The Relationship between Zinc Intake and Serum/Plasma Zinc Concentration in Children: A Systematic Review and Dose-Response Meta-Analysis

Nutrients 2012, 4, 841-858; doi:10.3390/nu4080841 nutrients ISSN 2072-6643 www.mdpi.com/journal/nutrients Review The Relationship between Zinc Intake and Serum/Plasma Zinc Concentration in Children: A Systematic Review and Dose-Response Meta-Analysis Victoria Hall Moran 1, *, Anna-Louise Stammers 2 , Marisol Warthon Medina 2 , Sujata Patel 2 , Fiona Dykes 1 , Olga W. Souverein 3 , Carla Dullemeijer 3 , Carmen Pérez-Rodrigo 4 , Lluis Serra-Majem 5 , Mariela Nissensohn 5 and Nicola M. Lowe 2 1 Maternal & Infant Nutrition & Nurture Unit, University of Central Lancashire, Preston PR1 2HE, UK; E-Mail: [email protected] 2 International Institute of Nutritional Sciences and Food Safety Studies, University of Central Lancashire, Preston PR1 2HE, UK; E-Mails: [email protected] (A.-L.S.); [email protected] (M.W.M.); [email protected] (S.P.); [email protected] (N.M.L.) 3 Division of Human Nutrition, Wageningen University, PO Box 8129, 6700 EV Wageningen, The Netherlands; E-Mails: [email protected]l (O.W.S.); Carla.Dullem[email protected] (C.D.) 4 Community Nutrition Unit, Bilbao City Council, Bilbao 48001, Spain; E-Mail: [email protected] 5 Department of Clinical Sciences, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria 35016, Spain; E-Mails: [email protected]pgc.es (L.S.-M.); [email protected] (M.N.) * Author to whom correspondence should be addressed; E-Mail: [email protected]; Tel.: +44-1772-893830; Fax: +44-1772-892998. Received: 4 May 2012; in revised form: 27 June 2012 / Accepted: 10 July 2012 / Published: 26 July 2012 Abstract: Recommendations for zinc intake during childhood vary widely across Europe. The EURRECA project attempts to consolidate the basis for the definition of micronutrient requirements, taking into account relationships among intake, status and health outcomes, in order to harmonise these recommendations. Data on zinc intake and biomarkers of zinc status reported in randomised controlled trials (RCTs) can provide estimates of dose-response relationships which may be used for underpinning zinc reference values. This systematic review included all RCTs of apparently healthy children aged 1–17 years published by February 2010 which provided data on zinc intake and biomarkers of zinc status. OPEN ACCESS Nutrients 2012, 4 842 An intake-status regression coefficient ( 󰆹) was calculated for each individual study and calculated the overall pooled  󰆹 and SE ( 󰆹) using random effects meta-analysis on a double log scale. The pooled dose-response relationship between zinc intake and zinc status indicated that a doubling of the zinc intake increased the serum/plasma zinc status by 9%. This evidence can be utilised, together with currently used balance studies and repletion/depletion studies, when setting zinc recommendations as a basis for nutrition policies. Keywords: zinc; children; serum zinc; systematic review; dose-response; dietary recommendations; EURRECA 1. Introduction Suboptimal dietary zinc intake is increasingly recognised as an important public health issue. Although the lack of generally accepted biomarkers of zinc status has impeded estimation of the global prevalence of zinc deficiency, based on information regarding the amount of zinc present in national food supplies, it has been estimated that the risk of low dietary intake of absorbable zinc and consequent zinc deficiency affects between one-third and one-half of the world’s population [1] and rates of deficiency may approach 73% in some regions [2]. Although severe zinc deficiency is uncommon in European populations, marginal deficiency is likely to be much more prevalent [3], with associations to immune system dysfunction and restricted physical development [4]. Children are particularly vulnerable to suboptimal zinc status during periods of rapid growth that create increased zinc needs that may not be met [5,6]. It is estimated that over 450,000 deaths per year (4.4% of all