The Jou nal o Nu i ion
Communi y and In e na ional Nu i ion
Ma e nal and In an Supplemen a ion wi h
Small-Quan i y Lipid-Based Nu ien
Supplemen s Inc eases In an s’ I on S a us a
18 Mon hs o Age in a Semiu ban Se ing in
Ghana: A Seconda y Ou come Analysis o he
iLiNS-DYAD Randomized Con olled T ial
Se h Adu-A a wuah,1Rebecca T Young,2Anna La ey,1Ha ie Ok onipa ,1,2Pe Asho n,3Ulla Asho n,3
B ie a M Oaks,4Ma y A imond,5and Ka h yn G Dewey 2
1Depa men o Nu i ion and Food Science, Uni e si y o Ghana, Legon, Acc a, Ghana; 2P og am in In e na ional and Communi y
Nu i ion, Depa men o Nu i ion, Uni e si y o Cali o nia, Da is, CA; 3Cen e o Child Heal h Resea ch, Uni e si y o Tampe e and
Tampe e Uni e si y Hospi al, Tampe e, Finland; 4Depa men o Nu i ion and Food Sciences, Uni e si y o Rhode Island, Kings on, RI;
and 5In ake—Cen e o Die a y Assessmen , FHI 360, Washing on, DC
ABSTRACT
Backg ound: In e en ions a e needed o add ess i on de iciency in low-income se ings.
Objec i e: This seconda y ou come analysis aimed o compa e he hemoglobin (Hb) and i on s a us [zinc p o opo phy in
(ZPP)] o child en bo n o women en olled in he iLiNS-DYAD ial in Ghana.
Me hods: Women ≤20 wk p egnan (n=1320) we e assigned o ecei e 60 mg Fe/d and 400 µg olic acid/d un il deli e y
and placebo he ea e , and no supplemen a ion o in an s (IFA g oup); o mul iple mic onu ien s con aining 20 mg Fe/d
un il 6 mo pos pa um and no supplemen a ion o in an s (MMN); o small-quan i y lipid-based nu ien supplemen s
(SQ-LNSs) con aining 20 mg Fe/d un il 6 mo pos pa um, and SQ-LNSs o in an s om 6 o 18 mo o age (LNS). We
compa ed in an s’ Hb (g/L) and ZPP (µmol/mol heme) a 6 and 18 mo o age.
Resul s: A 6 mo o age, g oups did no di e in mean ±SD Hb (o e all: 113 ±9.9 g/L) o geome ic mean (95% CI) ZPP
[o e all: 62.6 (60.6, 64.7)]. A 18 mo o age, mean ±SD Hb (o e all: 112 ±10.4 g/L) did no di e signi ican ly be ween
g oups, whe eas geome ic mean (95% CI) ZPP was lowe (P=0.031) in he LNS g oup [53.9 (50.7, 57.3)] han he IFA
[60.4 (56.7, 64.3)] bu no he MMN [58.8 (55.6, 62.2)] g oup. Fu he , he LNS g oup, compa ed wi h he IFA and MMN
g oups combined, had a lowe p e alence o ele a ed (>70) ZPP (27.5% compa ed wi h 35%; P=0.02) and a ma ginally
lowe p e alence o anemia (38.7% compa ed wi h 44.9%; P=0.06). These esul s gene ally emained unchanged
when con olling o p especi ied co a ia es o co ec ing o in lamma ion.
Conclusions: In his se ing, p o iding SQ-LNSs o mul iple mic onu ien s wi h 20 mg Fe/d, compa ed wi h i on
(60 mg/d) and olic acid, o p egnan women does no a ec hei in an s’ Hb o i on s a us a 6 mo o age, bu ma e nal
and in an supplemen a ion wi h SQ-LNSs inc eases in an s’ i on s a us a 18 mo o age. This ial was egis e ed a
clinical ials.go as NCT00970866. J Nu 2019;149:149–158.
Keywo ds: mic onu ien supplemen a ion, i on and olic acid, mul iple mic onu ien supplemen s, small-quan i y
lipid-based nu ien supplemen s, in an s
In oduc ion
Inadequa e mic onu ien in ake is common in low-income
coun ies (1) and has been associa ed wi h inc eased isk
o pe ina al mo bidi y and mo ali y (2), low bi h weigh
(3), and poo child g ow h and de elopmen (4). Conse-
quen ly, add essing he mic onu ien needs o women and
child en especially du ing he “ i s 1000 d” is a global
p io i y (5–7).
As pa o he In e na ional Lipid-based Nu ien Sup-
plemen s (iLiNS) P ojec , we de eloped small-quan i y lipid-
based nu ien supplemen s (SQ-LNSs), which can be used
o en ich home-p epa ed oods o women and child en (8),
© 2019 Ame ican Socie y o Nu i ion. This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License
(h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed euse, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly
ci ed.
Manusc ip ecei ed May 24, 2018. Ini ial e iew comple ed Augus 8, 2018. Re ision accep ed Augus 10, 2018.
Fi s published online Janua y 8, 2019; doi: h ps://doi.o g/10.1093/jn/nxy225. 149
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and he eby inc ease he in akes o essen ial nu ien s wi hou
causing subs an ial changes in usual die a y p ac ices. Du ing
he las se e al yea s, simila o di e en o mula ions o SQ-
LNS p oduc s (9) ha e been used in many in e en ion ials
and p og ams wo ldwide (10).
In he iLiNS-DYAD andomized, con olled supplemen a ion
ial in Ghana, we e alua ed he e icacy o SQ-LNSs gi en
o women du ing p egnancy and he i s 6 mo pos pa um,
and o hei o sp ing om 6 o 18 mo o age, based on
e idence ha child malnu i ion in de eloping coun ies o en
begins in u e o and con inues a e bi h (11). We p e iously
epo ed he p ima y g ow h ou comes (12,13)aswellas
se e al o he seconda y ou comes (14–18)o he ialand
showed ha ma e nal–in an supplemen a ion wi h SQ-LNSs,
compa ed wi h ma e nal-only supplemen a ion wi h i on and
olic acid o mul iple mic onu ien s, p omo ed in an and child
g ow h in ou ial se ing.
In Wes A ica, an es ima ed 80% o child en <5 y o age
a e anemic (19), up o one-hal o which a e es ima ed o be due
o i on de iciency (20). Possible consequences o i on de iciency
anemia (IDA) include cogni i e impai men in child en (21)
and lowe school pe o mance (22). In his p esen analysis o
seconda y ou comes o he ial, we aimed o de e mine he
impac o he iLiNS-DYAD in e en ion on child en’s blood
hemoglobin (Hb) and i on s a us and in lamma ion bioma ke s
a 6 and 18 mo o age.
Me hods
S udy se ing, design, and pa icipan s
The iLiNS-DYAD Ghana ial (NCT00970866) has been desc ibed
in de ail p e iously (12–14). B ie ly, he ial was conduc ed in he
Somanya–Odumasi–Kpong a ea, a semiu ban se ing ∼70 km no h
o Acc a, and was designed as a pa ially double-blind, indi idually
andomized, con olled ial wi h 3 equal-size g oups. Women ≥18
yoldand≤20 wk p egnan iden i ied om an ena al clinics we e
ec ui ed a e ob aining in o med consen o hemsel es and o hei
in an s upon deli e y. Exclusion c i e ia we e: no conside ed as a
esiden o he a ea, in en ion o mo e ou o he a ea, milk o peanu
alle gy, pa icipa ion in ano he ial, HIV in ec ion, as hma, epilepsy,
ube culosis, any malignancy, o unwillingness o ecei e ieldwo ke s
o ake he s udy supplemen .
