Global and regional child mortality and burden of disease attributable to zinc deficiency Randomized efficacy trial of a micronutrient-fortified beverage in primary school children in Tanzania. Combined zinc and iron compared with iron supplementation of diets of 6- to 12-year old village schoolchildren in southern Iran. A multimicronutrient-fortified seasoning powder enhances the hemoglobin, zinc, and iodine status of primary school children in North East Thailand: a randomized controlled trial of efficacy. A multinutrient-fortified beverage enhances the nutritional status of children in Botswana. A micronutrient-fortified seasoning powder reduces morbidity and improves short-term cognitive function, but has no effect on anthropometric measures in primary school children in northeast Thailand: a randomized controlled trial. Effect of a 12-mo micronutrient intervention on learning and memory in well-nourished and marginally nourished school-aged children: 2 parallel, randomized, placebo-controlled studies in Australia and Indonesia. A micronutrient-fortified beverage prevents iron deficiency, reduces anemia and improves the hemoglobin concentration of pregnant Tanzanian women. Fortifying milk with ferrous gluconate and zinc oxide in a public nutrition program reduced the prevalence of anemia in toddlers. Effect of a zinc-fortified formula on immunocompetence and growth of malnourished infants. Growth of infants fed a zinc supplemented formula. A multiple-micronutrient-fortified beverage affects hemoglobin, iron, and vitamin A status and growth in adolescent girls in rural Bangladesh. Additional zinc delivered in a liquid supplement, but not in a fortified porridge, increased fat-free mass accrual among young Peruvian children with mild-to-moderate stunting. Na2EDTA enhances the absorption of iron and zinc from fortified rice flour in Sri Lankan children. Effects of separate delivery of zinc or zinc and vitamin A on hemoglobin response, growth, and diarrhea in young Peruvian children receiving iron therapy for anemia. Cofortification of iron-fortified flour with zinc sulfate, but not zinc oxide, decreases iron absorption in Indonesian children. Linear growth of low income preschool children receiving a zinc supplement. Zinc nutritional status of young middle-income children and effects of consuming zinc-fortified breakfast cereals. Home-fortification with iron and zinc sprinkles or iron sprinkles alone successfully treats anemia in infants and young children. Multiple micronutrient-fortified rice affects physical performance and plasma vitamin B-12 and homocysteine concentrations of Indian school children. Effect of Consuming Zinc-fortified Bread on Serum Zinc and Iron Status of Zinc-deficient Women: A Double Blind, Randomized Clinical Trial GRADE guidelines: 4. Rating the quality of evidence--study limitations (risk of bias). Longitudinal measurements of zinc absorption in Peruvian children consuming wheat products fortified with iron only or iron and 1 of 2 amounts of zinc. A trial of zinc supplementation in young rural Gambian children. Treatment for iron deficiency anaemia with a combined supplementation of iron, vitamin A and zinc in women of Dinajpur, Bangladesh Effects of vitamin A, vitamin A plus iron and multiple micronutrient-fortified seasoning powder on preschool children in a suburb of Chongqing, China. Effects of fortified milk on morbidity in young children in north India: community based, randomised, double masked placebo controlled trial Impact of micronutrient fortification of yoghurt on micronutrient status markers and growth – a randomized double blind controlled trial among school children in Bangladesh Micronutrient Fortified Milk Improves Iron Status, Anemia and Growth among Children 1–4 Years: A Double Masked, Randomized, Controlled Trial Plasma zinc concentration increases within 2 weeks in healthy Senegalese men given liquid supplemental zinc, but not zinc-fortified wheat bread. Effect of micronutrient supplementation on health and nutritional status of schoolchildren: growth and morbidity. The effect of zinc-supplemented bread consumption on school children with asymptomatic zinc deficiency. A multi-micronutrient beverage enhances the vitamin A and zinc status of Nigerian primary schoolchildren. Effect of Micronutrient-Fortified Milk on Zinc Intake and Plasma Concentration in Adolescent Girls Fortified juice drink improved iron and zinc status of schoolchildren. Multi-micronutrient-fortified biscuits decreased prevalence of anemia and improved micronutrient status and effectiveness of deworming in rural Vietnamese school children. Effectiveness of Fortified Flour for Enhancement of Vitamin and Mineral Intakes and Nutrition Status in Northwest Chinese Villages Magnitude of Zinc Deficiency amongst Under Five Children in India Community-level micronutrient fortification of school lunch meals improved vitamin A, folate, and iron status of schoolchildren in Himalayan villages of India.
Background / Objectives : Zinc is an essential micronutrient and deficiency can lead to an increased risk for infectious diseases and growth retardation among children under 5 years of age . We aim ed to estimate disease-specific and all-cause mortality attributable to zinc deficiency . Subject/ Methods : We estimated the prevalence of zinc deficiency in Latin America , Africa and Asia , where based on zinc availability in the diet and childhood stunting rates , zinc deficiency is widespread . The relative risks of death among zinc-deficient children for diarrhea , malaria and pneumonia were estimated from r and omized controlled trials . We used the comparative risk assessment methods to calculate deaths and burden of disease ( measured in disability-adjusted life years , DALYs ) from each of these three diseases attributable to zinc deficiency in these regions . Results : Zinc deficiency was responsible for 453 207 deaths ( 4.4 % of childhood deaths ) , and 1.2 % of the burden of disease ( 3.8 % among children between 6 months and 5 years ) in these three regions in 2004 . Of these deaths , 260 502 were in Africa , 182 546 in Asia and 10 159 in Latin America . Zinc deficiency accounted for 14.4 % of diarrhea deaths , 10.4 % of malaria deaths and 6.7 % of pneumonia deaths among children between 6 months and 5 years of age . Conclusions : Zinc deficiency contributes to substantial morbidity and mortality , especially from diarrhea .  Zinc supplementation provided as an adjunct treatment for diarrhea may be the best way to target children most at risk of deficiency BACKGROUND Dietary supplements providing physiologic amounts of several micronutrients simultaneously have not been thoroughly tested for combating micronutrient deficiencies . OBJECTIVE We determined whether a beverage fortified with 10 micronutrients at physiologic doses influenced the iron and vitamin A status and growth of rural children ( aged 6 - 11 y ) attending primary schools . DESIGN In this r and omized , double-blind , placebo-controlled efficacy trial , children were assigned to receive the fortified beverage or an unfortified beverage at school for 6 mo . RESULTS There were nonsignificant differences at baseline between children in the fortified and nonfortified groups in iron status , serum retinol , and anthropometry . At the 6-mo follow-up , among children with anemia ( hemoglobin < 110 g/L ) , there was a significantly larger increase in hemoglobin concentration in the fortified group than in the nonfortified group ( 9.2 and 0.2 g/L , respectively ) . Of those who were anemic at baseline , 69.4 % in the nonfortified group and 55.1 % in the fortified group remained anemic at follow-up ( RR : 0.79 ) , a cure rate of 21 % . The prevalence of children with low serum retinol concentrations ( < 200 microg/L ) dropped significantly from 21.4 % to 11.3 % in the fortified group compared with a nonsignificant change ( 20.6 % to 19.7 % ) in the nonfortified group . At follow-up , mean incremental changes in weight ( 1.79 compared with 1.24 kg ) , height ( 3.2 compared with 2.6 cm ) , and BMI ( 0.88 compared with 0.53 ) were significantly higher in the fortified group than in the nonfortified group . CONCLUSION The fortified beverage significantly improved hematologic and anthropometric measurements and significantly lowered the overall prevalence of anemia and vitamin A deficiency The effects of supplementation of the diets of 6- to 12-year-old children in a village near Shiraz in Iran with  zinc plus iron or iron alone , together with the indispensable amino acids in the form of egg white protein , vitamins , minerals , and corn oil have been evaluated . Initially 48 of 59 children had zinc concentrations  below the minimum found in well-nourished persons . Eight months of supplementation with zinc plus iron ( 20 mg daily of elemental zinc as carbonate and 20 mg ferrous