mortalities) among children between six months and five years of age are attributable to zinc deficiency [7]. Zinc deficiency also has an impact of child morbidity, impairing growth and contributing to childhood stunting [8,9]. Physiological requirements for zinc peak at the time of the pubertal growth spurt, the onset of which varies according to gender. In girls the onset of the growth spurt (OGS) occurs at 10.1 years and peak height velocity (PHV) occurs at 12.0 years. In boys OGS and PHV occur at 11.8 and 14.2 years, respectively [10]. Even after the growth spurt has ceased, adolescents may require additional zinc to replete tissue zinc pools depleted during puberty [11]. Marginal zinc status during the pubertal growth spurt has been associated with slower skeletal growth, maturation, and reduced bone mineralisation [12–14]. As nearly a third of total skeletal mineral is accumulated in the 3–4 year period immediately after the onset of puberty [15] suboptimal zinc intake may have long-term consequences on bone health. Although a sensitive and specific biomarker has yet to be identified, a recent systematic review concluded that plasma (or serum) zinc concentration was responsive to both zinc supplementation and depletion and is the most widely used biomarker for zinc [16]. However, meta-analytic methods have not yet been used to model zinc status as a function of zinc intake levels. Understanding the relationship between dietary intake and micronutrient status is essential for deriving dietary recommendations. The recommendations for zinc intake during childhood vary widely across Europe and comparisons are difficult due to differences in categorisation. For example between 4 and 6 age categories are used Nutrients 2012, 4 843 to describe micronutrient recommendations in childhood with different age cut-off points being used by different European countries [17,18]. Recommendations for zinc intake differ between males and females at the age of 15 years in most countries, but also differ at the age of 10 years in some countries. Zinc intake values range from 2.9 to 10.0 mg/day in children aged 5 years, 5.7 to 15.5 mg/day (boys) and 4.6 to 15.0 mg/day (girls) in children aged 10–15 years [17]. The EURRECA project attempts to consolidate the basis for the definition of micronutrient requirements across Europe, taking into account relationships among intake, status and health outcomes, in order to harmonise these recommendations [19]. This paper presents a systematic review of the data from all available randomised controlled trials (RCTs) meeting EURRECA’s quality standard [20], which investigated zinc intake and biomarkers of zinc status, and combines these studies in meta-analyses to model zinc concentrations in serum or plasma as a function of zinc intake. 2. Methods 2.1. Search Strategy This research was conducted within the framework of the European Micronutrient Recommendations Aligned (EURRECA) Network of Excellence that aims to identify the micronutrient requirements for optimal health in European populations (EURRECA [21]). This review was part of a wider review process to identify studies assessing the effect of zinc intake on different outcomes (biomarkers of zinc status and health outcomes). The wider searches were performed of literature published up to and including February 2010 using MEDLINE, Embase, and Cochrane using search terms for “study designs in humans” and “zinc” and “intake OR status”. Both indexing and text terms were used and languages included were restricted to those spoken in the EURRECA Network (English, Dutch, French, German, Hungarian, Italian, Norwegian, Polish, Spanish, Greek, and Serbian). The full Ovid MEDLINE search strategy can be found in Table 1. Reference lists of retrieved articles and published literature reviews were also checked for relevant studies. Authors were contacted to request missing data or clarify methods or results. The search process is illustrated in Figure 1. Table 1. Search strategy: MEDLINE February 2010 [22]. No. Search Term Results 1 randomised