The ial was app o ed by 3 e hics commi ees (Uni e si y o
Cali o nia, Da is; Ghana Heal h Se ice; and Noguchi Memo ial
Ins i u e o Medical Resea ch) and moni o ed by a Da a and Sa e y
Moni o ing Boa d.
Suppo ed by Bill & Melinda Ga es Founda ion g an OPP49817 o he
Uni e si y o Cali o nia, Da is ( o KGD).
Au ho disclosu es: SA-A, RTY, AL, HO, PA, UA, BMO, MA, and KGD, no con lic s
o in e es .
The indings and conclusions con ained wi hin a e hose o he au ho s and
do no necessa ily e lec posi ions o policies o he Bill & Melinda Ga es
Founda ion.
Supplemen al Tables 1–4 a e a ailable om he “Supplemen a y da a” link in
he online pos ing o he a icle and om he same link in he online able o
con en s a h ps://academic.oup.com/jn/.
Add ess co espondence o SA-A (e-mail: [email p o ec ed]).
Abb e ia ions used: AGP,α-1 glycop o ein; CRP, C- eac i e p o ein; GDHS,
Ghana Demog aphic and Heal h Su ey; Hb, hemoglobin; IDA, i on de iciency
anemia; IFA, i on and olic acid; iLiNS, In e na ional Lipid-based Nu ien
Supplemen s; INACG, In e na ional Nu i ional Anemia Consul a i e G oup;
LNS, lipid-based nu ien supplemen ; MMN, mul iple mic onu ien ; SQ-LNS,
small-quan i y lipid-based nu ien supplemen ; ZPP, zinc p o opo phy in.
G oup assignmen s and blinding
As epo ed p e iously (12–14), ec ui ed women who emained eligible
we e, a e baseline assessmen s, andomly assigned o consume 60 mg
Fe +400 µg olic acid/d (IFA supplemen o g oup), mul iple mic onu-
ien s con aining 18 i amins and mine als (MMNs supplemen o
g oup), o 20 g SQ-LNS/d (LNS g oup) du ing p egnancy. In he i s
6 mo pos pa um, women in he IFA g oup we e assigned 200 mg Ca/d
as placebo, and hose in he MMN and LNS g oups assigned he same
supplemen s as du ing p egnancy. F om 6 o 18 mo o age, in an s bo n
o women in he IFA and MMN g oups we e assigned o ecei e no
mic onu ien supplemen a ion, whe eas hose o women in he LNS
g oup we e assigned o consume SQ-LNSs designed o in an s. The
IFA and MMN supplemen s we e p o ided as capsules in blis e packs
o 10, whe eas he SQ-LNS o women was in 20-g sache s, and ha o
in an s in 10-g sache s (gi en 2/d).
The ollowing indi iduals comple ed he g oup assignmen s (12,
13,17): 1) he S udy S a is ician a UC Da is, Jane M Pee son,
de eloped he alloca ions in blocks o 9 (SAS o Windows e sion 9.4);
2) someone a he Uni e si y o Ghana no in ol ed in he ec ui men
o subjec s p epa ed he en elopes con aining he assignmen s, which
we e numbe ed and s acked by block numbe ; and 3) he S udy Nu se
a he ield si e pe o med he andom assignmen . A each en ollmen ,
he S udy Nu se shu led 9 en elopes aken om he op o he s ack
and asked he pa icipan o make a pick o e eal he assignmen . The
Nu se hen e u ned he unused en elopes o he op o he s ack. When
he e we e <9 women le o be en olled, he Nu se shu led wha e e
numbe o en elopes emained. Any alloca ion in o ma ion was kep
secu ely by he Field Supe iso in Ghana and he S udy S a is ician a
UC Da is only.
A en ollmen , he S udy Nu se ga e women a 2-wk supply o
supplemen s, ad ice o ake 1 capsule/d wi h wa e a e a meal, o
one 20-g SQ-LNS sache /d mixed wi h ood, and a s anda d nu i ion
message abou he need o “ea mea , ish, eggs, ui s, and ege ables”
whene e possible (12,13). The IFA and MMN capsules we e known
o he s udy eam and pa icipan s only by hei colo codes (3 colo s
o IFA and 3 o MMN). I was no possible o blind s udy wo ke s
and pa icipan s o he capsules and he LNSs owing o hei appa en
di e ences, bu labo a o y s a and da a analys s had no knowledge o
he g oup assignmen s.
Follow-up
Du ing p egnancy, ieldwo ke s isi ed women in hei homes biweekly
o deli e supplemen s. All li e-bo n single on in an s deli e ed by he
women we e en olled in o he s udy. In cases o mul iple bi hs, only
1 in an was selec ed andomly, and he selec ed in an was en olled i
he o she was bo n ali e. A e women ga e bi h, ieldwo ke s isi ed
hem and hei in an s weekly, bu deli e ed he women’s supplemen s
o placebo biweekly as be o e.
Women exi ed he s udy a 6 mo pos pa um, bu he weekly isi s
o he in an s con inued. A 6 mo o age, he S udy Nu se deli e ed
he “minimum message” on complemen a y eeding o all mo he s a
he labo a o y a e he in an s’ i s labo a o y assessmen : “B eas eed
you baby as you did be o e 6 mo o age; do no o ge o eed you
baby mea , ish, eggs, ui s and ege ables whene e you can.” Du ing
he nex usual weekly home isi , ieldwo ke s deli e ed he i s supply
o SQ-LNSs o in an s in he LNS g oup, ad ised hose mo he s o
ca egi e s on how o eed he supplemen s (i.e., mix he en i e con en
o 1 sache wi h 2–3 ablespoons o ood o he in an be o e eeding
addi ional oods i he in an desi es, 2 imes/d), and epea ed he
“minimum message” on complemen a y eeding gi en by he S udy
Nu se. Fo in an s in he IFA and MMN g oups who we e no assigned
o any supplemen s, ieldwo ke s also epea ed he “minimum message”
o hei mo he s o ca egi e s. Fieldwo ke s deli e ed a esh supply
o in an s’ SQ-LNSs du ing he usual weekly isi s, bu he “minimum
message” was no epea ed again he ea e . In an s exi ed he s udy a
18 mo o age.
150 Adu-A a wuah e al.
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T ial supplemen s
As p e iously epo ed (8,12–14,16), he IFA e lec ed he Ghana
Heal h Se ice’s s anda d mic onu ien supplemen a ion o p egnan
women in Ghana a he ime o he s udy (23). The daily dose o
MMN con ained 18 i amins and mine als a 1 o 2 imes he RDA
o p egnancy, excep i on. Fo i on, we used 20 mg/d ins ead o he
30 mg/d in he UNICEF/WHO/Uni ed Na ions Uni e si y In e na ional
Mul iple Mic onu ien P epa a ion (UNIMMAP) o mula ion (24)o
he 30–60 mg/d in he WHO guideline (23), because o p e ious
e idence (25) showing ha 20 mg Fe/d was jus as e ec i e as
40 mg/d o 80 mg/d in ea ing anemia du ing p egnancy and was likely
o cause ewe gas oin es inal side e ec s compa ed wi h a 30–60 mg/d
dosage. The SQ-LNS o women had simila mic onu ien con en s o
he MMN, plus ene gy, p o ein, and essen ial a y acids as well as he
maximum amoun s o calcium, magnesium, phospho us, and po assium
ha could be included gi en echnical and o ganolep ic cons ain s.