iron as fumarate ) failed to stimulate growth or bone development or to bring about an increase in plasma zinc concentrations . However , supplementation with iron in the above amount was associated with an acceleration of growth in height and weight . The persistence of low concentrations of zinc in plasma and the failure of supplemental zinc to stimulate growth are attributed to the poor availability of both dietary and supplemental zinc result ing from sequestering action of fiber and phytate present in large amounts in the unleavened whole meal bread consumed by villagers . In addition , the results suggest that simultaneous administration of iron and zinc supplements may impair utilization of the metals Anemia and co-existing deficiencies of zinc , iron , iodine , and vitamin A occur among children in many developing countries including NE Thail and , probably contributing to impairments in growth , immune competence , and cognition . Sustainable strategies are urgently required to combat these deficiencies . We assessed the efficacy of a micronutrient-fortified seasoning powder served with a school lunch on reducing anemia and improving the micronutrient status of rural NE Thai children . Children ( n = 569 ) aged 5.5 - 13.4y from 10 schools were r and omly assigned to receive a seasoning powder either unfortified or fortified with zinc ( 5 mg ) , iron ( 5 mg ) , vitamin A ( 270 microg ) , and iodine ( 50 microg ) ( per serving ) and incorporated into a school lunch prepared central ly and delivered 5 d/wk for 31 wk . Teachers monitored school lunch consumption . Baseline and final micronutrient status , hemoglobinopathies , and infection or inflammation were assessed from blood and urine sample s. For the primary outcome , anemia ( based on hemoglobin ) , no intervention effect was apparent ( odds ratio : 1.02 95 % CI : 0.69 , 1.51 ) after adjustment for design strata . The odds of zinc ( based on serum zinc ) and urinary iodine deficiency in the fortified group were 0.63 ( 0.42 , 0.94 ) and 0.52 ( 0.38 , 0.71 ) times those in the unfortified group , respectively . Fortification had no effect on serum retinol ( 0.61 : 0.25,1.51 ) , ferritin ( 1.12 : 0.43 , 2.96 ) , or mean red cell volume ( 1.16 : 0.82 , 1.64 ) . Therefore , a micronutrient-fortified seasoning powder is a promising vehicle for improving zinc , iodine , and hemoglobin status , and its potential for incorporation into lunch programs in day care centers and schools in NE Thail and warrants investigation Due to their widespread acceptability , multinutrient-fortified foods and beverages may be useful in reducing micronutrient deficiencies , especially in developing countries . We studied the efficacy of a new fortified beverage in improving the nutritional status of children in Botswana . We screened 311 lower income urban school children , ages 6 - 11 y , in two primary schools near Gaborone . Children were given seven 240-mL servings weekly of either an experimental beverage ( EXP ) fortified with 12 micronutrients or an isoenergetic placebo drink ( CON ) for 8 wk . Weight , mid-upper arm circumference , hemoglobin , retinol , ferritin , vitamin B-12 , folate and riboflavin status were measured at baseline and at the end of the study . Plasma zinc and serum transferrin receptors also were measured at study end . A total of 145 children in the EXP group and 118 in the CON group completed the trial . Using multivariate analysis , the changes in mid-upper arm circumference , weight for age and total weight were significantly better in the EXP group than in the CON group ( P < 0.01 ) . Ferritin , riboflavin and folate status were significantly better in the EXP group than in the CON group at study end ( P < 0.01 ) , but serum vitamin B-12 was not . Zinc was significantly higher and transferrin receptors were significantly lower at the conclusion of the study in the EXP group than in the CON group ( P < 0.001 ) . Mean plasma retinol concentrations , which were low ( < 0.7 micro mol/L ) in both groups , did not change . We conclude that a micronutrient-fortified beverage may be beneficial as part of a comprehensive nutritional supplementation program in population s at risk for micronutrient deficiencies BACKGROUND Reductions in iodine and zinc deficiencies and improvements in hemoglobin were achieved from a micronutrient-fortified seasoning powder consumed in school lunches by children in northeast Thail and . OBJECTIVE The objective was to determine whether fortification with 4 micronutrients in a school lunch results in changes in children 's growth , morbidity , and cognitive function compared with no fortification . DESIGN In a r and omized controlled trial of 569 children aged 5.5 - 13.4 y from 10 schools , we compared the efficacy of a seasoning powder fortified with or without 5 mg Fe , 5 mg Zn , 50 mug I , and 270 mug vitamin A per serving consumed with a school lunch 5 d/wk . Here we report on results of the secondary functional outcomes . RESULTS The groups were comparable concerning compliance and loss to follow-up . The intervention had no statistically significant effect on anthropometric measures over 31 wk , but reduced the incidence of respiratory-related illnesses [ rate ratio ( RR ) : 0.83 ; 95 % CI : 0.73 , 0.94 ] , symptoms of runny nose ( RR : 0.80 ; 95 % CI : 0.70 , 0.92 ) , cough ( RR : 0.80 ; 95 % CI : 0.66 , 0.96 ) , and diarrhea ( RR : 0.38 ; 95 % CI : 0.16 , 0.90 ) . For the visual recall test , those in the fortified group recalled 0.5 more items ( 95 % CI : 0.1 , 0.9 ) than did the controls . There were no statistically significant differences between groups in the results of the digits forward and backward tests or in school grade s at the conclusion of the 2 semesters . CONCLUSION The beneficial effects on morbidity and visual recall over a short period , in addition to some biochemical improvements , highlight the potential of this micronutrient-fortified seasoning powder supplied in a school lunch . This trial was registered at clinical trials.gov as ACTRN12605000341628 BACKGROUND Little is known about the combined effect of micronutrients and essential fatty acids on cognitive function in school-aged children . OBJECTIVE We assessed the effect of micronutrients , long-chain n-3 fatty acids , or both on indicators of cognitive performance in well-nourished and marginally nourished school-aged children . DESIGN Two 2-by-2 factorial r and omized controlled double-blind trials were performed home-based in Adelaide , South Australia , and at 6 primary schools in Jakarta , Indonesia . A total of 396 children ( aged 6 - 10 y ) in Australia and 384 children in Indonesia were r and omly allocated to receive a drink with a micronutrient mix ( iron , zinc , folate , and vitamins A , B-6 , B-12 , and C ) , with docosahexanoic acid ( DHA , 88 mg/d ) and eicosapentaenoic acid ( EPA , 22 mg/d ) , or with both or placebo 6 d/wk for 12 mo .  Biochemical indicators were determined at baseline and 12 mo . Cognitive performance was measured at baseline , 6 mo , and 12 mo . RESULTS The micronutrient treatment significantly improved plasma micronutrient concentrations in Australian and Indonesian children . DHA+EPA treatment increased plasma DHA and total plasma n-3 fatty acids in both countries . The micronutrient treatment result ed in significant increases in scores on tests representing verbal learning and memory in Australia ( estimated effect size : 0.23 ; 95 % CI : 0.01 , 0.46 ) . A similar effect was observed among Indonesian girls ( estimated effect size : 0.32 ; 95 % CI : -0.01 , 0.64 ) . No effects were found on tests measuring general intelligence or attention . No effects of DHA+EPA on the factors of cognitive tests were observed . CONCLUSION In well-nourished school-aged children , fortification with multiple micronutrients can result in improvements in verbal learning and memory Maternal malnutrition continues to be a major contributor to adverse reproductive outcomes in developing countries , despite longst and ing efforts to fortify foods or to distribute medicinal supplements to pregnant women . The objective of this study was to test the effect of a micronutrient-fortified beverage containing 11 micronutrients ( iron , iodine , zinc , vitamin A , vitamin C , niacin , riboflavin , folate , vitamin B-12 , vitamin B-6 and vitamin E ) on the hemoglobin , iron and vitamin A status of pregnant women in Tanzania . A group of 259 pregnant women with gestational ages of 8 to 34 wk were enrolled in a r and omized double-blind controlled trial in which study women received 8 wk of supplementation .  