controlled trial.pt. 280,821 2 controlled clinical trial.pt. 79,998 3 randomised.ab. 196,604 4 placebo.ab. 117,891 5 clinical trials as topic.sh. 146,242 6 randomly.ab. 145,491 7 trial.ab. 203,467 8 randomised.ab. 38,423 9 6 or 3 or 7 or 2 or 8 or 1 or 4 or 5 734,511 10 (animals not (human and animals)).sh. 4,482,479 11 9 not 10 642,665 12 (cohort* or “case control*” or cross-sectional* or “cross sectional” or case-control* or prospective or “systematic review*”).mp. 768,885 Nutrients 2012, 4 844 Table 1. Cont. 13 exp meta-analysis/ or expmulticenter study/ or follow-up studies/ or prospective studies/ or intervention studies/ or epidemiologic studies/ or case-control studies/ or exp cohort studies/ or longitudinal studies/ or cross-sectional studies/ 1,013,635 14 13 or 12 1,203,767 15 14 not 10 1,154,385 16 11 or 15 1,599,094 17 ((zinc or Zn or zinc sulphate or zinc gluconate or zinc acetate or methionine or zinc isotope*) adj3 (intake* or diet* or supplement* or deplet* or status or serum or plasma or leukocyte or concentration* or expos* or fortif* or urine or hair)).ti,ab. 16,681 18 Nutritional Support/ or Dietary Supplements/ or nutritional requirements/ or Breast feeding/ or exp infant food/ or bottle feeding/ or infant formula/ 63,098 19 exp Nutritional Status/ or exp Deficiency Diseases/ or supplementation/ or diet supplementation/ or dietary intake/ or exp diet restriction/ or exp mineral intake/ or Diet/ or Food, Fortified/ or nutrition assessment/ or Nutritive Value/ 176,014 20 (intake* or diet* or supplement* or deplet* or status or serum or plasma or leukocyte or concentration* or expos* or fortif* or urine or hair).ti,ab. 3,166,092 21 18 or 19 or 20 3,263,114 22 zinc/ 41,027 23 22 and 21 20,745 24 23 or 17 26,943 25 24 and 16 2410 2.2. Criteria for the Consideration of Studies for This Review Included studies were RCTs in apparently healthy child (human) populations aged from 1 to 17 years that supplied zinc supplementation either as capsules or part of a fortified meal. If supplemental zinc was provided as a component of a fortified meal, studies were only considered acceptable if zinc was the only constituent that was different between treatment groups. Only studies that measured zinc status as serum or plasma zinc were included; and those that reported sufficient data or had sufficient data obtainable from the authors to estimate  󰆹 and SE ( 󰆹) for the assumed linear relation on the log e –log e scale. Studies were excluded if they were a group RCT (community trial), or were commentaries, reviews, or duplicate publications from the same study. Studies were excluded if children were hospitalised, had severe protein-energy malnutrition or a chronic disease or if supplemental zinc was provided for less than 6 weeks. 2.3. Selection of Articles Of 4719 identified articles in the wider search on zinc intake, status and priority health outcomes in all populations, 2557 were excluded based upon screening of the title and abstract. Two independent reviewers screened 10% of the abstracts in duplicate and any discrepancies were discussed before screening the remaining references. Following subdivision into appropriate population groups the full texts of the 328 manuscripts were assessed to determine inclusion and exclusion by two independent reviewers and disagreements rectified through discussion. 302 studies were excluded because they did not meet the inclusion criteria. Of the remaining 26 studies, 8 studies were excluded as they had not Nutrients 2012, 4 845 investigated the relation between zinc intake and zinc related biomarkers, but related either intake or status directly to a health endpoint. For the purpose of this paper, 18 RCTs remained. Table 2 presents the characteristics of the included studies. Figure 1. Study selection process for systematic review (* some papers reported more than one relationship). 