Including 20 mg Fe/d in he SQ-LNS o women made i possible o
ha e jus one p oduc o bo h p egnancy and lac a ion, assuming ha
his amoun , in addi ion o i on om he usual die , would gi e a o al
daily in ake ha was close o he amoun in he UNIMMAP o mula ion
(24) and would he e o e mee he RDA o 27 mg Fe o p egnancy,
while a he same ime no g ea ly exceeding he RDA (9 mg/d) o
lac a ion (8).
The SQ-LNS o in an s was designed o gene ally supply he
WHO/FAO Recommended Nu ien In ake o key mic onu ien s o
in an s 7–12 mo o age, wi h a ew excep ions (8). We used an i on
dosage (6 mg/d) ha was app oxima ely he WHO/FAO Recommended
Nu ien In ake o in an s 7–12 mo o age when assuming high
bioa ailabili y (6.2 mg/d), and 33% lowe han he dosage p e iously
used in Ghana (26), because o conce ns abou inc easing he isk o
mala ia and in ec ions in an a ea o high mala ia endemici y (27). Zinc
con en (8 mg/d) was kep highe (8,28) han he 4 mg/d used in ou
p e ious s udy (26) because zinc abso p ion may be dec eased in he
s udy a ea’s p edominan ly maize-based die high in phy a e.
Da a collec ion
Women’s baseline assessmen s included sociodemog aphic cha ac e -
is ics; ges a ional age (by using ul asound biome y, Aloka SSD
500); an h opome ic s a us [by using s anda d p ocedu es (29)];
enous blood Hb concen a ion (HemoCue Hb301; Hemocue AG);
zinc p o opo phy in concen a ion (ZPP) (Hema o luo ome e ; A i
Biomedical Co.); and pe iphe al mala ia pa asi emia (Vision Bio ech)
(13). Hb concen a ion was measu ed wi hin 2 min a e he blood d aw.
We used he o iginal A i co e -slides and 3-le el con ol ma e ial o
he ZPP measu emen s, a e ed blood cells we e washed 3 imes wi h
no mal saline. Women’s supplemen in akes we e moni o ed biweekly
by collec ing unused blis e packs o SQ-LNS sache s a each isi . In
addi ion, du ing he biweekly in e iews, women we e asked on how
many days since he las isi hey had consumed he supplemen s,
easons (i any) hey did no consume he supplemen s, and, o hose
in he LNS g oup, whe he someone else had consumed some o
he supplemen s. Any disc epancies be ween he esponses o hese
ques ions and he numbe o capsules o sache s emaining since he
las isi we e esol ed du ing he in e iew.
Fo in an s in he LNS g oup, supplemen in akes we e moni o ed
weekly by aining mo he s o use a calenda g id o indica e, on a daily
basis, whe he in an s consumed he supplemen . Calenda g ids we e
checked a each weekly isi . Mo he s unable o use he calenda g id
we e asked o ecall he child en’s supplemen in akes o each day since
he las isi . In addi ion, ieldwo ke s collec ed any unused SQ-LNS
sache s a each isi , and econciled he numbe o sache s emaining
since he las isi wi h he consump ion in o ma ion eco ded on he
calenda g id o p o ided by he mo he . A 6 and 18 mo o age, in an s
we e b ough o he labo a o y, whe e we collec ed enous blood, and
measu ed Hb concen a ion wi hin 2 min, as well as measu ing ZPP
concen a ions and pe iphe al mala ia pa asi emia o all in an s using
he same echniques used o he women. The in an s’ plasma samples
ob ained a e cen i uging he blood a 1252 ×g o 15 min a a
oom empe a u e o ∼23°Cwe es o edinGhanaa −33°C, be o e
being ai - eigh ed on d y ice o he USDA Wes e n Human Nu i ion
Resea ch Cen e (WHNRC) in Da is, CA, whe e we de e mined he C-
eac i e p o ein (CRP) and α-1 glycop o ein (AGP) concen a ions in a
andomly selec ed subsample o in an s by using a Cobas In eg a 400
plus Au oma ic Analyze (Roche Diagnos ic Co p.).
The seconda y ou comes e alua ed he ein we e in an s’ Hb (g ams
pe li e ), ZPP (mic omoles pe mole o heme), CRP (millig ams pe
li e ), and AGP (g ams pe li e ) concen a ions a 6 and 18 mo o age,
and he pe cen ages o in an s wi h anemia (indica ed by low Hb), i on
de iciency (indica ed by ele a ed ZPP), and IDA (low Hb plus ele a ed
ZPP) a 6 and 18 mo o age.
Sample size and da a analysis
As desc ibed p e iously (12,13), he sample size o he iLiNS-DYAD-
Ghana s udy was based on de ec ing an e ec size o Cohen’s d(30)
o 0.3 be ween any 2 g oups o any con inuous a iables, wi h a 2-
sided 5% es and 80% powe . We p e iously epo ed he empo a y
mislabeling o some IFA and MMN supplemen s (12,13), as a esul
o which 170 women in he IFA g oup inad e en ly ecei ed MMN
capsules ei he h oughou (n=85) o du ing pa o (n=85) hei
p egnancy be o e ecei ing he in ended IFA capsules, and 170 women
in he MMN g oup ecei ed IFA capsules ei he h oughou (n=78) o
du ing pa o (n=92) hei p egnancy be o e ecei ing he in ended
MMN capsules. In o al, 1320 women we e en olled.
This p esen analysis includes all o he child en o whom da a we e
a ailable, consis en wi h ou analysis o he p ima y g ow h ou comes
(12). Fo CRP and AGP analyses (as well as se e al o he biochemical
ou comes in he ial), howe e , he a ge sample size was based on
de ec ing an e ec size o ≥0.5 be ween any 2 g oups, wi h a 2-sided
5% es and 80% powe . This equi ed 105 subjec s/g oup, o 315
subjec s o he 3 g oups, a e aking in o accoun ≤25% a i ion.
The subsample o he CRP and AGP analyses was selec ed om he
child en whose mo he s had no been p egnan du ing he pe iod when
he empo a y mislabeling occu ed.
The analysis epo ed he ein was pa o he iLiNS-DYAD-Ghana
s a is ical analysis plan, which we pos ed a ou websi e (www.ilins.o g)
be o e da a analysis began. Bo h he s a is ical analysis plan and he
ial p o ocol a clinical ials.o g lis ed child en’s blood Hb and i on
s a us as seconda y ou comes o be analyzed sepa a ely om he
p ima y ou comes. We used Hb <100 g/L o de ine anemia in women
(14,31,32). Fo child en, we de ined anemia by using he cu o o
Hb <110 g/L acco ding o he WHO (32,33), as well as by he cu o
alues o Hb <105 g/L o 6 mo o age desc ibed by Domellö e al. (34),
and Hb <100 g/L o 18 mo o age (31) desc ibed by he In e na ional
Nu i ional Anemia Consul a i e G oup (INACG), because o conce ns
ha he WHO cu o may be se oo high. We de ined ele a ed ZPP as
ZPP >70 µmol/mol heme (35–37); ele a ed CRP as CRP >5.0 mg/L
(38); and ele a ed AGP as AGP >1.0 g/L (38). In an s’ Hb alues we e
conside ed o be no mally dis ibu ed, bu he ZPP, CRP, and AGP
alues (Shapi o–Wilk W <0.95 in all cases) we e ln- ans o med be o e
analysis.
