Accepted Manuscript Prevalence of Iron and Zinc deficiencies among preschool children aged 3-5 years in Vhembe district, Limpopo province, South Africa S.A. Motadi, X.G. Mbhenyane, H.V. Mbhatsani, N.S. Mabapa, R.L. Mamabolo PII:
S0899-9007(14)00438-9
DOI:
10.1016/j.nut.2014.09.016
Reference:
NUT 9382
To appear in:
Nutrition
Received Date: 11 June 2014 Revised Date:
18 August 2014
Accepted Date: 9 September 2014
Please cite this article as: Motadi S, Mbhenyane X, Mbhatsani H, Mabapa N, Mamabolo R, Prevalence of Iron and Zinc deficiencies among preschool children aged 3-5 years in Vhembe district, Limpopo province, South Africa, Nutrition (2014), doi: 10.1016/j.nut.2014.09.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Prevalence of Iron and Zinc deficiencies among preschool children aged 3-5
2
years in Vhembe district, Limpopo province, South Africa
3
1
4 5
1
6 7
2
Motadi SA, 2Mbhenyane XG, 1Mbhatsani HV, 1Mabapa NS, 1Mamabolo RL
RI PT
Nutrition Department, School of Health Sciences, University of Venda, Thohoyandou, 0950, South Africa Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Maitland, 7602, Stellenbosch, South Africa
9
SC
8
ABSTRACT
Background: Children under five years constitute the most vulnerable group and their nutritional status
11
is a sensitive indicator of community health and nutrition.
12
Objective: To determine the prevalence of zinc and iron deficiency among preschool children aged 3-5
13
years in Vhembe district, Limpopo province, South Africa.
14
Design: This study included 349 preschool children recruited from two municipalities of Vhembe
15
district, Limpopo province, South Africa. Municipalities were purposively selected and subjects were
16
chosen by simple random sampling. Body weight and height were measured using standard techniques.
17
Serum zinc, iron, ferritin, transferrin saturation, transferrin and CRP levels were also assesses as well as
18
haemoglobin levels.
19
Results: The prevalence of wasting, stunting and underweight was 1.4%, 18.6% and 0.3% respectively
20
while 20.9% of the children were overweight and 9.7% were obese. The prevalence of zinc deficiency
21
was 42.6% and anaemia was 28%, and both were higher in female as compared to male children. When
22
using serum ferritin and transferrin saturation 7 (2%) children had iron deficiency anaemia. Combined
23
iron and zinc deficiencies using ferritin was found in 8 (2.3%) of the children while when using
24
transferrin saturation they were found in 42 (12%) children.
25
Conclusion: Iron and zinc deficiencies as well as anaemia were common in the preschool children
26
accompanied by high prevalence of stunting; and overweight and obesity. The results call for
27
interventions to combat this escalating problem of child malnutrition in the form of nutritional education
28
for mothers and food handlers at the preschools so as to ensure food diversification in these children.
AC C
EP
TE D
M AN U
10
29 30
KEYWORDS: Iron deficiency, zinc deficiency, pre-school children, stunting, overweight 1
ACCEPTED MANUSCRIPT
31
INTRODUCTION
32
Despite the legislated fortification of staple foods in South Africa [1], there is a general shortage
34
of iron and zinc in a large part of the population’s diets [2]. Furthermore, iron and zinc
35
deficiencies still appear to be important public health problems in many low–income countries
36
[2], as iron deficiency has an impact on psychomotor development, cognitive functions and
37
growth [3]. On the other hand zinc deficiency has been associated with poor growth, depressed
38
immune function, increased susceptibility to and severity of infections and neurobehavioral
39
abnormalities [3]. Diets of many people in rural communities of South Africa consist of plant
40
sources with very minimal amounts of animal sources which are rich sources of both iron and
41
zinc [4].
M AN U
SC
RI PT
33
42
Iron deficiency is particularly prevalent in infants and young children. These age groups have a
44
higher risk of developing iron deficiency because of the high demand of iron during the period of
45
rapid growth. Iron deficiency exists in all countries, but its magnitude is higher in South East
46
Asia (57%) and Africa (46%) [5]. The cause of nutritional anaemia may be due to inadequate
47
iron intake from food and low iron bioavailability.