2.4. Data Extraction For each of the identified manuscripts, data was extracted independently by two reviewers into a standardised database. Extracted data included population characteristics, dose of elemental zinc in intervention and placebo supplements, duration of the study, dietary intake of zinc, and mean concentration of zinc in plasma or serum at the end of the intervention period. Serum/plasma zinc concentrations were converted to µmol/L when applicable. Nutrients 2012, 4 846 Table 2. Summary of included trials reporting the effect of dietary zinc intake on serum/plasma zinc status in children. First Author, Year, Country Participants Treatment Groups (n) Mean Zn Intake (mg/day) Mean (SD) Plasma/Serum Zn (µmol/L) Duration Zinc Status Biomarker [Analytical Method] Main Results Mahloudji, 1975, Iran [23] Males & females aged 6–12 years Fe only (12); Fe + 20 mg/day Zn (13) 5.65; 25.65 8.95 (1.80) 8.50 (1.93) 8 months Plasma Zn [AAS] No significant difference between plasma Zn of the supplemented and placebo groups Hambidge, 1979, USA [24] Males & females aged 33–90 months Male placebo (15); Male Zn FM 2.57 mg/day (20); Female placebo (14); Female Zn FM 2.57 mg/day (11) 6.3; 9.27; 6.3; 9.27 11.06 (2.23) 11.85 (2.23) 10.61 (1.81) 11.96 (1.81) 9 months Plasma Zn [AES] Plasma Zn significantly higher in Zn supplemented compared to placebo (girls and combined sexes only p < 0.05) Walravens, 1983, USA [25] Males & females aged 2–6 years Placebo (16); 10 mg/day Zn (16) 4.6; 15.9 11.32 (2.14) 10.86 (2.14) 12 months Plasma Zn [AES] No significant difference between plasma Zn of the supplemented and placebo groups Gibson, 1989, Canada [26] Males aged 59–95 months Placebo (21); 10 mg Zn/day (18) 6.4; 16.7 15.8 (3.5) 17.9 (3.4) 6 months Serum Zn [AAS] No significant correlation between serum Zn and dietary Zn levels Cavan, 1993, Guatemala [27] Males & females, mean age 81.5 (±7.0) months 1 Placebo (74); 10 mg Zn/day (71) 5.65; 15.65 14.9 (2.1) 16.2 (2.9) 25 weeks Plasma Zn [AAS] Plasma Zn significantly higher in Zn supplemented compared to placebo (p < 0.01) Friis, 1997, Zimbabwe [28] Males and females aged 11–17 years Placebo (121); 30–50 mg/day Zn (122) 5.65; 45.65 2 10.89 (2.5) 11.71 (2.4) 12 months Serum Zn [AAS] The decline in zinc concentration was significantly lower in the Zn supplemented group compared to the placebo group (p < 0.02) Rosado, 1997, Mexico [29] Males & females aged 18–36 months Placebo (55); 20 mg Zn/day (54) 5.65; 25.65 14.4 (4.45) 16.8 (5.88) 12 months Plasma Zn [AAS] Plasma Zn increased significantly in the Zn supplemented group over the 12 months period (p < 0.01) Ruz, 1997, Chile [30] Males & females aged 27–50 months Placebo (33); 10 mg/day Zn (36) 6.4; 17.1 17.7 (1.9) 17.6 (2.2) 6 months Plasma Zn [AAS] No significant difference between plasma Zn of the supplemented and placebo groups Sandstead, 1998, China [31] (3 regions) Males & females aged 6–9 years Chonqing MN, no Zn (35); 20 mg/day Zn + MN (35); Quindgdao MN, no Zn (36); 20mg/day Zn + MN (36); Shanghai MN, no Zn (37); 20 mg/day Zn + MN (37) 5.65; 25.65; 5.65; 25.65; 5.65; 25.65 19.83 (4.12) 23.6 (4.12) 20.42 (4.08) 22.97 (4.08) 17.9 (2.75) 17.97 (2.75) 10 weeks Plasma Zn [AAS] Plasma Zn significantly higher in Zn supplemented compared to placebo (p < 0.05) in Chonqing and Quindgdao groups. Nutrients 2012, 4 847 Table 2. Cont. Clark, 1999, UK [32] Peripubertal females, mean age 12.2 (±0.3) years Placebo (19); 15 mg Zn/day (23) 6.6; 21.6 12.6 (1.0) 16.7 (4.9) 6 weeks Serum Zn [no method given] Serum Zn significantly higher in Zn supplemented compared to placebo (p < 0.001) Smith, 1999, Belize [33] Males & females aged 22–66 months Placebo (10); 70 mg Zn/day (12) 5.65; 75.65 11.7 (0.68) 13.5 (0.68) 6 months Serum Zn [AAS] Serum Zn significantly higher in Zn supplemented compared to placebo (p < 0.001) Munoz, 2000, Mexico [34] Males & females aged 18–36 months Placebo (54); 20 mg/day Zn (47) 5.65; 25.65 14.3 (4.7) 16.8 (5.6) 6 months Plasma Zn [AAS] Serum Zn significantly higher in Zn supplemented compared to placebo (p < 0.0001) Lopez de Romana, 2005, Peru [35] Males & females aged 3–4 years Fe FM (12); Fe + 3 mg/day Zn FM (10); Fe + 9 mg/day Zn FM (12); 4.71; 8.72; 15.7 11.87 (1.88) 11.65 (1.25) 