We analyzed da a on an in en ion- o- ea basis (by including
child en ega dless o adhe ence o ea men ), using SAS o Windows
e sion 9.4 (SAS Ins i u e). Backg ound ma e nal and household a i-
ables we e summa ized by in e en ion g oups based on supplemen s
women we e in ended o ecei e when en olled. Because o he p o ocol
iola ion associa ed wi h he consump ion o mislabeled IFA o MMN
capsules, we analyzed ou da a by using 2 scena ios, as done p e iously
(12): in he i s , in e en ion g oups we e based on he supplemen s
women we e in ended o ecei e when en olled; in he second, g oups
we e based on he supplemen s women ac ually ecei ed when en olled.
In addi ion, we pe o med a seconda y analysis by using a 2-g oup
compa ison in which he IFA and MMN g oups we e combined and
compa ed wi h he LNS g oup (12).
We analyzed con inuous and bina y ou comes a 6 and 18 mo
o age, by using linea and logis ic eg ession models (SAS, PROC
GLIMMIX), wi h Tukey–K ame adjus men o mul iple compa isons.
We compa ed g oup means ±SDs (o SEs) o geome ic means (95%
CIs) o con inuous ou come measu es, and g oup pe cen ages (95%
Ma e nal and in an SQ-LNS and in an i on s a us 151
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TABLE 1 Cha ac e is ics o women (n=1320) en olled in he iLiNS-DYAD-Ghana nu ien supplemen a ion ial, by g oup acco ding
o he supplemen s women we e in ended o ecei e when en olled1
Backg ound cha ac e is ics IFA (n=441) MMN (n=439) LNS (n=440)
Age, y 27 ±5 (441) 27 ±6 (439) 27 ±6 (440)
Fo mal educa ion, y 8 ±4 (441) 8 ±4 (439) 8 ±4 (440)
Ges a ional age a en ollmen , wk 16.2 ±3.3 (438) 16.0 ±3.2 (438) 16.1 ±3.3 (435)
Asse index20.05 ±1.01 (433) 0.05 ±0.99 (431) –0.09 ±1.00 (432)
Housing index20.05 ±0.98 (433) –0.03 ±1.02 (431) –0.01 ±1.00 (432)
HFIAS sco e32.8 ±4.6 (436) 2.4 ±4.1 (429) 2.6 ±4.0 (432)
Ma ied o cohabi ing, n/N (%) 406/441 (92.1) 413/439 (94.1) 405/440 (92.0)
P imipa ous women, n/N (%) 162/441 (36.7) 137/439 (31.2) 147/440 (33.4)
Posi i e o mala ia a baseline,4n/N (%) 40/441 (9.1) 39/438 (8.9) 54/440 (12.3)
Posi i e o mala ia a 36 wk,4n/N (%) 30/348 (8.6) 34/362 (9.4) 38/336 (11.3)
Anemic a baseline,5n/N (%) 55/441 (12.5) 70/438 (16.0) 60/440 (13.6)
Anemic a 36 wk,5n/N (%) 13/349 (3.7) 23/362 (6.4) 27/338 (8.0)
1Values a e means ±SDs (N)o n/N (%). HFIAS, Household Food Insecu i y Access Scale; IFA, I on and Folic Acid g oup andomly assigned o ecei e 60 mg Fe/d and 400 mg
olic acid/d du ing p egnancy and 200 mg Ca/d as placebo du ing he i s 6 mo pos pa um; iLiNS, In e na ional Lipid-based Nu ien Supplemen s; LNS, Lipid-based Nu ien
Supplemen g oup andomly assigned o ecei e 20 g small-quan i y Lipid-based Nu ien Supplemen s/d wi h he same mic onu ien s as he MMN g oup, plus 4 mo e mine als
(calcium, phospho us, po assium, and magnesium) and mac onu ien s un il 6 mo pos pa um; MMN, Mul iple Mic onu ien g oup andomly assigned o ecei e 18 i amins
and mine als, including 20 mg Fe, daily un il 6 mo pos pa um; n, numbe o pa icipan s iden i ied as “yes” o he a iable in ques ion; N, o al numbe o pa icipan s in he
g oup in ques ion.
2P oxy indica o s o household socioeconomic s a us; highe alues ep esen highe socioeconomic s a us.
3HFIAS sco e is a p oxy indica o o household ood insecu i y (42); highe alues ep esen highe ood insecu i y.
4Rapid diagnos ic es (Clea iew Mala ial Combo; Vision Bio ech).
5Anemia de ined as blood hemoglobin concen a ion <100 g/L (31,32,43).
CIs) o bina y ou comes. Along wi h g oup compa isons, we es ima ed
con as s be ween g oups (e ec size) and hei 95% CIs (39), including
di e ence in means and a io o log- ans o med means o con inuous
ou comes, and RRs (40) o bina y ou comes.
Bo h unadjus ed and adjus ed analyses we e pe o med. In he
adjus ed analyses, only p especi ied po en ial co a ia es (ma e nal age,
heigh , BMI, educa ion, ges a ional age a en ollmen , p imipa i y,
season a en ollmen , baseline anemia s a us, and p oxy indica o s o
household socioeconomic s a us and child sex) signi ican ly associa ed
wi h he ou come a α=0.1 in bi a ia e analyses we e included in
he inal models. Fo bina y ou comes, he adjus ed pe cen ages we e
gene a ed by using he echnique desc ibed by Kleinman and No on
(41).
In he subsample o child en o whom he e we e CRP and AGP
da a, we pe o med a sensi i i y analysis as done p e iously (14), by
co ec ing o he e ec o in lamma ion (CRP and AGP) on he Hb and
i on s a us ou comes (38) and epea ing he abo e analyses. We used
3 in lamma ion ca ego ies, namely: e e ence (no mal CRP and AGP),
incuba ion ( aised CRP and no mal AGP), and ea ly ( aised CRP and
AGP) o la e (no mal CRP and aised AGP) con alescence, o calcula e
he co ec ed Hb and ZPP alues (44).
We ha e p esen ed s a is ics in he ex as means ±SDs o
geome ic means (95% CIs) o con inuous ou comes, and pe cen ages
o bina y ou comes. As we published p e iously, he sel - epo ed
adhe ence o supplemen in ake o women (p egnancy/lac a ion) was
88.1%/85.7% o he IFA g oup, 87.0%/85.0% o he MMN g oup,
and 83.7%/80.0% o he LNS g oup (45), and ha o he in an s in
he LNS g oup was 73.5% (12).
Resul s
Da a we e collec ed be ween Decembe 2009 and Ma ch 2014.
In o al, 1320 women we e en olled. A baseline, he women
we e ∼27 y o age on a e age, had ∼8 y o o mal educa ion,
and we e a ∼16 weeks o ges a ion (Table 1); 10% es ed
posi i e in he apid diagnos ic es o mala ia, and 14% had
Hb <100 g/L.
We en olled 1228 in an s a bi h ou o 1257 deli e ies;
in an s om 29 deli e ies who we e s illbo n could no be
en olled (Figu e 1). In all, 1197 in an s a ended he labo a o y
isi a 6 mo o age, and 1185 o he 1228 en olled comple ed
he s udy a 18 mo o age. The easons some in an s did no
comple e he s udy we e dea h (n=27), pa en al e usal (n=9),
and eloca ion om he s udy si e (n=7). Only 1.4% o in an s
a 6 mo o age and 1.1% a 18 mo o age had posi i e esul s in
he apid diagnos ic es o mala ia; hese esul s did no di e
by g oup a ei he o he 2 ime poin s.