48
TE D
43
Recently, there has been heightened interest in the role of zinc in humans, as it plays an
50
indispensable role as a key component of a host of enzymes crucial for optimal metabolism and
51
body functioning [6]. In addition, zinc is an anti-inflammatory and antioxidant agent and also
52
functions in cell-mediated immune responses, while in childhood it is required for optimal
53
growth and development, as well as brain functioning [7].
AC C
54
EP
49
55
In developing countries, for instance, poor nutrition (especially micronutrient deficiencies) is not
56
only responsible for over 10 million preventable child deaths yearly [8], it is also a risk factor
57
preventing an additional estimated 200 million children under 5 years old from attaining their
58
full cognitive developmental potential [3]. Like many other developing populations, a recent
59
national survey conducted among South African children revealed that 27.9% were anemic while
60
45.3% were zinc deficient [9]. Although large nutritional national studies [5, 9, 10] have been
61
conducted among South African children, there is paucity of data concerning the prevalence of 2
ACCEPTED MANUSCRIPT
62
iron and zinc deficiency in rural pre-school children in particular. In view of this the study was
63
conducted to evaluate iron and zinc status in preschool children residing in a rural area of
64
Limpopo province, South Africa.
65
SUBJECTS AND METHODS
RI PT
66 67 68
Study population
69
The study was conducted in Vhembe district which is one of five municipal districts of Limpopo
71
province. The district is divided into four local municipalities namely Thulamela, Makhado,
72
Musina and Mutale.
M AN U
SC
70
73
Simple random sampling was used to select two municipalities (Mutale and Makhado). Mutale
75
had an estimated population of 91870 and 148 villages whereas Makhado had an estimated
76
population of 516,031 and 290 villages [11]. A list of preschools was obtained from the
77
Department of Education, Vhembe district, and each preschool was assigned a number from
78
which 16 were randomly selected to be included in the study. The same procedure was used to
79
select 380 children (3-5 years of age) to participate in the study. Children who were 3-5 years old
80
and whose parents consented and were present on the day of data collection were included in the
81
study. The children had to be free from infection and not taking any medication and present on
82
the day of data collection. Children whose parents/guardians did not give consent were excluded
83
from the study.
EP
AC C
84
TE D
74
85
Anthropometric assessments were performed according to standard procedures described by the
86
International Society for the Advancement of Kinanthropometry [12]. The following
87
measurements were taken in duplicate using calibrated equipments with the children wearing
88
light clothing and no shoes: standing height and weight. Height was measured to the nearest 0.1
89
cm using a calibrated portable stadiometer; weight was measured to the nearest 0.01 kg on a
90
portable Seca solar scale (model 0213). The solar scale and stadiometer were calibrated before
91
measurements using a calibration weight and steel tape, respectively.
92
3
ACCEPTED MANUSCRIPT
A professional nurse checked for clinical signs of zinc deficiency by administering an oral zinc
94
taste test. This was done by placing 10ml of liquid zinc in the child’s mouth, then letting the
95
child hold it in the mouth for ten to fifteen seconds while observing facial expressions and taste.
96
The nurse then asked the children what liquid zinc tasted like and recorded the results. Clinical
97
signs which could be identified by the naked eye were also recorded.
RI PT
93
98 99
Biochemical analysis
100
Fasting venous blood was collected for blood analysis. Haemoglobin was measured by
102
standardized procedures at Ampath laboratories using a STKS analyzer (Beckman Coulter Inc.,
103
California, USA), using 3-level controls provided by the manufacturer, within 2h of blood
104
collection. Serum zinc was measured using
105
immunosorbent assays were used to measure serum transferrin saturation (Tsaturation) and
106
ferritin (Ramco Laboratories, Inc., Stafford, Texas) and C-reactive protein (CRP) (Human
107
Biochemical and Diagnostic Laboratories, South Africa) by SYNCHRON LX® System(s),
108
UniCel® DxC 600/800 System(s) and SYNCHRON® Systems CAL 5
109
immunoturbidimetric test (Human Biochemical and Diagnostic Laboratories, South Africa).