Hemoglobin , ferritin and dried blood spot retinol were measured at baseline and at the end of the supplementation period . The supplement result ed in a 4.16 g/L increase in hemoglobin concentration and a 3 micro g/L increase in ferritin and reduced the risk of anemia and iron deficiency anemia by 51 and 56 % , respectively . The risk of iron deficiency was reduced by 70 % among those who had iron deficiency at baseline and by 92 % among those who had adequate stores . The micronutrient-fortified beverage may be a useful and convenient preventative measure , one that could help improve the nutritional status of women both before and during pregnancy and thereby help avoid some of the potential maternal and fetal consequences of micronutrient deficiencies We aim ed to assess the efficacy of whole cow 's milk fortified with ferrous gluconate and zinc oxide , along with ascorbic acid , in reducing the prevalence of anemia and improving iron  status of low income children 10 - 30 mo of age . Healthy children were r and omly assigned to drink 400 mL/d of cow 's whole milk , either fortified milk ( FM ) with 5.8 mg/400 mL of iron as ferrous gluconate , 5.28 mg/400 mL of zinc as zinc oxide , and 48 mg/400 mL of ascorbic acid , or nonfortified milk ( NFM ) with 0.2 mg iron/400 mL , 1.9 mg zinc/400 mL , and 6.8 mg ascorbic acid/400 mL. Hemoglobin , serum ferritin , soluble transferrin receptors ( TfR ) , and C-reactive protein concentrations were measured at baseline and 6 mo after intervention . The prevalence of anemia declined from 41.4 to 12.1 % ( P < 0.001 ) , or 29 percentage points , in the FM group ; there was no change in the NFM group . Hemoglobin ( coefficient = 0.22 , P < 0.01 ) was positively and TfR ( coefficient = -0.29 , P < 0.001 ) negatively associated with treatment , controlling for their respective baseline values , age , and gender . Treatment with FM was negatively associated with the likelihood of being anemic ( pseudo R(2 ) = 0.085 , P < 0.03 ) after 6 mo of intervention . Ferrous gluconate added to whole cow 's milk as a fortificant along with ascorbic acid is efficacious in reducing the prevalence of anemia and in improving iron status  of Mexican toddlers . The results of this study lead to broadening a subsidized FM distribution program to 4.2 million beneficiary children 1 - 11 y of age in Mexico This study attempted to define the possible contribution of zinc nutrition to immunocompetence and growth in severely malnourished infants . The effect of zinc supplementation was evaluated in marasmic infants during nutritional rehabilitation by using a controlled double-blind design in which 19 infants fed a zinc-fortified formula were compared with 20 infants fed the same non-supplemented formula .  Evaluation of immunocompetence , growth , and zinc , copper , and iron status was performed on admission and at 30 , 60 , and 105 d of nutritional rehabilitation . Although energy intake was similar in both groups , the zinc-supplemented infants had significantly higher linear growth gain , and their immune function improved as demonstrated by conversion of their delayed hypersensitivity skin reactions , enhanced lymphoproliferative response to PHA , and increased salivary IgA concentrations . Thus , the use of a zinc-fortified formula during nutritional rehabilitation can prevent the development of zinc deficiency and improve growth and immune function Some infant milk formulae have a lower zinc content than the original cow 's milk . Zinc is a nutrient necessary for growth and , in this double-blind controlled study , the effects of supplementing Similac with iron with 4 mg/liter of zinc were determined . By 6 months of age , mean growth increments for the supplemented male infants were 2.1 cm greater in length ( P less than 0.025 ) and 535 g greater in weight ( P less than 0.05 ) than for male controls . Growth increments for female test and control infants did not differ significantly . Plasma zinc levels were , at 3 months of age , significantly higher for both male and female supplemented infants . By 6 months , only the male supplemented infants maintained significantly higherplasma zinc levels ( P less than 0.025 ) . The addition of zinc was associated with a lower incidence of disturbed gastrointestinal function ( P less than 0.005 ) and not accompanied by any signs of toxicity Adolescent girls have high nutrient needs and are susceptible to micronutrient deficiencies . The objective of this study was to test the effect of a multiple-micronutrient-fortified beverage on  hemoglobin ( Hb ) concentrations , micronutrient status , and growth among adolescent girls in rural Bangladesh . A total of 1125 girls ( Hb > or = 70 g/L ) enrolled in a r and omized , double-blind , placebo-controlled trial and were allocated to either a fortified or nonfortified beverage of similar taste and appearance . The beverage was provided at schools 6 d/wk for 12 mo . Concentrations of Hb and serum ferritin ( sFt ) , retinol , zinc , and C-reactive protein were measured in venous blood sample s at baseline , 6 mo , and 12 mo . In addition , weight , height , and mid-upper arm circumference ( MUAC ) measurements were taken . The fortified beverage increased the Hb and sFt and retinol concentrations at 6 mo ( P < 0.01 ) . Adolescent girls in the nonfortified beverage group were more likely to suffer from anemia ( Hb < 120 g/L ) , iron deficiency ( sFt < 12 microg/L ) , and low serum retinol concentrations ( serum retinol < 0.70 micromol/L ) ( OR = 2.04 , 5.38 , and 5.47 , respectively ; P < 0.01 ) . The fortified beverage group had greater increases in weight , MUAC , and BMI over 6 mo ( P < 0.01 ) . Consuming the beverage for an additional 6 mo did not further improve the Hb concentration , but the sFt level continued to increase ( P = 0.01 ) . The use of multiple-micronutrient-fortified beverage can contribute to the reduction of anemia and improvement of micronutrient status and growth in adolescent girls in rural Bangladesh The exact mechanism whereby zinc influences growth is unknown , although it has been postulated that zinc may stimulate appetite and energy intake or enhance fat-free mass ( FFM ) accrual directly . We compared energy intake , reported appetite , and body composition of 6- to 8-mo-old Peruvian children with initial length-for-age Z-score ( LAZ ) < -0.5 SD who were r and omly assigned to receive daily for 6 mo : 1 )  3 mg/d zinc in a liquid supplement ; 2 )  3 mg/d zinc in a fortified porridge ; or 3 ) no extra zinc in either the supplement or porridge . There were no group-wise differences in changes in dietary energy intakes or body composition or in the prevalence of reported poor appetite . However , among children with an initial LAZ less than the median ( -1.1 SD ) , those who received zinc as a liquid supplement had a 0.41 kg greater increase in FFM than those who did not receive zinc ( P < 0.05 ) . We concluded that daily provision of 3 mg of supplemental zinc did not affect energy intake or reported appetite . Among children with initial mild-to-moderate stunting , those who received the zinc supplement had a greater increase in FFM than those who did not receive additional zinc . It is possible that the growth-restricted children were more likely to be zinc deficient and that FFM accrual may be an early growth response to supplemental zinc . Zinc supplements may be more efficacious than the same dose of zinc provided in fortified food ; therefore , further research is needed on the optimal level of zinc fortification that will result in improved health outcomes in population s with high rates of zinc deficiency Rice flour was proposed as a vehicle for iron and zinc fortification in Sri Lanka . Although widely consumed , rice flour has not been evaluated as a fortified food , and the absorption of minerals including iron and zinc from this flour is unknown . Determination of the bioavailability of these nutrients is a critical step before commencing a fortification program . We r and omly divided 53 Sri Lankan schoolchildren ages 6 - 10 y into 4 groups that consumed a local dish prepared with 25 g of fortified rice flour labeled with one of the following : 1 ) (58)FeSO(4 ) 2 ) (58)FeSO(4 ) + Na(2)EDTA 3 ) (58)FeSO(4 ) + (67)ZnO or , 4 ) (58)FeSO(4 ) + Na(2)EDTA + (67)ZnO. The levels of iron and zinc were 60 mg/kg ; the rice flour also contained folate at 2 mg/kg in each group . Na(2)EDTA was added at a Fe : Na(2)EDTA , 1:1 molar ratio . A total of 48 children completed the trial .  