O e all, he child en’s mean ±SD Hb concen a ion was
113 ±9.9 g/L a 6 mo o age and 112 ±10.4 g/L a 18 mo o
age, whe eas he geome ic mean (95% CI) ZPP concen a ion
was 62.6 µmol/mol heme (60.6, 64.7 µmol/mol heme) a
6 mo o age and 57.6 µmol/mol heme (55.7, 59.7 µmol/mol
heme) a 18 mo o age. When using he WHO cu o (32,
33), he p e alence o anemia was 35.3% a 6 mo o age and
42.9% a 18 mo o age, whe eas he p e alence o IDA was
19.1% a 6 mo o age and 21.0% a 18 mo o age. When using
he cu o s desc ibed by Domellö e al. (34) and he INACG
(31), howe e , he o e all p e alences o anemia (18.6% a
6moo age;5.2%a 18moo age)andIDA(11.9%a
6 mo o age; 3.9% a 18 mo o age) we e much lowe .
G oup compa isons
In he unadjus ed analyses o con inuous ou comes (Table 2),
mean Hb and geome ic mean ZPP concen a ions a 6 mo o
age did no di e by in e en ion g oup, bu geome ic mean
CRP and AGP we e signi ican ly lowe in he IFA and LNS
g oups han in he MMN g oup. A 18 mo o age, mean
Hb and geome ic mean CRP and AGP concen a ions did
no di e by in e en ion g oup, bu geome ic mean ZPP
concen a ion was lowe in he LNS g oup compa ed wi h
he IFA, bu no he MMN g oup, whe eas he IFA and
MMN g oups did no di e in any o hese ou comes. In
he seconda y analysis in which he IFA and MMN g oups
we e combined (Supplemen al Table 1), geome ic mean (95%
CI) ZPP concen a ion a 18 mo o age was signi ican ly
lowe (P=0.008) in he LNS g oup [53.9 µmol/mol heme
(50.7, 57.3 µmol/mol heme)] han in he IFA +MMN g oup
[59.6 µmol/mol heme (57.1, 62.1 µmol/mol heme)].
152 Adu-A a wuah e al.
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misca iages misca iages
sllbi hs
misca iages
sllbi hs
sllbi hs
FIGURE 1 S udy p o ile showing in an s whose mo he s we e en olled in o he ial, and he easons some in an s we e los o ollow-up.
IFA, I on and Folic Acid g oup: in an s we e assigned o ecei e no supplemen s, hei mo he s we e assigned o ecei e 60 mg Fe/d and 400
µg olic acid/d du ing p egnancy and 200 mg Ca/d as placebo du ing he i s 6 mo pos pa um; LNS, Lipid-based Nu ien Supplemen g oup:
in an s we e assigned o ecei e 20 g Lipid-based Nu ien Supplemen /d (designed o in an s) con aining 6 mg Fe/d om 6 o 18 mo o age,
hei mo he s ecei ed 20 g Lipid-based Nu ien Supplemen /d (designed o women) wi h he same mic onu ien s as he MMN g oup du ing
p egnancy and he i s 6 mo pos pa um—bo h Lipid-based Nu ien Supplemen p oduc s con ained 4 addi ional mine als (calcium, phospho us,
po assium, and magnesium) as well as mac onu ien s; MMN, Mul iple Mic onu ien g oup: in an s we e assigned o ecei e no supplemen s,
hei mo he s we e assigned o ecei e a mul iple mic onu ien capsule con aining 18 i amins and mine als, including 20 mg Fe, daily du ing
p egnancy and he i s 6 mo pos pa um.
In he unadjus ed analyses o bina y ou comes (Table 3),
he e was a end (P=0.07) owa ds a lowe p e alence o
ele a ed ZPP in he LNS g oup han in he o he 2 g oups a
18 mo o age when g oups we e based on supplemen s women
we e in ended o ecei e when en olled; when g oups we e
based on supplemen s women ac ually ecei ed when en olled,
he p e alence o ele a ed ZPP a 18 mo o age was signi ican ly
lowe in he LNS g oup han in he o he 2 g oups, which
did no di e in his ou come ega dless o how g oups we e
analyzed. The in e en ion g oups did no di e in any o he
o he bina y ou comes. In he seconda y analysis (Supplemen al
Table 2), child en in he LNS g oup had a ma ginally lowe
p e alence o anemia (38.7% compa ed wi h 44.9%; P=0.06)
based on he WHO cu o , and a signi ican ly lowe RR (95%
CI) o ele a ed ZPP [0.79 µmol/mol heme (0.64, 0.97 µmol/mol
heme); P=0.02] a 18 mo o age compa ed wi h he IFA and
MMN g oups combined.
The esul s we e unchanged in he adjus ed analyses (da a
no shown), excep o he p e alence o ele a ed ZPP, in which
case he di e ence be ween he LNS g oup and he o he 2
g oups became nonsigni ican , al hough he poin es ima es
we e consis en wi h he unadjus ed esul s. Finally, in he
sensi i i y analysis in which Hb and ZPP alues we e co ec ed
o in lamma ion in a subsample (Supplemen al Table 3), he
geome ic mean (95% CI) ZPP concen a ion a 18 mo o
age was signi ican ly lowe (P=0.044) in he LNS g oup
[53.9 µmol/mol heme (50.7, 57.3 µmol/mol heme)] han in
he IFA [59.6 µmol/mol heme (56.2, 63.3 µmol/mol heme)] o
he MMN [59.5 µmol/mol heme (56.0, 63.1 µmol/mol heme)]
g oup, whe eas he IFA and MMN g oups did no di e in his
ou come. None o he bina y ou come measu es gene a ed om
he in lamma ion-co ec ed Hb and ZPP alues (Supplemen al
Table 4) di e ed be ween he 2 in e en ion g oups.