110
The coefficients of variance (CV) for all assays were
S0899-9007(14)00438-9
DOI:
10.1016/j.nut.2014.09.016
Reference:
NUT 9382
To appear in:
Nutrition
Received Date: 11 June 2014 Revised Date:
18 August 2014
Accepted Date: 9 September 2014
Please cite this article as: Motadi S, Mbhenyane X, Mbhatsani H, Mabapa N, Mamabolo R, Prevalence of Iron and Zinc deficiencies among preschool children aged 3-5 years in Vhembe district, Limpopo province, South Africa, Nutrition (2014), doi: 10.1016/j.nut.2014.09.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Prevalence of Iron and Zinc deficiencies among preschool children aged 3-5
2
years in Vhembe district, Limpopo province, South Africa
3
1
4 5
1
6 7
2
Motadi SA, 2Mbhenyane XG, 1Mbhatsani HV, 1Mabapa NS, 1Mamabolo RL
RI PT
Nutrition Department, School of Health Sciences, University of Venda, Thohoyandou, 0950, South Africa Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Maitland, 7602, Stellenbosch, South Africa
9
SC
8
ABSTRACT
Background: Children under five years constitute the most vulnerable group and their nutritional status
11
is a sensitive indicator of community health and nutrition.
12
Objective: To determine the prevalence of zinc and iron deficiency among preschool children aged 3-5
13
years in Vhembe district, Limpopo province, South Africa.
14
Design: This study included 349 preschool children recruited from two municipalities of Vhembe
15
district, Limpopo province, South Africa. Municipalities were purposively selected and subjects were
16
chosen by simple random sampling. Body weight and height were measured using standard techniques.
17
Serum zinc, iron, ferritin, transferrin saturation, transferrin and CRP levels were also assesses as well as
18
haemoglobin levels.
19
Results: The prevalence of wasting, stunting and underweight was 1.4%, 18.6% and 0.3% respectively
20
while 20.9% of the children were overweight and 9.7% were obese. The prevalence of zinc deficiency
21
was 42.6% and anaemia was 28%, and both were higher in female as compared to male children. When
22
using serum ferritin and transferrin saturation 7 (2%) children had iron deficiency anaemia. Combined
23
iron and zinc deficiencies using ferritin was found in 8 (2.3%) of the children while when using
24
transferrin saturation they were found in 42 (12%) children.
25
Conclusion: Iron and zinc deficiencies as well as anaemia were common in the preschool children
26
accompanied by high prevalence of stunting; and overweight and obesity. The results call for
27
interventions to combat this escalating problem of child malnutrition in the form of nutritional education
28
for mothers and food handlers at the preschools so as to ensure food diversification in these children.
AC C
EP
TE D
M AN U
10
29 30
KEYWORDS: Iron deficiency, zinc deficiency, pre-school children, stunting, overweight 1
ACCEPTED MANUSCRIPT
31
INTRODUCTION
32
Despite the legislated fortification of staple foods in South Africa [1], there is a general shortage
34
of iron and zinc in a large part of the population’s diets [2]. Furthermore, iron and zinc
35
deficiencies still appear to be important public health problems in many low–income countries
36
[2], as iron deficiency has an impact on psychomotor development, cognitive functions and
37
growth [3]. On the other hand zinc deficiency has been associated with poor growth, depressed
38
immune function, increased susceptibility to and severity of infections and neurobehavioral
39
abnormalities [3]. Diets of many people in rural communities of South Africa consist of plant
40
sources with very minimal amounts of animal sources which are rich sources of both iron and
41
zinc [4].
M AN U
SC
RI PT
33
42
Iron deficiency is particularly prevalent in infants and young children. These age groups have a
44
higher risk of developing iron deficiency because of the high demand of iron during the period of
45
rapid growth. Iron deficiency exists in all countries, but its magnitude is higher in South East
46
Asia (57%) and Africa (46%) [5]. The cause of nutritional anaemia may be due to inadequate
47
iron intake from food and low iron bioavailability.