Absorption of (58)Fe from a meal was significantly greater ( P < 0.01 ) in the groups administered FeSO(4 ) + Na(2)EDTA ( 4.7 + /- 3.6 % ) than in those administered FeSO(4 ) without Na(2)EDTA ( 2.2 + /- 1.3 % ) . Fractional absorption of zinc was 13.5 + /- 6.0 % in the FeSO(4 ) + Na(2)EDTA group and 8.8 + /- 2.0 % in the FeSO(4 ) group ( P = 0.037 ) . Although zinc absorption was low , our results demonstrated a benefit in using Na(2)EDTA to improve both iron and zinc absorption . We conclude that the fortification of rice flour is feasible , although additional strategies such as dephytinization or an increase in the level of iron and zinc fortification should be considered to obtain a higher proportion of the daily requirement of total absorbed iron and zinc INTRODUCTION Anemia is the most prevalent nutritional deficiency in the world . Attempts to improve iron indexes are affected by deficiency of and interaction between other micronutrients . OBJECTIVE Our goal was to assess whether zinc added to iron treatment alone or with vitamin A improves iron indexes and affects diarrheal episodes . DESIGN This was a r and omized , placebo-controlled , double-blind trial conducted in Peru . Anemic children aged 6 - 35 mo were assigned to 3 treatment groups : ferrous sulfate ( FS ; n = 104 ) , ferrous sulfate and zinc sulfate ( FSZn ; n = 109 ) , and ferrous sulfate , zinc sulfate , and vitamin A ( FSZnA ; n = 110 ) . Vitamin A or its placebo was supplied only once ; iron and zinc were provided under supervision > /=1 h apart 6 d/wk for 18 wk . RESULTS The prevalence of anemia was 42.97 % . The increase in hemoglobin in the FS group ( 19.5 g/L ) was significantly less than that in the other 2 groups ( 24.0 and 23.8 g/L in the FSZn and FSZnA groups , respectively ) . The increase in serum ferritin in the FS group ( 24.5 mug/L ) was significantly less than that in the other 2 groups ( 33.0 and 30.8 mug/L in the FSZn and FSZnA groups , respectively ) . The median duration of diarrhea and the mean number of stools per day was significantly higher in the FS group than in other 2 groups ( P < 0.005 ) . CONCLUSION Adding zinc to iron treatment increases hemoglobin response , improves iron indexes , and has positive effects on diarrhea . No additional effect of vitamin A was found BACKGROUND Iron deficiency is a major nutritional concern in developing countries , and food fortification is a common strategy to treat it . In Indonesia  wheat flour is fortified with 60 mg Fe/kg , but because of increasing concerns about marginal zinc status in at-risk population s , consideration is being given to cofortifying flour with zinc . However , little is known about the effect of zinc fortification of flour on iron bioavailability or about the optimum form of zinc supplementation . OBJECTIVE We measured iron and zinc bioavailability from wheat-flour dumplings containing 25 g flour fortified with 60 mg Fe/kg , either alone or with 60 mg Zn/kg as zinc oxide or as zinc sulfate . DESIGN Ninety children aged 4 - 8 y were recruited and assigned r and omly to the 3 groups ; 86 completed the study .  Iron and zinc absorption were measured with established stable-isotope methods . RESULTS Iron absorption from the flour fortified with iron only was good ( 15.9 + /- 6.8 % ) , but when corrections were made for hemoglobin concentrations , it was significantly lower from the flour cofortified with zinc sulfate ( 11.5 + /- 4.9 % ; P < 0.05 ) but not from the flour cofortified with zinc oxide ( 14.0 + /- 8.9 % ) . Zinc absorption was not significantly different between the zinc oxide and zinc sulfate cofortified flours ( 24.1 + /- 8.2 % compared with 23.7 + /- 11.2 % ; P = 0.87 ) . CONCLUSIONS Iron and zinc appear to be highly bioavailable from foods made from fortified flour , but zinc sulfate cofortification may have a detrimental effect on iron absorption The effects of a zinc supplement on growth velocity were assessed in a double-blind , pair-matched controlled study in 40 children with low growth percentiles . Participants were low-income Spanish-American children , 2 to 6 yr of age with heights below the 10th percentile and nutritional or biochemical evidence of zinc deficiency . After 1 yr , the mean height velocity of the zinc-supplemented children was slightly , but significantly ( p less than 0.005 ) , greater than that of control children . This effect was primarily due to a greater height achievement of the zinc-supplemented boys . Increases in height-for-age z-scores were also significant for the supplemented males ( p less than 0.001 ) and for the combined sexes ( p less than 0.05 ) . This study indicates the existence of a growth-limiting syndrome of mild zinc deficiency in children The effects of consuming zinc-fortified ready-to-eat breakfast cereals were determined in a double-blind controlled study . The 96 healthy young children who participated ( mean age 58 months ) consumed either zinc-fortified cereal , providing 25 % United States Recommended Dietary Allowance per 1 ounce serving ( test children ) or nonzinc-fortified cereals ( controls ) for a 9-month period . The test children were calculated on average to receive an additional 2.57 mg of zinc per day from this fortification program . This increment increased their mean daily zinc intake to a level that approached the Recommended Dietary Allowance ( 10 mg ) of the National Academy of Sciences for children less than 10 years of age . By the end of the period , the test children ( combined sexes ) had a mean increment of plasma zinc that was 6.5 micrograms/dl greater than that of the control children ( P less than 0.02 ) . The test girls had a greater increment ( 28.5 micrograms/g ) in hair zinc content than controls girls ( P less than 0.05 ) . There were no significant differences in other biochemical parameters including plasma copper and serum cholesterol . No significant differences in food intake or growth velocity were associated with the consumption of the zinc-fortified cereal . Multiple sex and time related differences occurred in plasma , hair , urine , and parotid saliva zinc concentrations that were unrelated to the type of cereal consumed Although iron deficiency is the most common single-nutrient deficiency in infants and children , other deficiencies may develop concurrently , including zinc deficiency . In previous studies , we used home-fortification with " Sprinkles , " single-serve sachets containing microencapsulated ferrous fumarate added to weaning foods , to successfully treat anemia . This mode of micronutrient delivery is amenable to the delivery of other micronutrients . However , the relative efficacy of multiple micronutrient supplements for the treatment of anemia requires evaluation due to possible nutrient interactions . Thus , we evaluated the relative efficacy of Sprinkles formulated with iron and zinc in anemic infants , compared with Sprinkles formulated with iron alone . We studied 304 anemic infants ( mean age 10.3 + /- 2.5 mo ; hemoglobin 87.4 + /- 8.4 g/L ) in rural Ghana . A combined supplementation group ( FeZn ) received daily Sprinkles containing 80 mg iron and 10 mg zinc ; a comparison group ( Fe ) received Sprinkles ( 80 mg iron ) without zinc for 2 mo . The rate of recovery from anemia was higher in the Fe group compared with the FeZn group ( 74.8 vs. 62.9 % ; P = 0.048 ) . The plasma zinc concentration decreased significantly in both groups ( P < 0.05 ) . A significant decline in the height for age Z-score was observed in the FeZn group ( P = 0.0011 ) , but there was no change in the Fe group . These results suggest that in a controlled setting , home-fortification using micronutrient Sprinkles with iron , or iron and zinc , was very successful in treating anemia ; however , this intervention alone was insufficient to improve zinc status or promote catch-up growth in this stunted and wasted population Fortifying rice with multiple micronutrients could be a promising strategy for combat micronutrient deficiencies in developing countries . We determined the efficacy of extruded rice grains fortified with multiple micronutrients on the prevalence of anemia , micronutrient status , and  physical and cognitive performance  in 6- to 12-y-old , low-income school children in Bangalore , India . In a r and omized , double-blind , controlled trial , 258 children were assigned to 1 of 3 intervention groups to receive rice-based lunch meals fortified with multiple micronutrients with either low-iron ( 6.25 mg ) or high-iron ( 12.5 mg ) concentrations or identical meals with unfortified rice . The meals were provided 6 d/wk for 6 mo . Anthropometric , biochemical , physical performance , and cognitive assessment s were taken at baseline and endpoint . At baseline , study groups were comparable , with 61 % of the children being anemic . However , only < 10 % were deficient in iron , vitamin A , and zinc . After 6 mo , plasma vitamin B-12 and homocysteine concentrations ( both P < 0.001 ) as well as physical performance ( P < 0.05 ) significantly improved in the intervention arms . No between-group differences were observed in hemoglobin concentration , anemia , and deficiencies of other micronutrients or cognitive function after 6 mo , but paired analyses revealed a small reduction in anemia prevalence in children in the low-iron group . The fortified rice was efficacious in improving vitamin B-12 status and physical performance in Indian school children After iron deficiency , zinc deficiency is the major micronutrient deficiency in developing countries , and staple food fortification is an effective strategy to prevent and improve it among at-risk- population s. No action has been taken to reduce zinc deficiency via flour fortification so far in Iran , and little is known about the influence of zinc fortification of flour on serum zinc and the iron status , and also about the optimum and effective amount of zinc compound that is used in food fortification . The objective of this study is to evaluate the influence of consuming zinc-fortified breads on the zinc and iron status in the blood serum . In this study , three types of bread were prepared from non-fortified and fortified flours , with 50 and 100 ppm elemental zinc in the form of sulfate .  