Discussion
We ound ha supplemen a ion o women’s die wi h 60 mg
Fe/d and 400 µg olic acid/d du ing p egnancy and placebo
in he i s 6 mo pos pa um, o mul iple mic onu ien
supplemen s o SQ-LNSs con aining 20 mg Fe/d du ing bo h
Ma e nal and in an SQ-LNS and in an i on s a us 153
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TABLE 2 Unadjus ed con inuous ou come measu es (hemoglobin and bioma ke s o i on s a us and in lamma ion) o in an s in he
iLiNS-DYAD andomized ial o daily nu ien supplemen a ion in a semiu ban se ing in Ghana, by in e en ion g oup1
In e en ion g oup based on supplemen s mo he s
we e in ended o ecei e when en olled
In e en ion g oup based on supplemen s mo he s
ac ually ecei ed when en olled
Ou come a iable
IFA
(n=441)
MMN
(n=439)
LNS
(n=440) P2
IFA
(n=441)
MMN
(n=439)
LNS
(n=440) P2
Hemoglobin, g/L
6 mo 113 ±11 (310) 113 ±10 (325) 114 ±10 (313) 0.72 114 ±10 (308) 112 ±10 (327) 114 ±10 (313) 0.17
18 mo 112 ±11 (333) 112 ±11 (328) 113 ±10 (328) 0.21 112 ±11 (321) 112 ±10 (340) 113 ±10 (328) 0.19
ZPP, µmol/mol heme
6 mo 62.8 (59.1, 66.7)
[300]
61.5 (58.3, 65.0)
[316]
63.5 (60.0, 67.1)
[299]
0.49 60.8 (57.3, 64.5)
[301]
63.4 (60.0, 67.1)
[315]
63.5 (60.0, 67.1)
[299]
0.74
18 mo 60.4 (56.7, 64.3)b
[329]
58.8 (55.6, 62.2)ab
[323]
53.9 (50.7, 57.3)a
[320]
0.031 59.6 (56.2, 63.3)b
[317]
59.5 (56.0, 63.1)ab
[335]
53.9 (50.7, 57.3)a
[320]
0.026
CRP, mg/L
6 mo 0.32 (0.22, 0.46)a
[102]
0.65 (0.43, 0.99)b
[100]
0.41 (0.28, 0.60)ab
[101]
0.033 — — —
18 mo 0.58 (0.39, 0.84)
[101]
0.71 (0.50, 1.01)
[101]
0.94 (0.63, 1.42)
[100]
0.19 — — —
AGP, g/L
6 mo 0.80 (0.75, 0.86)ab
[102]
0.90 (0.84, 0.97)b
[100]
0.80 (0.74, 0.86)a
[101]
0.027 — — —
18 mo 0.96 (0.89, 1.04)
[101]
0.94 (0.88, 1.00)
[101]
1.03 (0.96, 1.11)
[100]
0.17 — — —
1All supplemen s we e in ended o daily consump ion. The subsample o he CRP and AGP analyses was selec ed om he child en whose mo he s we e no p egnan du ing
he pe iod when he empo a y mislabeling occu ed. Resul s a e based on ANOVA (SAS PROC GLIMMIX). Values o hemoglobin a e means ±SDs (numbe o pa icipan s
analyzed o he ou come); alues o ZPP, CRP, and AGP a e geome ic means (95% CIs) [numbe o pa icipan s analyzed o he ou come in ques ion]. Fo each analysis scena io,
alues in he same ow wi hou a common supe sc ip le e a e signi ican ly di e en a α=0.05. AGP, α-1 acid glycop o ein; CRP, C- eac i e p o ein; IFA, I on and Folic Acid
g oup: in an s we e assigned o no supplemen s, hei mo he s we e assigned o ecei e 60 mg Fe/d and 400 µg olic acid/d du ing p egnancy and 200 mg Ca/d as placebo
du ing he i s 6 mo pos pa um; iLiNS, In e na ional Lipid-based Nu ien Supplemen s; LNS, Lipid-based Nu ien Supplemen g oup: in an s we e assigned o ecei e 20 g
Lipid-based Nu ien Supplemen /d (designed o in an s) con aining 6 mg Fe/d om 6 o 18 mo o age, hei mo he s ecei ed 20 g Lipid-based Nu ien Supplemen /d (designed
o women) wi h he same mic onu ien s as he MMN g oup du ing p egnancy and he i s 6 mo pos pa um—bo h Lipid-based Nu ien Supplemen p oduc s con ained
4 addi ional mine als (calcium, phospho us, po assium, and magnesium) as well as mac onu ien s; MMN, Mul iple Mic onu ien g oup: in an s we e assigned o ecei e no
supplemen s, hei mo he s we e assigned o ecei e a mul iple mic onu ien capsule con aining 18 i amins and mine als, including 20 mg Fe, daily du ing p egnancy and he
i s 6 mo pos pa um; ZPP, zinc p o opo phy in.
2P alues compa e he means o geome ic means o 3 g oups, wi h Tukey–K ame adjus men o pai wise compa isons.
pe iods, did no esul in di e ences in in an Hb o i on s a us
a 6 mo o age. Howe e , in an s who consumed SQ-LNSs om
6 o18moo age,a e hei mo he shadbeengi enSQ-LNSs
du ing p egnancy and lac a ion, had g ea e i on supply o Hb
syn hesis and ma ginally lowe p e alence o anemia han hei
coun e pa s who did no consume any supplemen s om 6
o 18 mo o age and whose mo he s consumed i on and olic
acid du ing p egnancy only, o mul iple mic onu ien s du ing
p egnancy and lac a ion.
We p e iously epo ed he main weaknesses o ou
s udy, including he inabili y o blind he s udy women and
ieldwo ke s o who was in he LNS g oup (in which women
and child en ecei ed SQ-LNSs) and who was in he non-LNS
g oups (in which women ecei ed IFA o MMN capsules and
child en ecei ed no supplemen a ion), assessmen o adhe ence
o supplemen in akes ia ma e nal epo ing a he han
h ough di ec obse a ion, and he exposu e o 340 women in
he IFA and MMN g oups o unin ended supplemen s du ing
all o pa o p egnancy (12,13). Fu he , de e mining CRP
and AGP in a subsample may ha e limi ed ou abili y o de ec
signi ican di e ences among g oups in he sensi i i y analysis
in which we co ec ed o he e ec o in lamma ion on he Hb
and i on s a us ou comes.
The s udy, howe e , had se e al s eng hs, such as using
a ully andomized design, ha ing ac i e con ol g oups, and
comple e blinding o he labo a o y wo ke s in ol ed in sample
collec ion and analysis. Ou app oach o measu ing anemia
by using a ious Hb cu o s was an added s eng h o he
s udy. As p e iously epo ed (12), he unin ended exposu e o
IFA o MMN supplemen s occu ed on only 13% o ollow-
up days, and no women in he LNS g oup we e exposed o
any o he supplemen apa om he in ended SQ-LNSs. We
compa ed se e al seconda y ou comes simul aneously, and i
is possible ha some o ou indings may be due o chance
because o mul iple es ing (46). Howe e , hese ou comes we e
p especi ied, measu ed a he same ime, and highly co ela ed,
and i was logical ha hey would be analyzed oge he (47).
Unde hese ci cums ances, co ec ing o mul iplici y may be
unnecessa y and coun e p oduc i e (46).
We chose ZPP concen a ion (i.e., ZPP:H a io, exp essed
as µmol/mol heme) as he indica o o child en’s i on s a us
because i measu es he adequacy o i on supply o he bone
ma ow o Hb syn hesis (48), and is able o de ec i on
de iciency in he bone ma ow a ea ly s ages (49,50). In
in an s, i on s o es a e o en low o deple ed (48)becauseo he
high i on equi emen (51) o g ow h and de elopmen , and
in addi ion, i on s o es may be deple ed be o e abso p ion is
su icien ly up egula ed.
I is no ewo hy ha in an s in he 3 g oups did no di e
in mean Hb concen a ion o i on s a us a 6 mo o age.