12.60 (1.51) 70 days Plasma Zn [ICP-MS] No significant differences in plasma Zn were found between treatments Silva, 2006, Brazil [36] Males & females aged 12–59 months 3 Placebo (30); 10 mg/day Zn (28) 5.65; 15.65 8.0 (0.58) 13.4 (0.25) 4 months Serum Zn [AAS] Serum Zn significantly higher in Zn supplemented compared to placebo (p < 0.05) Sandstead, 2008, USA (Mexican Americans) [37] Males & females aged 6–7 years MN, no Zn (25); 20 mg/day Zn + MN (25) 5.65; 25.65 15.4 (1.5) 15.6 (1.2) 10 weeks Plasma Zn [AAS] Mean plasma Zn increased significantly in both groups compared to baseline (p < 0.05) Wuehler, 2008, Ecuador [38] Males & females aged 12–30 months Placebo (56); 3 mg Zn/day (50); 7 mg Zn/day (52); 10 mg Zn/day (54) 5.65; 8.65; 12.65; 15.65 10.6 (1.6) 12.3 (1.6) 13.3 (1.7) 14.0 (1.7) 4 6 months Plasma Zn [ICP-MS] The mean change in plasma zinc concentrations from baseline increased progressively with higher doses of supplemental Zn (p < 0.001) de Oliveira, 2009, Brazil [39] Pubescent males, mean age 13 ( ± 0.4) years Placebo (26); 22 mg Zn/day (21) 5.65; 27.65 16.9 (2.1) 18.7 (3.5) 12 weeks Plasma Zn [ICP-MS] Plasma Zn significantly higher in Zn supplemented compared to placebo (p < 0.05) Uckarde, 2009, Turkey [40] Males & females aged 8–9 years Placebo (109); 15 mg/day Zn (109) 5.65; 20.65 19.19 (1.80) 19.50 (2.41) 10 weeks Serum Zn [CS] Both supplemented and placebo groups had significantly higher serum Zn at follow up (p < 0.05) AAS, atomic absorption spectroscopy; AES, atomic emission spectroscopy; ICP-MS, inductively coupled plasma mass spectrometry; CS, caloric spectrophotometry; MN, micronutrients; FM, fortified meal; 1 all participants also received MN supplements; 2 children weighing <29.5 kg were given 30 mg Zn/day and those >29.5 kg were given 50 mg Zn/day, this figure is an average of the two doses; 3 all participants also received Fe fortified milk; 4 geometric means. Nutrients 2012, 4 848 2.5. Data Synthesis One study that included two zinc-treated groups and two control groups (males and females) was treated as two independent estimates in the analysis [24] and one study that included three zinc-treated groups and three control groups (from different regions of China) [31] and was treated as three independent estimates in the analysis. Where studies provided outcome data for two or more zinc-treated groups they were included as separate estimates in the meta-analysis [35,38]. In one study zinc status was measured at 6 months and 12 months in the same population [26] and only the measure at 6 months was used in the analysis (where n was the largest). If dietary intake of zinc (in addition to the intervention) was not reported we imputed a value of 5.65 mg/day, the mean dietary intake level of the RCTs (n = 7) that did report dietary zinc intake. As mean baseline serum/plasma zinc concentrations were infrequently reported, the serum/plasma zinc concentrations in the control group of the RCTs were used as a proxy of the baseline serum/plasma zinc concentrations for our analyses. 2.6. Pre-Specified Potential Factors Modifying the Association A pooled meta-analysis was performed combining the evidence from all the available RCTs. In addition, we investigated whether age, dose of zinc, duration of the supplementation, and type of supplement (zinc only vs. zinc with other micronutrients) were variables that modified the association. 2.7. Statistical Analyses As we wanted to estimate the dose-response relation between zinc intake and serum/plasma zinc, the data presented in the studies had to be transformed to a common statistic, namely a regression coefficient ( 󰆹) and the standard error (SE ( 󰆹)) of this regression coefficient. The transformations used to derive this common single-study estimate from the available summary statistics per study have been described elsewhere [41]. In short, we estimated an intake-status regression coefficient ( 󰆹) for each individual study, based on the assumption of a linear relation on the log e –log e -scale (natural logarithm of intake vs. natural