Eighty zinc-deficient women aged 19 to 49 years were r and omly assigned to three groups ; The volunteers received , daily , ( 1 ) a non-fortified bread , ( 2 ) a high-zinc bread , and ( 3 ) a low-zinc bread for one month .  Serum zinc and iron were measured by Atomic Absorption before and after the study . Results showed a significant increase in serum zinc and iron levels in all groups ( p < 0.001 ) except in the control ( p > 0.05 ) . Absorption of zinc and iron in the group that consumed high-zinc bread was significantly greater than that in the group that received low-zinc bread ( p < 0.01 ) . It was concluded that fortification of flour with 50–100 ppm zinc was an effective way to achieve adequate zinc intake and absorption in zinc-deficient people . It also appeared that consuming zinc-fortified bread improved iron absorption In the GRADE approach , r and omized trials start as high- quality evidence and observational studies as low- quality evidence , but both can be rated down if most of the relevant evidence comes from studies that suffer from a high risk of bias . Well-established limitations of r and omized trials include failure to conceal allocation , failure to blind , loss to follow-up , and failure to appropriately consider the intention-to-treat principle . More recently recognized limitations include stopping early for apparent benefit and selective reporting of outcomes according to the results . Key limitations of observational studies include use of inappropriate controls and failure to adequately adjust for prognostic imbalance . Risk of bias may vary across outcomes ( e.g. , loss to follow-up may be far less for all-cause mortality than for quality of life ) , a consideration that many systematic review s ignore . In deciding whether to rate down for risk of bias -- whether for r and omized trials or observational studies -- authors should not take an approach that averages across studies . Rather , for any individual outcome , when there are some studies with a high risk , and some with a low risk of bias , they should consider including only the studies with a lower risk of bias BACKGROUND Information is needed on the fractional absorption of zinc ( FAZ ) and absorbed zinc ( AZ ) during prolonged exposure to zinc-fortified foods . OBJECTIVE The objective was to measure FAZ and AZ from diets fortified with different amounts of zinc and to determine whether zinc absorption changes over approximately 7 wk . DESIGN Forty-one stunted , moderately anemic children received daily , at breakfast and lunch , 100 g wheat products fortified with 3 mg Fe ( ferrous sulfate ) and 0 ( group Zn-0 ) , 3 ( group Zn-3 ) , or 9 ( group Zn-9 ) mg Zn ( zinc sulfate ) per 100 g flour . FAZ was measured on days 2 - 3 and 51 - 52 ; meal-specific AZs were calculated as the product of FAZ and zinc intake . RESULTS For the breakfast and lunch meals combined , mean total zinc intakes were 2.14 , 4.72 , and 10.04 mg/d in groups Zn-0 , Zn-3 , and Zn-9 , respectively , during the initial absorption studies ; mean ( + /-SD ) FAZ values were 0.341 + /- 0.111 , 0.237 + /- 0.052 , and 0.133 + /- 0.041 , respectively , on days 2 - 3 ( P < 0.001 ) and did not change significantly on days 51 - 52 in the subset of 31 children studied twice . Mean initial AZ was positively related to zinc intake ( 0.71 + /- 0.18 , 1.11 + /- 0.21 , and 1.34 + /- 0.47 mg/d , respectively ; P < 0.001 ) ; final values did not differ significantly from the initial values . CONCLUSIONS AZ from meals containing zinc-fortified wheat products increases in young children relative to the level of fortification and changes only slightly during approximately 7-wk periods of consumption . Although consumption of zinc-fortified foods may reduce FAZ , zinc fortification at the levels studied positively affects total daily zinc absorption , even after nearly 2 mo of exposure to zinc-fortified diets The present study tested the hypothesis that inadequate Zn intake might be responsible for failure to thrive and impaired catch-up growth in young rural Gambian children , and that Zn supplements might be beneficial . Gambian children might be deprived of Zn because of its poor availability from their predominantly plant-based diet . Rural Gambian children ( 110 ; fifty boys , sixty girls ) aged between 0.57 and 2.30 years were divided into two matched groups , one to receive 70 mg Zn twice weekly for 1.25 years , and the other a placebo . Growth and mid-upper-arm circumference were measured at weekly intervals throughout the study and illnesses were monitored .  Capillary blood and urine sample s were collected at 0 , 2 and 8 weeks . Body weights and arm circumferences showed a linear increase , plus a seasonal effect ( rainy season faltering ) . For body weight there was no significant overall effect of the supplement . For arm circumference , a very small ( 2 % ) but significant ( P < 0.01 ) difference favoured the supplemented group . Plasma thymulin was much lower at the first clinic than at the second and third clinics , and in vitro Zn stimulation was greater at the first clinic . There was , however , no effect of Zn in vivo . Likewise , Zn did not significantly benefit T-cell numbers or ratios , secretory IgA in urine , circulating hormone levels or biochemical indices of Zn status . One index of intestinal permeability , i.e. lactulose : creatinine , was improved ( P < 0.02 ) by the supplement , but the lactulose : mannitol value was not ; this requires further investigation . Dietary Zn deficiency is , thus , unlikely to be of major overall importance for rural Gambian children 's ability to thrive , and blanket Zn supplementation is not justified . There may , however , be vulnerable sub-groups who would benefit from Zn supplements Objective : The study was set up to determine to what extent the addition of a supplement of vitamin A alone or in combination with zinc would improve st and ard iron treatment and correction of iron deficiency anaemia . Design : 216 non-pregnant anaemic women of 15–45 years of age with haemoglobin levels ≤100 g/l were r and omly assigned to three treatment groups . One group ( A ) received iron alone , a second group ( B ) received iron and vitamin A , and a third group ( C ) received iron , vitamin A and zinc . Every woman was given one iron capsule per day for 60 days as FeSO4 containing 60 mg of elemental iron . In addition , groups B and C received 200 000 IU of vitamin A , given as a supervised dose , on the first day of the treatment after collection of the blood sample . Group C received one zinc tablet per day for 60 days as zinc gluconate containing 15 mg of elemental zinc . Setting : The north-western part of Bangladesh in the urban slums of Dinajpur district between February and August 1995.Subjects : To select women with a haemoglobin level of ≤100 g/l , all the women of four r and omly selected municipal slums of the district in the targeted age group ( 328 ) were invited to take part in the study . Blood sample s were analysed for haemoglobin , serum iron , total iron binding capacity ( TIBC ) , ferritin , retinol and zinc . Results : Out of the 328 women screened , 254 ( 77.5 % ) had a haemoglobin level ≤100 g/l and 322 ( 98 % ) ≤120 g/l . The three treatment schedules significantly increased haemoglobin levels and improved iron parameters , except for serum iron in the group who received iron alone . The group who received iron , vitamin A and zinc responded best with an increase in haemoglobin of 17.9 g/l as compared to the group receiving iron alone ( 13.4 g/l ) . Iron and vitamin A treatment gave an intermediate response of 15.9 g/l . However , these differences are only statistically significant only for the group who received iron , vitamin A and zinc and only for the increase in haemoglobin , P=0.03 . Conclusion : The results are suggestive that the addition of vitamin A and zinc to the treatment for anaemia can increase haemoglobin levels more than with iron alone . Sponsorship : The present study was financed by grant FWO 