We p e iously epo ed (14) ha mo he s o in an s in he
MMN and LNS g oups, who consumed supplemen s wi h a
154 Adu-A a wuah e al.
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TABLE 3 Unadjus ed bina y ou come measu es (anemia and bioma ke s o i on s a us) o in an s in he iLiNS-DYAD andomized
ial o daily nu ien supplemen a ion in a semiu ban se ing in Ghana, by in e en ion g oup1
In e en ion g oups based on supplemen s mo he s
we e in ended o ecei e when en olled
In e en ion g oups based on supplemen s mo he s
ac ually ecei ed when en olled
IFA
(n=441)
MMN
(n=439)
LNS
(n=440) P2
IFA
(n=441)
MMN
(n=439)
LNS
(n=440) P2
Anemia3
6 mo 37.1 (31.9, 42.6)
[310]
35.4 (30.4, 40.7)
[325]
33.5 (28.5, 39.0)
[313]
0.65 33.4 (28.4, 38.9)
[308]
38.8 (33.7, 44.2)
[327]
33.5 (28.5, 39.0)
[313]
0.26
18 mo 42.6 (37.4, 48.0)
[333]
47.3 (41.9, 52.7)
[328]
38.7 (33.6, 44.1)
[328]
0.09 43.9 (38.6, 49.4)
[321]
45.9 (40.6, 51.2)
[340]
38.7 (33.6, 44.1)
[328]
0.16
Anemia4
6 mo 19.7 (15.6, 24.5)
[310]
19.4 (15.4, 24.1)
[325]
16.6 (12.9, 21.2)
[313]
0.55 19.2 (15.1, 23.9)
[308]
19.9 (15.9, 24.6)
[327]
16.6 (12.9, 21.2)
[313]
0.54
18 mo 6.0 (3.9, 9.1)
[333]
4.9 (3.0, 7.8)
[328]
4.6 (2.8, 7.5)
[328]
0.68 5.6 (3.6, 8.7)
[321]
5.3 (3.4, 8.2)
[340]
4.6 (2.8, 7.5)
[328]
0.83
Ele a ed ZPP5
6 mo 31.7 (26.6, 37.2)
[300]
37.7 (32.5, 43.1)
[316]
35.8 (30.5, 41.4)
[299]
0.28 34.6 (29.4, 40.1)
[301]
34.9 (29.8, 40.4)
[315]
35.8 (30.5, 41.4)
[299]
0.95
18 mo 35.3 (30.3, 40.6)
[329]
34.7 (29.7, 40.0)
[323]
27.5 (22.9, 32.7)
[320]
0.07 36.6 (31.5, 42.0)b
[317]
33.4 (28.6,
38.7)ab [335]
27.5 (22.9, 32.7)a
[320]
0.046
IDA6
6 mo 19.0 (14.9, 23.8)
[300]
18.7 (14.7, 23.4)
[316]
19.7 (15.6, 24.6)
[299]
0.94 17.9 (14.0, 22.7)
[301]
19.7 (15.7, 24.5)
[315]
19.7 (15.6, 24.6)
[299]
0.82
18 mo 23.4 (19.1, 28.3)
[329]
21.4 (17.2, 26.2)
[323]
18.1 (14.3, 22.7)
[320]
0.25 23.3 (19.0, 28.3)
[317]
21.5 (17.4, 26.2)
[335]
18.1 (14.3, 22.7)
[320]
0.26
IDA7
6 mo 12.0 (8.8, 16.2)
[300]
11.7 (8.6, 15.8)
[316]
12.0 (8.8, 16.2)
[299]
0.99 11.6 (8.5, 15.8)
[301]
12.1 (8.9, 16.2)
[315]
12.0 (8.8, 16.2)
[299]
0.98
18 mo 4.9 (3.0, 7.8)
[329]
3.4 (1.9, 6.0)
[323]
3.4 (1.9, 6.1)
[320]
0.55 4.4 (2.6, 7.3)
[317]
3.9 (2.3, 6.6)
[335]
3.4 (1.9, 6.1)
[320]
0.82
1All supplemen s we e in ended o daily consump ion. Resul s a e based on logis ic eg ession models (SAS PROC GLIMMIX). Values a e pe cen ages (95% CIs) o pa icipan s
iden i ied as “yes” o he ou come in ques ion [numbe o pa icipan s analyzed o he ou come in ques ion]. Values in he same ow wi hou a common supe sc ip le e a e
signi ican ly di e en a α=0.05. IDA, i on de iciency anemia; IFA, I on and Folic Acid g oup: in an s we e assigned o ecei e no supplemen s, hei mo he s we e assigned o
ecei e 60 mg Fe/d and 400 µg olic acid/d du ing p egnancy and 200 mg Ca/d as placebo du ing he i s 6 mo pos pa um; iLiNS, In e na ional Lipid-based Nu ien Supplemen s;
LNS, Lipid-based Nu ien Supplemen g oup: in an s we e assigned o ecei e 20 g Lipid-based Nu ien Supplemen /d (designed o in an s) con aining 6 mg Fe/d om 6 o
18 mo o age, hei mo he s ecei ed 20 g Lipid-based Nu ien Supplemen /d (designed o women) wi h he same mic onu ien s as he MMN g oup du ing p egnancy and
he i s 6 mo pos pa um—bo h LNS p oduc s con ained 4 addi ional mine als (calcium, phospho us, po assium, and magnesium) as well as mac onu ien s; MMN, Mul iple
Mic onu ien g oup: in an s we e assigned o ecei e no supplemen s, hei mo he s we e assigned o ecei e a mul iple mic onu ien capsule con aining 18 i amins and
mine als, including 20 mg Fe, daily du ing p egnancy and he i s 6 mo pos pa um; ZPP, zinc p o opo phy in.
2P alues compa e all 3 g oups, wi h Tukey–K ame adjus men o pai wise compa isons.
3Anemia de ined as blood hemoglobin <110 g/L (33).
4Anemia de ined as blood hemoglobin <105 g/L o child en a 6 mo o age (34), and blood hemoglobin <100 g/L o child en a 18 mo o age (31,34).
5Ele a ed ZPP conside ed indica i e o i on de iciency was de ined as ZPP >70 µmol/mol heme. This (mode a e) cu o is consis en wi h ZPP concen a ion >10 h pe cen ile
o p eschool child en (35–37).
6IDA was de ined as blood hemoglobin <110 g/L and ZPP >70 µmol/mol heme (33,35–37).
7IDA was de ined as blood hemoglobin <105 g/L (34) and ZPP >70 µmol/mol heme (33,35–37) o child en a 6 mo o age, and blood hemoglobin <100 g/L (31,34)and
ZPP >70 µmol/mol heme (33,35–37) o child en a 18 mo o age.
lowe i on con en (20 mg/d) han did hose in he IFA g oup
(60 mg/d), had a lowe mean Hb concen a ion, lowe i on
s a us (highe mean ZPP and plasma ans e in ecep o ), and a
highe p e alence o anemia a 36 weeks o ges a ion. The e o e,
he in an s in he MMN and LNS g oups we e expec ed o be
mo e likely han hose in he IFA g oup o be anemic and/o o
ha e lowe i on s a us (e.g., highe mean ZPP concen a ion)
by 6 mo o age, because o e idence ha an in an ’s isk o
de eloping anemia a e bi h is ela ed o he mo he ’s anemia
and i on s a us a deli e y (52–54), whe eas ma e nal i on
in ake pos pa um does no a ec b eas -milk i on con en (55).
On he o he hand, in an s in he LNS g oup we e p e iously
epo ed o ha e a g ea e mean bi h weigh han hose in he
IFA g oup (13), and hus may ha e had g ea e i on s o es a
bi h (52,56). Ou indings sugges ha any isk o de eloping
anemia among child en in he LNS g oup (and possibly he
MMN g oup) du ing he i s 6 mo a e deli e y as a esul o
hei mo he s consuming supplemen s wi h lowe i on con en
du ing p egnancy may ha e been o se h ough g ea e i on
s o es esul ing om inc eased bi h weigh . Few andomized
con olled ials ha e examined he impac o p ena al i on
supplemen a ion on he Hb concen a ion o i on s a us o he
o sp ing du ing he i s 6 mo o li e (57). Ou s udy p o ides
e idence ha in his se ing whe e i on de iciency in in ancy is
common (58), he consump ion o SQ-LNSs du ing p egnancy
(in compa ison wi h he s anda d dose o i on and olic acid)
does no comp omise he Hb p oduc ion o i on s a us o in an s
a 6 mo o age. The ex en o which he inc eased bi h weigh
in he LNS g oup con ibu ed o he Hb concen a ion and i on
s a us a 6 mo o age equi es u he in es iga ion.