48
TE D
43
Recently, there has been heightened interest in the role of zinc in humans, as it plays an
50
indispensable role as a key component of a host of enzymes crucial for optimal metabolism and
51
body functioning [6]. In addition, zinc is an anti-inflammatory and antioxidant agent and also
52
functions in cell-mediated immune responses, while in childhood it is required for optimal
53
growth and development, as well as brain functioning [7].
AC C
54
EP
49
55
In developing countries, for instance, poor nutrition (especially micronutrient deficiencies) is not
56
only responsible for over 10 million preventable child deaths yearly [8], it is also a risk factor
57
preventing an additional estimated 200 million children under 5 years old from attaining their
58
full cognitive developmental potential [3]. Like many other developing populations, a recent
59
national survey conducted among South African children revealed that 27.9% were anemic while
60
45.3% were zinc deficient [9]. Although large nutritional national studies [5, 9, 10] have been
61
conducted among South African children, there is paucity of data concerning the prevalence of 2
ACCEPTED MANUSCRIPT
62
iron and zinc deficiency in rural pre-school children in particular. In view of this the study was
63
conducted to evaluate iron and zinc status in preschool children residing in a rural area of
64
Limpopo province, South Africa.
65
SUBJECTS AND METHODS
RI PT
66 67 68
Study population
69
The study was conducted in Vhembe district which is one of five municipal districts of Limpopo
71
province. The district is divided into four local municipalities namely Thulamela, Makhado,
72
Musina and Mutale.
M AN U
SC
70
73
Simple random sampling was used to select two municipalities (Mutale and Makhado). Mutale
75
had an estimated population of 91870 and 148 villages whereas Makhado had an estimated
76
population of 516,031 and 290 villages [11]. A list of preschools was obtained from the
77
Department of Education, Vhembe district, and each preschool was assigned a number from
78
which 16 were randomly selected to be included in the study. The same procedure was used to
79
select 380 children (3-5 years of age) to participate in the study. Children who were 3-5 years old
80
and whose parents consented and were present on the day of data collection were included in the
81
study. The children had to be free from infection and not taking any medication and present on
82
the day of data collection. Children whose parents/guardians did not give consent were excluded
83
from the study.
EP
AC C
84
TE D
74
85
Anthropometric assessments were performed according to standard procedures described by the
86
International Society for the Advancement of Kinanthropometry [12]. The following
87
measurements were taken in duplicate using calibrated equipments with the children wearing
88
light clothing and no shoes: standing height and weight. Height was measured to the nearest 0.1
89
cm using a calibrated portable stadiometer; weight was measured to the nearest 0.01 kg on a
90
portable Seca solar scale (model 0213). The solar scale and stadiometer were calibrated before
91
measurements using a calibration weight and steel tape, respectively.
92
3
ACCEPTED MANUSCRIPT
A professional nurse checked for clinical signs of zinc deficiency by administering an oral zinc
94
taste test. This was done by placing 10ml of liquid zinc in the child’s mouth, then letting the
95
child hold it in the mouth for ten to fifteen seconds while observing facial expressions and taste.
96
The nurse then asked the children what liquid zinc tasted like and recorded the results. Clinical
97
signs which could be identified by the naked eye were also recorded.
RI PT
93
98 99
Biochemical analysis
100
Fasting venous blood was collected for blood analysis. Haemoglobin was measured by
102
standardized procedures at Ampath laboratories using a STKS analyzer (Beckman Coulter Inc.,
103
California, USA), using 3-level controls provided by the manufacturer, within 2h of blood
104
collection. Serum zinc was measured using
105
immunosorbent assays were used to measure serum transferrin saturation (Tsaturation) and
106
ferritin (Ramco Laboratories, Inc., Stafford, Texas) and C-reactive protein (CRP) (Human
107
Biochemical and Diagnostic Laboratories, South Africa) by SYNCHRON LX® System(s),
108
UniCel® DxC 600/800 System(s) and SYNCHRON® Systems CAL 5
109
immunoturbidimetric test (Human Biochemical and Diagnostic Laboratories, South Africa).
110
The coefficients of variance (CV) for all assays were