1.5.092.96 and Nutrition Tiers Monde Preschool children in developing countries are likely to have multiple , concurrent micronutrient deficiencies . This study was design ed to evaluate the effectiveness of different combinations of nutritional fortified diet to improve the blood levels of iron , vitamin A and other essential micronutrients in the preschool population of Banan District of Chongqing , China . From December 2005 to June 2006 , a total of 226 2 - 6 y old preschool children were recruited from three nurseries in the area , and they were r and omly assigned to three different fortified diet groups for 6 mo . Group I was fortified with vitamin A ; groups II and III were fortified with vitamin A plus iron and vitamin A plus iron , thiamine , riboflavin , folic acid , niacinamide , zinc and calcium , respectively . Subjects ' weight and height were measured for assessing the children 's growth and development . Blood sample s were taken at the beginning and the end of the 6-mo study period for measuring serum levels of micronutrients . Group III with the multiple micronutrient fortified diet was the most effective to improve the serum level of retinol from [ media ( P25 , P75 ) : 1.06 ( 0.89 , 1.32 ) ] micromol/L to 1.29 ( 1.04 , 1.39 ) micromol/L ( p<0.05 ) and retinol binding protein from 17.0 ( 12.6 , 25.6 ) mg/L to 31.6 ( 24.4 , 44.0 ) mg/L ( p<0.05 ) and to mobilize the stored iron in the liver ( p<0.05 ) . In addition , the three groups ' hemoglobin levels were elevated from 117.0 ( 109.0 , 124.1 ) g/L , 114.0 ( 109.2 , 119.7 ) g/L and 115.0 ( 109.5 , 122.7 ) g/L to 125.7 ( 119.2 , 133.1 ) g/L , 126.5 ( 122.2 , 135.9 ) g/L and 125.1 ( 119.8 , 131.6 ) g/L over the 6 mo of intervention period , but there were no difference among the three groups ( p>0.05 ) . Nevertheless , unexpected results were obtained when comparing the effects on growth status among the different supplement groups . Our study has demonstrated that a multiple micronutrient fortified diet for 6 mo is more effective to improve the levels of hemoglobin , serum retinol , and RBP as well as to facilitate the mobilization of iron storage in preschool children Objective To evaluate the efficacy of milk fortified with specific multiple micronutrients on morbidity in children compared with the same milk without fortification . Design Community based , double masked , individually r and omised trial . Setting Peri-urban settlement in north India . Participants Children ( n=633 ) aged 1 - 3 r and omly allocated to receive fortified milk ( n=316 ) or control milk ( n=317 ) . Intervention One year of fortified milk providing additional 7.8 mg zinc , 9.6 mg iron , 4.2 � g selenium , 0.27 mg copper , 156 � g vitamin A , 40.2 mg vitamin C , 7.5 mg vitamin E per day ( three feeds ) . Main outcome measures Days with severe illnesses , incidence and prevalence of diarrhoea , and acute lower respiratory illness . Results Study groups were comparable at baseline ; compliance in the groups was similar . Mean number of episodes of diarrhoea per child was 4.46 ( SD 3.8 ) in the intervention ( fortified milk ) group and 5.36 ( SD 4.1 ) in the control group . Mean number of episodes of acute lower respiratory illness was 0.62 ( SD 1.1 ) and 0.83 ( SD 1.4 ) , respectively . The fortified milk reduced the odds for days with severe illnesses by 15 % ( 95 % confidence interval 5 % to 24 % ) , the incidence of diarrhoea by 18 % ( 7 % to 27 % ) , and the incidence of acute lower respiratory illness by 26 % ( 3 % to 43 % ) . Consistently greater beneficial effects were observed in children aged ≤24 months than in older children . Conclusion Milk is well accepted as a means of delivery of micronutrients . Consumption of milk fortified with specific micronutrients can significantly reduce the burden of common morbidities among preschool children , especially in the first two years of life . Trial registration NCT00255385 Background Interventions providing foods fortified with multiple micronutrients can be a cost-effective and sustainable strategy to improve micronutrient status and physical growth of school children . We evaluated the effect of micronutrient-fortified yoghurt on the biochemical status of important micronutrients ( iron , zinc , iodine , vitamin A ) as well as growth indicators among school children in Bogra district of Bangladesh . Methods In a double-masked r and omized controlled trial ( RCT ) conducted in 4 primary schools , 1010 children from classes 1–4 ( age 6–9 years ) were r and omly allocated to receive either micronutrient fortified yoghurt ( FY , n = 501 ) or non-fortified yoghurt ( NFY , n = 509 ) . For one year , children were fed with 60 g yoghurt everyday providing 30 % RDA for iron , zinc , iodine and vitamin A.  Anthropometric measurements and blood/urine sample s were collected at base- , mid- and end-line . All children ( FY , n = 278 , NFY , n = 293 ) consenting for the end-line blood sample were included in the present analyses . Results Both groups were comparable at baseline for socio-economic status variables , micronutrient status markers and anthropometry measures . Compliance was similar in both the groups . At baseline 53.4 % of the population was anemic ; 2.1 % was iron deficient ( ferritin < 15.0 μg/L and TfR > 8.3 mg/L ) . Children in the FY group showed improvement in Hb ( mean difference : 1.5 ; 95 % CI : 0.4 - 2.5 ; p = 0.006 ) as compared to NFY group . Retinol binding protein ( mean diff : 0.05 ; 95 % CI : 0.002 - 0.09 ; p = 0.04 ) and iodine levels ( mean difference : 39.87 ; 95 % CI : 20.39 - 59.35 ; p < 0.001 ) decreased between base and end-line but the decrease was significantly less in the FY group . Compared to NFY , the FY group had better height gain velocity ( mean diff : 0.32 ; 95 % CI : 0.05 - 0.60 ; p = 0.02 ) and height-for-age z-scores ( mean diff : 0.18 ; 95 % CI : 0.02 - 0.33 ; p = 0.03 ) . There was no difference in weight gain velocity , weight-for-age z-scores or Body Mass Index z-scores . Conclusion In the absence of iron deficiency at baseline the impact on iron status would not be expected to be observed and hence can not be evaluated . Improved Hb concentrations in the absence of a change in iron status suggest improved utilization of iron possibly due to vitamin A and zinc availability . Fortification improved height gain without affecting weight gain . Trial registration Clinical Trial.gov : Background Multiple micronutrient deficiencies are highly prevalent among preschool children and often lead to anemia and growth faltering . Given the limited success of supplementation and health education programs , fortification of foods could be a viable and sustainable option . We report results from a community based double-masked , r and omized trial among children 1–4 years evaluating the effects of micronutrients ( especially of zinc and iron ) delivered through fortified milk on growth , anemia and iron status markers as part of a four group study design , running two studies simultaneously . Methods and Findings Enrolled children ( n = 633 ) were r and omly allocated to receive either micronutrients fortified milk ( MN = 316 ) or control milk ( Co = 317 ) . Intervention of MN milk provided additional 7.8 mg zinc , 9.6 mg iron , 4.2 µg selenium , 0.27 mg copper , 156 µg vitamin A , 40.2 mg vitamin C , and 7.5 mg vitamin E per day ( three serves ) for one year . Anthropometry was recorded at baseline , mid- and end- study . Hematological parameters were estimated at baseline and end- study . Both groups were comparable at baseline . Compliance was over 85 % and did not vary between groups . Compared to children consuming Co milk , children consuming MN milk showed significant improvement in weight gain ( difference of mean : 0.21 kg/year ; 95 % confidence interval [ CI ] 0.12 to 0.31 , p<0.001 ) and height gain ( difference of mean : 0.51 cm/year ; 95 % CI 0.27 to 0.75 , p<0.001 ) . Mean hemoglobin ( Hb ) ( difference of 13.6 g/L ; 95 % CI 11.1 to 16.0 , p<0.001 ) and serum ferritin levels ( difference of 7.9 µg/L ; 95 % CI 5.4 to 10.5 , p<0.001 ) also improved . Children in MN group had 88 % ( odds ratio = 0.12 , 95 % CI 0.08 to 0.20 , p<0.001 ) lower risk of iron deficiency anemia . Conclusions / Significance Milk provides an acceptable and effective vehicle for delivery of specific micronutrients , especially zinc and iron . Micronutrient bundle improved growth and iron status and reduced anemia in children 1–4 years old . Trial Registration Clinical Trials.gov The responsiveness of plasma zinc concentration to zinc fortification is uncertain . Our objective in this study was to determine whether plasma zinc concentration changes in response to consuming zinc-fortified foods or liquid zinc supplements . We conducted a 4-wk double-blind , r and omized trial among 132 healthy Senegalese men ≥ 18 y. Participants received 1 of 4 interventions : 1 ) ( control ) 200 g/d of wheat bread fortified with iron and folic acid , but not zinc , and a liquid multivitamin supplement without zinc between meals ; 2 ) ( zinc supplement ) the same bread and the same multivitamin supplement with 15 mg zinc as ZnSO(4 ) added ; 3 ) ( moderate zinc fortification ) the same bread cofortified with 7.5 mg zinc as ZnO and the same multivitamin supplement without zinc ; or 4 ) ( high zinc fortification ) the same bread cofortified with 15 mg zinc as ZnO and the same multivitamin supplement without zinc .  