F om 6 o 18 mo o age, he i on dosage (6 mg/d) gi en o
in an s in he LNS g oup was lowe han ha used in mos home
Ma e nal and in an SQ-LNS and in an i on s a us 155
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o i ica ion ials (59) including ou p e ious s udy in Ghana
(26). Howe e , a simila dosage was used in SQ-LNS p oduc s
in a ial in Bu kina Faso (60), whe e in an s consuming hese
p oduc s om 9 o 18 mo o age along wi h mala ia and
dia hea ea men had lowe p e alence o anemia and i on
de iciency han did child en who ecei ed no in e en ion. In
China, he consump ion o a o i ied ood supplemen con ain-
ing 6 mg Fe/d by in an s 4–12 mo o age inc eased he child en’s
mean Hb concen a ion compa ed wi h he consump ion o an
un o i ied ood supplemen (61). Thus, i is likely ha he i on
dosage used in he p esen s udy was adequa e.
Ou esul s on in an s’ i on s a us a 18 mo o age a e
consis en wi h hose om Bu kina Faso (60) and ou p e ious
s udy in Ghana (62) showing ha SQ-LNS supplemen a ion
educed he p e alence o i on de iciency when compa ed wi h
no supplemen a ion o in an s. In hose 2 p e ious s udies,
he pe cen age o child en wi h low e i in o ele a ed se um
ans e in ecep o was lowe among hose who consumed SQ-
LNSs han among child en who did no consume any supple-
men s, al hough he geome ic mean ZPP concen a ion did no
di e be ween he in e en ion and nonin e en ion g oups in
Bu kina Faso (60), and ZPP was no measu ed in Ghana (62). A
p e ious me a-analysis demons a ed ha home o i ica ion o
complemen a y oods, including he use o SQ-LNSs, is e ec i e
o he p e en ion o IDA (59). In he cu en s udy, he e
we e no signi ican di e ences in mean Hb concen a ion o
p e alence o anemia, which appea s o con adic p e ious
esul s (60,62). Howe e , he e was a end o a di e ence
in anemia p e alence a 18 mo o age when compa ing he
LNS g oup wi h he o he 2 g oups combined, equi alen o
a 14% educ ion in he isk o anemia. A possible eason o
he lack o signi ican g oup di e ences could be ha in he
cu en ial, child en’s mean Hb concen a ion a 6 mo o age
(113 g/L) was ela i ely high, compa ed wi h ha (107 g/L) in
he p e ious s udy in Ghana (62) o ha (88 g/L) o he 9-mo-
old child en in Bu kina Faso (60). Thus, in an s in his s udy
may ha e been less likely o demons a e a esponse o SQ-LNSs
han in an s in he o he 2 s udies (60,62).
Acco ding o he Ghana Demog aphic and Heal h Su ey
(GDHS) 2014 epo (63), 78% o child en 12–17 mo o
age and 74% o child en 18–23 mo o age in Ghana we e
anemic when using he WHO cu o (Hb <110 g/L) o de ine
anemia. The ela i ely low anemia p e alence a 18 mo o
age obse ed in ou ial (42.9%) he e o e con lic s wi h
he GDHS 2014 epo , pe haps because o egional and/o
sub egional a ia ions in he dis ibu ion o anemia p e alence
in Ghana, o me hodological di e ences such as collec ion o
capilla y as opposed o enous blood, use o di e en models o
he Hemocue pho ome e , o di e en p o ocols o handling
samples o measu ing Hb concen a ion. I is unlikely ha
he disc epancy is due o a dec easing secula end o anemia
p e alence in Ghana, because he GDHS and ou ial we e
conduc ed a ound he same pe iod o ime.
Ou obse a ion ha nea ly 39% o he child en in he LNS
g oup we e anemic a 18 mo o age based on he WHO cu o o
110 g/L, despi e he SQ-LNS supplemen a ion, wa an s u he
discussion. In Wes A ica including Ghana, he main causes
o anemia in child en <5 y o age a e i on de iciency, mala ia,
schis osomiasis, sickle cell diso de s, and hookwo m in ec ion
(in dec easing o de o impo ance) (64). We do no ha e da a
on sickle cell diso de s, bu gi en he low pe cen age (∼1% a
6 o 18 mo o age) o child en who es ed posi i e o mala ia,
as well as he child en’s young age o 18 mo, i is unlikely ha
mala ia, schis osomiasis, and hookwo m in ec ions con ibu ed
subs an ially o anemia in ou sample. Thus, non esponsi e
anemia in he LNS g oup migh be due o poo i on abso p ion
o u iliza ion a ibu able o ac o s including: an inu i ional
compounds, e.g., phenolic compounds in he p edominan ly
plan -based die educing i on abso p ion (65–68); gas ic
acid hyposec e ion (69,70) educing i on abso p ion (71,
72); and hepcidin-induced inhibi ion o i on abso p ion and
anspo due o in lamma ion (73,74). Al e na i ely, he
WHO cu o may be oo high, leading o an o e es ima ion
o anemia p e alence. When using a lowe cu o o <100
g/L, as ecommended by INACG (31), anemia p e alence in
he LNS g oup a 18 mo o age was only 4.6%. In Ghana,
anemia p e alence in child en (using he s anda d cu o ) has
emained high (63) and supposedly nea ly un esponsi e o
a ious mala ia and helmin h educ ion in e en ions (75).
We conclude ha ma e nal and in an supplemen a ion wi h
SQ-LNSs inc eases in an s’ i on s a us in his semiu ban se ing
in Ghana. Mo e esea ch is needed o in es iga e he lack o Hb
esponse o mic onu ien supplemen a ion among child en in
his and simila se ings, and o iden i y app op ia e cu o s o
de ining anemia in child en (76).
Acknowledgmen s
We hank he labo a o y s a , Se h An wi, Ronnie Osei-
Boa eng, and F ancis Maunge , o hei oles in he blood
collec ion as well as Hb and ZPP de e mina ion; Lacey
Baldi iez and Se i Shahab-Fe dows a he WHNRC o
he CRP and AGP analyses; Jane M Pee son and Cha les
D A nold o con ibu ing o SAS p og amming; Elizabe h
L P ado o sugges ions; iLiNS P ojec S ee ing Commi ee
membe s Kenne h H B own, Mamane Zeilani, S ephen A Vos i,
Kenne h Male a, and Jean Bosco Oued aogo o ad ice in
ial concep ualiza ion; and Lindsay Allen o helping o de ine
he SQ-LNS o mula ion. The au ho s’ esponsibili ies we e
as ollows—SA-A, AL, PA, and KGD: designed he esea ch;
SA-A, AL, and HO: conduc ed he esea ch; SA-A and RTY:
pe o med he s a is ical analysis; SA-A and KGD: w o e he
manusc ip ; RTY, AL, HO, PA, UA, BMO, and MA: e iewed
he d a manusc ip ; and all au ho s: ead and app o ed he
inal manusc ip .
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