logarithm of status). This shape of this linear relationship on the log e –log e -scale corresponds to a monotonic concave function on the original scale for β < 1. This shape is assumed to be realistic for the biological relationship between zinc intake and plasma/serum zinc concentrations. As the true dose-response curve is unknown, this approximation provides a practical methodology to estimate the dose-response relationship. We calculated the overall pooled  󰆹 and SE ( 󰆹) using random effects meta-analysis, which estimates the between-study variance using the method of DerSimonian and Laird and used this estimate to modify the weights used to calculate the summary estimate. Residual heterogeneity between studies was evaluated using the I 2 statistic. Pre-specified potential factors that could modify the association were explored using stratified random effects meta-analyses. The statistical transformations to obtain  󰆹’s and SE ( 󰆹)’s were performed using GenStat version 13-SP2 (VSN International Ltd. [42]) and the meta-analysis was performed using STATA version 11.0 (College Station, TX, USA), with statistical significance defined as p < 0.05. Nutrients 2012, 4 849 2.8. Assessment of Risk of Bias in Included Studies In order to assess the quality of the included studies and the risk of bias, indicators of internal validity were collected during data extraction (Table 2). Based on the indicators two independent reviewers assessed the overall risk of bias and disagreements resolved by discussion. The criteria for judging these indicators were adapted from the Cochrane Handbook for Systematic Reviews [43]. 3. Results Twenty-four estimates of zinc intake and serum/plasma zinc status in 18 RCTs with children were eligible for meta-analysis. All studies were RCTs published between 1975 and 2009 which reported zinc intake and plasma/serum zinc concentrations. The 24 estimates included 1722 participants in total with sample sizes ranging from 10 to 122. The median duration of the trials was 24 weeks (range 6–52 weeks). In 11 studies zinc was supplemented alone at doses ranging from 3 to 70 mg/day and in 7 studies participants also received other micronutrients. Zinc was provided with iron supplements [23] or iron fortified milk [36], as part of a fortified meal [24,35], and with other micronutrients [27,31,37]. The zinc dose ranged from 10 to 20 mg/day when combined with other vitamin/minerals and 2.57 to 9 mg/day when provided in fortified meals. Most studies (n = 7) provided the zinc supplements in the form of zinc sulphate, but others used zinc citrate [32], zinc gluconate [33], zinc carbonate [23], zinc methionine [29,34], amino acid chelate [27], and elemental zinc in a syrup [28,40]. Studies were conducted in Latin America (n = 9), North America (n = 4), Asia (n = 3), Africa (n = 1) and Europe (n = 1). Habitual zinc intakes ranged from 4.6 to 7.1 mg/day (where data was provided) and ages of children ranged from 2 to 17 years. Most studies included, but did not differentiate between, males and females, but one study provided separate male and female data [24], one included only females [32], and one only males [39]. The majority of studies (n = 13) reported that zinc supplementation significantly increased zinc plasma/serum status or significantly reduced the decline in zinc serum values compared to placebo. Of these, two studies also reported increased plasma/serum zinc concentrations in the placebo group. Five studies failed to find a significant relationship between zinc supplementation and zinc status [23,25,26,30,35], four of which provided zinc supplements or fortified meals with a zinc concentration of 10 mg/day or less. Our meta-analysis of available studies suggested that zinc supplementation was associated with increased serum/plasma zinc concentrations. Combining the 18 RCTs in one meta-analysis yielded an overall pooled β-coefficient of 0.12 (95% CI 0.04, 0.20; p < 0.005; I 2 97.6%) (Figure 2). Since we applied a base-e logarithmic transformation on the zinc intake and serum/plasma zinc