Fasting blood sample s were collected twice at baseline and at d 15 and 29 of the intervention . There was no significant interaction between group and study day ( P = 0.11 ) . However , at d 15 , the mean change in plasma zinc concentration in the zinc-supplemented group was greater than in the placebo and fortification groups ( 0.72 μmol/L vs. -0.09 to 0.03 μmol/L ; P = 0.05 ) . At d 29 there were no significant group-wise differences . Across all time points , the zinc-supplemented group was the only group where plasma zinc concentration increased from baseline ( P = 0.006 ) . These results suggest that plasma zinc concentration may not be a sufficiently sensitive indicator to evaluate short-term responses to zinc fortification OBJECTIVE We evaluated the effect of a micronutrient-fortified beverage on growth and morbidity in apparently healthy schoolchildren . METHODS This was a double-blind , placebo-controlled , matched-pair , cluster , r and omized study in semi-urban middle-income residential schoolchildren aged 6 to 16 y.  Anthropometrics ( height and weight ) , clinical symptoms of deficiency , and morbidity data were collected at baseline in the supplemented group ( n = 446 in 10 grade s ) and the placebo group ( n = 423 in 10 grade s ) and after 14 mo of supplementation ( n = 355 in the supplement group and n = 340 in the placebo group from nine pairs ) . RESULTS After 14 mo of supplementation , there was a significant increase in mean increments of height and weight z scores of -0.04 and 0.02 , respectively , in the supplemented group compared with -0.14 and -0.09 in the placebo group . Velocity of weight ( 3.56 versus 3.00 ) was significantly ( P < 0.01 ) higher with supplementation . Although there were no differences in the incidence of common childhood diseases such as fever , cough and cold , diarrhea , and ear infections elicited for a reference period of 1 mo at every quarterly follow-up examination , the mean duration of illness ( calculated per person per year ) was significantly shorter ( 5.0 d ) in the supplemented group than in the placebo group ( 7.4 d ) . CONCLUSIONS The micronutrient-fortified beverage was beneficial in promoting growth and decreasing duration of common illnesses among middle-class residential schoolchildren who had adequate energy and protein intakes BACKGROUND Zinc deficiency has been seen in developing countries in which grain-based vegetable protein is consumed more often than animal protein . This study was done to emphasize the importance of zinc-fortified foods and to investigate bioavailability of zinc in zinc-fortified bread . METHODS Serum zinc concentrations in healthy 7- to 11-year-old school children were determined . In 24 of 101 children serum zinc concentrations were below 65 micrograms/ul . These 24 children with asymptomatic zinc deficiency were divided into two equal groups . The 12 children with low serum zinc concentrations received the zinc-fortified bread providing 2 mg/kg/day elemental zinc acetate for 90 days ( zinc-supplemented group ) , whereas the other 12 children received the same quality bread with no zinc fortification ( control group ) . RESULTS By the end of the period , the zinc-supplemented group had significantly higher serum and leukocyte zinc concentrations ( p < 0.01 ) and the weight , serum albumin levels , and alkaline phosphatase increased ( p < 0.01 ) . Immune functions improved , evidence d by conversion of delayed hypersensitivity skin reactions . Zinc-fortified bread ( 2 mg/kg/day ) caused no side effects or manifestations of zinc toxicity . CONCLUSIONS The results indicate that the bioavailability of zinc in the bread is satisfactory . The use of zinc-fortified bread was found to be an economical and readily accessible method to eliminate zinc deficiency and to prevent further occurrence Schoolchildren in Nigeria are rarely targeted by micronutrient interventions . We completed a 6-mo , double-blind , placebo-controlled trial to determine the effects of a multi-micronutrient beverage on biochemical and anthropometric indicators of nutritional status among schoolchildren participating in a pilot school feeding program in Nasarawa State , Nigeria . Children received 1 of 2 interventions 5 d/wk during school hours : 1 ) 250 mL/d of a multi-micronutrient beverage that included vitamin A , iron , and zinc ( micronutrient ) ; or 2 ) an isoenergetic control beverage ( control ) .  At baseline , 566 children 5 - 13 y old were r and omized to groups  ( micronutrient : n = 288 ; control : n = 278 ) . Height , weight , hemoglobin , and serum concentrations of C-reactive protein , ferritin , retinol , and zinc were measured at baseline and at the end of the study . A total of 270 children in the micronutrient group and 264 children in the control group completed the study .  Self-reports of vomiting increased in both groups at 6 mo ; however , the prevalence tended to be greater in the micronutrient group ( 21 % ) compared to the control group ( 14 % ) ( P = 0.06 ) . Biochemical changes were greater in the micronutrient group compared to control for serum retinol ( 0.10 ± 0.02 μmol/L vs. 0.02 ± 0.02 μmol/L ; P = 0.016 ) and zinc ( 1.0 ± 0.2 μmol/L vs. 0.6 ± 0.2 μmol/L ; P = 0.031 ) . The intervention did not significantly affect hemoglobin or serum ferritin concentrations . The cost effectiveness of the intervention needs to be further evaluated , as does the efficacy of the beverage on anemia and indicators of iron status Objective : To assess the effect of dietary fortified milk with zinc and other micronutrients on zinc intake and plasma zinc content of adolescent girls . Methods : The study included 108 schoolgirls ( 12–18 years old ) from northwest Mexico , r and omly assigned to either the control group ( CG ; n = 55 ) or the intervention group consuming a regular diet plus fortified milk ( MG ; n = 53 ) . At the beginning of the study , age , weight , and height were measured . Food intake by the 24-hour recall method and plasma zinc levels assessed by absorption spectrophotometry were determined before and after 27 days of fortified milk intake . Results : At baseline , no significant group-related differences were observed for energy , protein intake , zinc intake , and plasma zinc level ( p > 0.05 ) , and 35.2 % of participant girls did not achieve their zinc requirement . After 27 days of treatment , there were no significant differences in energy and protein intake between groups ( p > 0.05 ) . Zinc intake was higher for MG than CG ( 16.7 ± 8.3 mg/d vs 10.5 ± 6.4 mg/d ; p < 0.01 ) , and there was a lower proportion of low zinc intake in MG than for CG ( 7 vs 16 , respectively ; p = 0.04 ) . In addition , plasma zinc improved in the MG ( 116.6 ± 26.9 μg/dL , p < 0.01 ) compared with CG ( 98.5 ± 26.6 μg/dL ) , and it was mainly attributed to the fortified milk intake , as the main dietary zinc contributor . Conclusion : Fortified milk intake is effective in increasing both intake and plasma zinc levels of adolescent Mexican girls ; therefore , it could be an adequate strategy for zinc deficiency prevention or correction among adolescent girls Energy and micronutrient deficiency remain prevalent among Filipino children .  Juice drinks are commonly consumed and could be a viable vehicle for fortification to supplement the nutrient gap . This study determined the effects of a newly developed non-carbonated fortified juice drink on the iron , zinc and nutritional status of schoolchildren . One hundred r and omly selected anemic children were r and omly allocated into two groups in a doubly-masked placebo controlled manner : Group 1 received the fortified juice , Group 2 received the non-fortified juice for 100 days , five days a week under strict supervision . The juice drink was fortified with vitamin A , zinc , iron , vitamin C and lysine . The non-fortified juice was fortified only with vitamin C.  