to
accurately determine the true prevalence of ID. Also, Sprinkles distribution through an
integrated health promotion and income-generating program should be considered in an
effort to improve child health in resource poor, and high inflammation settings.

Table of Contents

CHAPTER 1 ...................................................................................................................................... 1
INTRODUCTION ............................................................................................................................... 1
CHAPTER 2 ...................................................................................................................................... 5
LITERATURE REVIEW ........................................................................................................................ 5
2.1. HEALTH AND NUTRITION CHALLENGES IN KENYA ............................................... 5
2.1.1. Basic Indicators of Kenya .............................................................................................. 5
2.1.2. Health and Nutrition Indicators in Nyanza Province, Kenya ......................................... 6
2.2. ANEMIA AND IRON DEFICIENCY ............................................................................ 8
2.2.1. Causes of anemia and iron deficiency ...................................................................... 9
2.2.2. Consequences of anemia and iron deficiency .......................................................... 9
2.2.3. Assessment of anemia and iron deficiency ............................................................ 10
2.2.4. Prevention and treatment of anemia and iron deficiency ....................................... 12
2.3. EFFECT OF INFLAMMATION ON IRON STATUS INDICATORS ............................. 13
2.4. EFFECT OF IRON AND ZINC SUPPLEMENTATION ON CHILDHOOD ILLNESS .. 15
CHAPTER 3 .................................................................................................................................... 18
EXPANDED METHODOLOGY .......................................................................................................... 18
3.1. STUDY METHODOLOGY ............................................................................................... 18
3.1.1. Study area and study population .................................................................................. 18
3.2. STUDY DESIGN AND DATA SOURCES ....................................................................... 19
3.3. SAMPLE SIZE CALCULATION AND SUBJECT SELECTION .................................... 21
3.3.1. Sample size calculation ................................................................................................ 21
3.3.2. Subject selection for quantitative data collection ......................................................... 21
3.4. OVERVIEW OF SPRINKLES DISTRIBUTION .............................................................. 24

3.5. LABORATORY DATA ANALYSES ............................................................................... 26
Blood collection: .................................................................................................................... 26
Hemoglobin concentration: .................................................................................................... 26
Malaria parasitemia: ............................................................................................................... 26
Zinc protoporphyrin: .............................................................................................................. 26
Plasma preparation: ................................................................................................................ 27
Ferritin, transferrin receptors, AGP, and CRP: ...................................................................... 27
Definition of iron deficiency and anemia: ............................................................................. 27
3.6. DATA COLLECTION AND MANAGEMENT ................................................................ 28
3.7. ANALYTICAL CONSIDERATIONS ............................................................................... 29
3.7.1. Design effects ............................................................................................................... 30
3.7.2. Two-stage, stratified cluster sampling design .............................................................. 30
3.7.3. Correlated data ............................................................................................................. 31
3.8. STATISTICAL ANALYSES ............................................................................................. 32
CHAPTER 4 .................................................................................................................................... 33
CORRECTING FOR THE INFLUENCE OF INFLAMMATION MODIFIES THE ESTIMATION OF IRON STATUS AMONG PRESCHOOL CHILDREN IN RURAL WESTERN KENYA .................................................................................................................. 33
ABSTRACT ........................................................................................................................... 35
INTRODUCTION ................................................................................................................. 37
SUBJECTS AND METHODS .............................................................................................. 39
RESULTS .............................................................................................................................. 44
DISCUSSION ........................................................................................................................ 46
REFERENCES ...................................................................................................................... 53
CHAPTER 5 .................................................................................................................................... 66
THE ASSESSMENT OF IRON DEFICIENCY IN KENYAN CHILDREN FROM CAPILLARY BLOOD .................................................. 66

ABSTRACT ........................................................................................................................... 68
INTRODUCTION ................................................................................................................. 70
SUBJECTS AND METHODS .............................................................................................. 72
RESULTS .............................................................................................................................. 77
DISCUSSION ........................................................................................................................ 79
REFERENCES ...................................................................................................................... 85
REFERENCES ...................................................................................................................... 85
CHAPTER 6 .................................................................................................................................. 104
SELLING SPRINKLES AS PART OF A HEALTH PRODUCTS PACKAGE MAY REDUCE DIARRHEA INCIDENCE BUT NOT RESPIRATORY ILLNESS IN PRESCHOOL CHILDREN IN WESTERN KENYA ..................................................................................... 104
ABSTRACT ......................................................................................................................... 106
INTRODUCTION ............................................................................................................... 108
SUBJECTS AND METHODS ............................................................................................ 110
DISCUSSION ...................................................................................................................... 119
REFERENCES .................................................................................................................... 125
CHAPTER 7 .................................................................................................................................. 137
SUMMARY AND CONCLUSIONS ...................................................................................... 137
7.1. KEY FINDINGS AND POTENTIAL SIGNIFICANCE ............................................. 137
7.2. LIMITATIONS AND STRENGTHS OF THE STUDY .............................................. 139
7.3. FUTURE RESEARCH ................................................................................................. 141
7.4. POLICY IMPLICATIONS ........................................................................................... 143
7.5. CONCLUSION ............................................................................................................. 143
LITERATURE CITED ............................................................................................................ 145

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