concentration before calculation of the study-specific  󰆹’s, the overall  󰆹 represents the difference in the log e transformed predicted value of serum/plasma zinc status for each one-unit difference in the log e transformed value in zinc intake. Therefore, an overall  󰆹 of 0.12 means that for every doubling in zinc intake, the difference in zinc serum or plasma concentration is 2  (2 0.12 = 1.09), which is 9%. This means that a person with a zinc intake of 14 mg/day has a zinc serum/plasma concentration that is 9% higher than a person who has a zinc intake of 7 mg/day. Nutrients 2012, 4 856 20. Matthys, C.; van ’t Veer, P.; de Groot, L.; Hooper, L.; Cavelaars, A.E.J.M.; Collings, R.; Donutske-Rutten, R.; Harvey, L.J.; Casgrain, A.; Rollin, F.; et al. EURRECA’s approach for estimating micronutrient requirements. Int. J. Vitam. Nutr. Res. 2011, 81, 256–263. 21. EURRECA Home Page. Available online: http://www.eurreca.org (accessed on 18 July 2012). 22. MEDLINE Home Page. Available online: http://www.ncbi.nlm.nih.gov/pubmed/ (accessed on 10 February 2010). 23. Mahloudji, M.; Reinhold, J.G.; Haghshenass, M.; Ronaghy, H.A.; Fox, M.R.; Halsted, J.A. Combined zinc and iron compared with iron supplementation of diets of 6to 12-year old village schoolchildren in southern Iran. Am. J. Clin. Nutr. 1975, 28, 721–725. 24. Hambidge, K.M.; Chavez, M.N.; Brown, R.M.; Walravens, P.A. Zinc nutritional status of young middle-income children and effects of consuming zinc-fortified breakfast cereals. Am. J. Clin. Nutr. 1979, 32, 2532–2539. 25. Walravens, P.A.; Krebs, N.F.; Hambidge, K.M. Linear growth of low income preschool children receiving a zinc supplement. Am. J. Clin. Nutr. 1983, 38, 195–201. 26. Gibson, R.S.; Smit Vanderkooy, P.D.; MacDonald, A.C.; Goldman, A.; Ryan, B.A.; Berry, M. A growth-limiting, mild zinc-deficiency syndrome in some Southern Ontario boys with low height percentiles. Am. J. Clin. Nutr. 1989, 49, 1266–1273. 27. Cavan, K.R.; Gibson, R.S.; Grazioso, C.F.; Isalgue, A.M.; Ruz, M.; Solomons, N.W. Growth and body composition of periurban Guatemalan children in relation to zinc status: A longitudinal zinc intervention trial. Am. J. Clin. Nutr.1993, 57, 344–352. 28. Friis, H.; Ndhlovu, P.; Mduluza, T.; Kaondera, K.; Sandstrom, B.; Michaelsen, K.F.; Vennervald, B.J.; Christensen, N.O. The impact of zinc supplementation on growth and body composition: A randomized, controlled trial among rural Zimbabwean schoolchildren. Eur. J. Clin. Nutr. 1997, 51, 38–45. 29. Rosado, J.L.; Lopez, P.; Munoz, E.; Martinez, H.; Allen, L.H. Zinc supplementation reduced morbidity, but neither zinc nor iron supplementation affected growth or body composition of Mexican preschoolers. Am. J. Clin. Nutr. 1997, 65, 13–19. 30. Ruz, M.; Castillo-Duran, C.; Lara, X.; Codoceo, J.; Rebolledo, A.; Alalah, E. A 14-mo zinc-supplementation trial in apparently healthy Chilean preschool children. Am. J. Clin. Nutr. 1997, 66, 1406–1413. 31. Sandstead, H.H.; Penland, J.G.; Alcock, N.W.; Dayal, H.H.; Chen, X.C.; Li, J.S.; Zhao, F.; Yang, J.J. Effects of repletion with zinc and other micronutrients on neuropsychologic performance and growth of Chinese children. Am. J. Clin. Nutr. 1998, 68, 470S–475S. 32. Clark, P.J.; Eastell, R.; Barker, M.E. Zinc supplementation and bone growth in pubertal girls. Lancet 1999, 354, 485. 33. Smith, J.C.; Makdani, D.; Hegar, A.; Rao, D.; Douglass, L.W. Vitamin A and zinc supplementation of preschool children. J. Am. Coll. Nutr. 1999, 18, 213–222. 34. Munoz, E.C.; Rosado, J.L.; Lopez, P.; Furr, H.C.; Allen, L.H. Iron and zinc supplementation improves indicators of vitamin A status of Mexican preschoolers. Am. J. Clin. Nutr. 2000, 71, 789–794. Nutrients 2012, 4 857 35. Lopez de Romana, D.; Salazar, M.; Hambidge, K.M.; Penny, M.E.; Peerson, J.M.; Krebs, N.F.; Brown, K.H. Longitudinal measurements of zinc absorption in Peruvian children consuming wheat products fortified with iron only or iron and 1 of 2 amounts of zinc. Am. J. Clin. Nutr. 2005, 81, 637–647. 