All children were dewormed prior to the intervention . Hemoglobin , plasma ferritin and plasma zinc , weight and height were assessed using st and ard methods before and after intervention . A two-day 24-hour food recall was also collected . The basal prevalence of anemia was significantly reduced in both the fortified group ( 100 % to 13 % ) and the non-fortified group ( 100 % to 40 % ) at endline . The mean plasma ferritin levels were similar in both groups at baseline and endline . At endline , mean plasma zinc in the fortified group has significantly increased by 20 μg/dL from a baseline value of 83.9 μg/dL to 103.9 μg/dL , while the non-fortified group remained at similar levels with baseline . Basal weight and height significantly increased among all children at endline . The fortified juice drink was effective in reducing the prevalence of anemia and improved the zinc status of children Concurrent micronutrient deficiencies are prevalent among Vietnamese school children . A school-based program providing food fortified with multiple micronutrients could be a cost-effective and sustainable strategy to improve health and cognitive function of  school children . However , the efficacy of such an intervention may be compromised by the high prevalence of parasitic infestation . To evaluate the efficacy of school-based intervention using multi-micronutrient-fortified biscuits with or without deworming on anemia and micronutrient status in Vietnamese schoolchildren , a r and omized , double-blind , placebo-controlled trial was conducted among 510 primary schoolchildren , aged 6 - 8 y , in rural Vietnam .  Albendazole ( Alb ) ( 400 mg ) or placebo was given at baseline . Nonfortified or multi-micronutrient-fortified biscuits including iron ( 6 mg ) , zinc ( 5.6 mg ) , iodine ( 35 microg ) , and vitamin A ( 300 microg retinol equivalents ) were given 5 d/wk for 4 mo . Multi-micronutrient fortification significantly improved the concentrations of hemoglobin ( + 1.87 g/L ; 95 % CI : 0.78 , 2.96 ) , plasma ferritin ( + 7.5 microg/L ; 95 % CI : 2.8 , 12.6 ) , body iron ( + 0.56 mg/kg body weight ; 95 % CI : 0.29 , 0.84 ) , plasma zinc ( + 0.61 micromol/L ; 95 % CI : 0.26 , 0.95 ) , plasma retinol ( + 0.041 micromol/L ; 95 % CI : 0.001 , 0.08 ) , and urinary iodine ( + 22.49 micromol/L ; 95 % CI : 7.68 , 37.31 ) . Fortification reduced the risk of anemia and deficiencies of zinc and iodine by > 40 % . Parasitic infestation did not affect fortification efficacy , whereas fortification significantly enhanced deworming efficacy , with the lowest reinfection rates in children receiving both micronutrients and Alb . Multi-micronutrient fortification of biscuits is an effective strategy to improve the micronutrient status of Vietnamese schoolchildren and enhances effectiveness of deworming Background Fortification of flour is one of the approaches for the control and prevention of vitamin and mineral deficiencies . Objective To assess the effect of fortification of flour with seven vitamins and minerals on a population of Chinese women . Methods Farmers who offered their l and for reforestation in 25 northwest provinces of China received compensation in the form of wheat flour ; the amount of flour given depended on the amount of l and that was given up for reforestation . This study observed the effects of providing families with fortified flour in the reforestation areas in Gansu Province . The study was conducted for 3 years . Families in the intervention village who offered l and for reforestation received flour fortified with seven vitamins and minerals , and those in the control village received unfortified flour . Seven surveys , spaced at least 6 months apart , were carried out in each village from 2004 to 2007 . At baseline and at each annual survey , measurements and blood sample s were taken from 300 adult female subjects aged 20 to 60 years to assess dietary intake , height , weight , body fat , hemoglobin , serum retinol , serum iron , free erythrocyte protoporphyrin , serum zinc . Serum folic acid was measured at baseline and 36-month only . At each 6-month survey , data were collected on anthropometric features , hemoglobin , and dietary intake . Results Consumption of fortified flour in the intervention village ranged from 158.7 to 232.7 g per person per day . Serum retinol status was significantly improved after 12-month intervention until the end of the trial compared with both the control group and the baseline level of the intervention group . Iron status expressed as FEP and SI levels showed higher than that of the control group and baseline levels only at 36-month . Hemoglobin levels of the intervention group were higher than that of the control group and baseline levels , but anemia prevalence of both the intervention and control groups remained unchanged in the intervention period . Levels of serum zinc showed increases compared with the control group and baseline data at 24-month and 36-month , and levels of serum folic acid of intervention group in 36-month was higher than that of both the control group and baseline level . Conclusions The evidence from this study confirms the positive bioeffectiveness of fortified flour in the rural female population in China , but a higher dosage of electrolytic elementary iron in flour fortification was suggested for anemia prevention and control Objective To estimate the prevalence of serum zinc deficiency in children of 6 months to 60 months of age . Methods A community based cross-sectional study was conducted to collect the data to establish the prevalence of  zinc deficiency in children in 6–60 months of age in five states namely , Uttar Pradesh(Northern region ) , Karnataka ( Southern region ) , Orissa ( Eastern region ) , Gujarat ( Western region ) and Madhya Pradesh ( Central region ) of the country . In each state , all the districts with ICDS scheme were enlisted and one district was selected with the help of R and om number table ( RNT ) . In each district , all the ICDS projects were selected and one ICDS project was selected with help of RNT . In the selected ICDS project , a cluster 5 Anganwadi centres ( AWC ) were selected . From the selected AWCs , three hundred children in the age group of 6–60 months were selected for the detailed study . A total of 1,655 subjects ( 836 males and 819 females ) were included . The blood sample s were collected from each child . The serum zinc estimation was done by atomic absorption spectrophotometer . Results The overall prevalence of zinc deficiency in five states was 43.8 % . The prevalence of zinc deficiency was highest in Orissa ( 51.3 % ) , followed by Uttar Pradesh ( 48.1 % ) , Gujarat ( 44.2 % ) , Madhya Pradesh ( 38.9 % ) and Karnataka ( 36.2 % ) . Conclusions The present study revealed a high prevalence of zinc deficiency in children belonging to Low Socio-economic Index ( LSI ) in Anemia and micronutrient deficiencies are common among Indian schoolchildren . We assessed the effectiveness of micronutrient fortification of meals cooked and fortified at school on anemia and micronutrient status of schoolchildren in Himalayan villages of India . In this placebo-controlled , cluster-r and omized study , 499 schoolchildren ( 6 - 10 y ) received either multiple micronutrients ( treatment group ) or placebo ( control group ) as part of school meals ( 6 d/wk ) for 8 mo . Both groups were dewormed at the beginning of the study . The micronutrient premix provided 10 mg iron , 375 microg vitamin A , 4.2 mg zinc , 225 microg folic acid , and 1.35 microg vitamin B-12 for each child per day ( approximately 75 % recommended dietary allowance ) . Blood sample s drawn before and after the intervention were analyzed for hemoglobin , ferritin , retinol , zinc , folate , and vitamin B-12 . Baseline prevalence of anemia ( 37 % ) , iron deficiency anemia ( 10 % ) , low serum ferritin ( 24 % ) , retinol ( 56 % ) , zinc ( 74 % ) , folate ( 68 % ) , and vitamin B-12 ( 17 % ) did not differ between groups . Postintervention , fewer in the treatment group had lower serum retinol [ odds ratio ( OR ) ( 95 % CI ) : 0.57 ( 0.33 - 0.97 ) ] and folate [ OR ( 95 % CI ) : 0.47 ( 0.26 - 0.84 ) ] than the control group . The serum vitamin B-12 concentration decreased in both groups , but the magnitude of change was less in the treatment than in the control group ( P < 0.05 ) . Total body iron ( TBI ) increased in both groups ; however , the change was greater in the treatment than in the control group ( P < 0.05 ) . Micronutrient fortification of school meals by trained school personnel was effective in improving vitamin A , folate , and TBI status while also reducing the magnitude of a decrease in vitamin B-12 status
BACKGROUND Zinc deficiency is a global nutritional problem , particularly in children and women residing in setting s where diets are cereal based and monotonous .
It has several negative health consequences .
Fortification of staple foods with zinc may be an effective strategy for preventing zinc deficiency and improving zinc-related health outcomes .
OBJECTIVES To evaluate the beneficial and adverse effects of fortification of staple foods with zinc on health-related outcomes and biomarkers of zinc status in the general population .