36. Silva, A.P.R.; Vitolo, M.R.; Zara, L.F.; Castro, C.F.S. Effects of zinc supplementation on 1to 5-year old children. J. Pediatr. 2006, 82, 227–231. 37. Sandstead, H.H.; Prasad, A.S.; Penland, J.G.; Beck, F.W.; Kaplan, J.; Egger, N.G.; Alcock, N.W.; Carroll, R.M.; Ramanujam, V.M.; Dayal, H.H.; et al. Zinc deficiency in Mexican American children: Influence of zinc and other micronutrients on T cells, cytokines, and antiinflammatory plasma proteins. Am. J. Clin. Nutr. 2008, 1067–1073. 38. Wuehler, S.E.; Sempertegui, F.; Brown, K.H. Dose-response trial of prophylactic zinc supplements, with or without copper, in young Ecuadorian children at risk of zinc deficiency. Am. J. Clin. Nutr. 2008, 87, 723–733. 39. De Oliveira, K.D.J.F.; Donangelo, C.M.; de Oliveira, A.V., Jr.; da Silveira, C.L.P.; Koury, J.C. Effect of zinc supplementation on the antioxidant, copper, and iron status of physically active adolescents. Cell Biochem. Funct. 2009, 27, 162–166. 40. Uçkarde; Y.; Ozmert, E.N.; Unal, F.; Yurdakök, K. Effects of zinc supplementation on parent and teacher behaviour rating scores in low socioeconomic level Turkish primary school children. Acta Paediatr. 2009, 98, 731–736. 41. Souverein, O.W.; Dullemeijer, C.; van ’t Veer, P.; van de Voet, H. Transformations of summary statistics as input in meta-analysis for linear dose-response models on a logarithmic scale: A methodology developed within EURRECA. BMC Med. Res. Methodol. 2012, 12, doi:10.1186/1471-2288-12-57. 42. VSN International Ltd. Home Page. Available online: http://www.vsni.co.uk/ (accessed on 18 July 2012). 43. Higgins, J.P.T.; Green, S. Cochrane Handbook for Systematic Reviews for Interventions, version 5.1.0 (updated March 2011); The Cochrane Collaboration, 2011. Available online: http://www.cochrane-handbook.org (accessed on 18 July 2012). 44. Brown, K.H.; Peerson, J.M.; Rivera, J.; Allen, L.H. Effect of supplemental zinc on the growth and serum zinc concentrations of prepubertal children: A meta-analysis of randomized controlled trials. Am. J. Clin. Nutr. 2002, 75, 1062–1071. 45. Hall Moran, V.; Skinner, A.; Warthon Medina, M.; Patel, S.; Dykes, F.; Souverein, O.W.; Dullemeijer, C.; Lowe, N.M. The relationship between zinc intake and serum/plasma zinc concentration in pregnant and lactating women: A systematic review with dose-response meta-analyses. J. Trace Elem. Med. Biol. 2012, 26, 74–79. 46. Lowe, N.M.; Woodhouse, L.R.; King, J.C. A comparison of the short-term kinetics of zinc metabolism in women during fasting and following a breakfast meal. Br. J. Nutr. 1998, 80, 363–370. 47. Lonnerdal, B. Dietary factors influencing zinc absorption. J. Nutr. 2000, 130, 1378S–1383S. 48. Hambidge, K.M.; Miller, L.V.; Westcott, J.E.; Krebs, N.F. Dietary reference intakes for zinc may require adjustment for phytate intake based upon model predictions. J. Nutr. 2008, 138, 2363–2366. Nutrients 2012, 4 858 49. Gibbs, M.M.; Carriquiry, A.L.; Capanzana, M.V.; Gibson, R.S. Establishing desirable fortificant levels for calcium, iron and zinc in foods for infant and young child feeding: examples from three Asian countries Matern. Child Nutr. 2012, doi:10.1111/j.1740-8709.2012.00405.x 50. Solomons, N.W.; Ruz, M. Zinc and iron interaction: Concepts and perspectives in the developing world. Nutr. Res. 1997, 17, 177–185. 51. Walker, C.F.; Kordas, K.; Stoltzfus, R.J.; Black, R.E. Interactive effects of iron and zinc on biochemical and functional outcomes in supplementation trials. Am. J. Clin. Nutr. 2005, 82, 5–12. 52. Domellof, M.; Cohen, R.J.; Dewey, K.G.; Hernell, O.; Rivera, L.L.; Lonnerdal, B. Iron supplementation of breast-fed Honduran and Swedish infants from 4 to 9 months of age. J. Pediatr. 2001, 138, 679–687. 53. Cetin, I.; Koletzko, B.; Moreno, L.A.; Matthys, C. Relevance of European alignment for micronutrients’ recommendation regarding pregnant and lactating women, infants, children and adolescents: an insight into preliminary steps of EURRECA. Matern. Child Nutr. 2010, 6, 3–4. © 2012 by the authors; licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution license (http://creativecommons.org/licenses/by/3.0/).