The role of zinc and iron-folic acid supplementation on early child temperament and eating behaviors in rural Nepal: a randomized controlled trial

Pamela J Surkan, Mary Katherine Charles, Joanne Katz, Emily H Siegel, Subarna K Khatry, Steven C LeClerq, Rebecca J Stoltzfus, James M Tielsch, Pamela J Surkan, Mary Katherine Charles, Joanne Katz, Emily H Siegel, Subarna K Khatry, Steven C LeClerq, Rebecca J Stoltzfus, James M Tielsch

Abstract

Child eating behaviors play an important role in nutrient intake, ultimately affecting child growth and later outcomes in adulthood. The study assessed the effects of iron-folic acid and zinc supplementation on child temperament and child eating behaviors in rural Nepal. Children (N = 569) aged 4-17 months in Sarlahi district, southern Nepal were randomized to receive daily supplements of placebo, iron-folic acid, zinc, or zinc plus iron-folic acid and followed for approximately 1 year. At baseline and four follow-up visits mothers completed questionnaires including information on demographic characteristics and child temperament and eating behaviors. The main effects of zinc and iron-folic acid supplementation on temperament and eating behaviors were assessed through crude and adjusted differences in mean cumulative score changes between visits 1 and 5. The adjusted rate-of-change for these outcomes was modeled using generalized estimating equations. Mean changes in temperament scores and in eating behavior scores between visits 1 and 5 were not significant in either the zinc or non-zinc group. Children in the iron-folic acid group increased temperament scores by 0.37 points over 5 visits (95% CI 0.02, 0.7), which was not significant after adjustment. Neither the adjusted rate-of-change in temperament scores between zinc and non-zinc (β = -0.03, 95% CI -0.3, 0.2) or iron-folic acid and non-iron-folic acid (β = 0.08, 95% CI -0.2, 0.3) were significantly different. Adjusted rate of change analysis showed no significant difference between zinc and non-zinc (β = -0.14, 95% CI -0.3, 0.04) or between iron and non-iron eating behavior scores (β = -0.11, 95% CI -0.3, 0.1). Only among children with iron-deficiency anemia at baseline was there a significant decrease in eating behavior score, indicating better eating behaviors, when supplemented with zinc (β = -0.3, 95% CI -0.6, -0.01), Ultimately, this effect of zinc on eating behaviors was the only effect we observed after approximately one year of micronutrient supplementation.

Trial registration: ClinicalTrials.gov NCT00109551.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. CONSORT Diagram of Participant Flow.
Fig 1. CONSORT Diagram of Participant Flow.
*Infants were ineligible for eating behavior measurements during a visit if they consumed only breast milk and/or water.
Fig 2. Mean Adjusted Temperament Score by…
Fig 2. Mean Adjusted Temperament Score by Zinc over Time.
Fig 3. Mean Adjusted Temperament Score by…
Fig 3. Mean Adjusted Temperament Score by Iron over Time.
Fig 4. Mean Adjusted Eating Behavior Score…
Fig 4. Mean Adjusted Eating Behavior Score by Zinc over Time.
Fig 5. Mean Adjusted Eating Behavior Score…
Fig 5. Mean Adjusted Eating Behavior Score by Iron over Time.

References

    1. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, et al. (2008) Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 371: 243–260. 10.1016/S0140-6736(07)61690-0
    1. Khan Y, Bhutta ZA (2010) Nutritional deficiencies in the developing world: current status and opportunities for intervention. Pediatr Clin North Am 57: 1409–1441. 10.1016/j.pcl.2010.09.016
    1. Siegel EH, Stoltzfus RJ, Khatry SK, Leclerq SC, Katz J, et al. (2006) Epidemiology of anemia among 4- to 17-month-old children living in south central Nepal. Eur J Clin Nutr 60: 228–235.
    1. Tielsch JM, Khatry SK, Stoltzfus RJ, Katz J, LeClerq SC, et al. (2007) Effect of daily zinc supplementation on child mortality in southern Nepal: a community-based, cluster randomised, placebo-controlled trial. Lancet 370: 1230–1239.
    1. Powell FC, Farrow CV, Meyer C (2011) Food avoidance in children. The influence of maternal feeding practices and behaviours. Appetite 57: 683–692. 10.1016/j.appet.2011.08.011
    1. Wachs TD, Pollitt E, Cueto S, Jacoby E, Creed-Kanashiro H (2005) Relation of neonatal iron status to individual variability in neonatal temperament. Dev Psychobiol 46: 141–153.
    1. Rothbart MK, Bates JE (2006) Temperament In: Eisenberg W, Damon W, Lerner RM, editors. Handbook of child psychology: Vol 3, Social, emotional and persoanlity development. 6th ed. Hoboken, NJ: Wiley; pp. 99–166.
    1. Bates J (1989) In: Kohnstamm G, Bates J, Rothbart M, editors. Temperament in Childhoodhood. New York: Wiley; pp. 3–26.
    1. Carey WB (1985) Temperament and increased weight gain in infants. J Dev Behav Pediatr 6: 128–131.
    1. Bithoney WG, Newberger EH (1987) Child and family attributes of failure-to-thrive. J Dev Behav Pediatr 8: 32–36.
    1. Nakao H, Aoyama H, Suzuki T (1990) Development of eating behavior and its relation to physical growth in normal weight preschool children. Appetite 14: 45–57.
    1. Haycraft E, Farrow C, Meyer C, Powell F, Blissett J (2011) Relationships between temperament and eating behaviours in young children. Appetite 56: 689–692. 10.1016/j.appet.2011.02.005
    1. Wachs TD (2006) Contributions of temperament to buffering and sensitization processes in children's development. Ann N Y Acad Sci 1094: 28–39.
    1. Dubois L, Farmer AP, Girard M, Peterson K (2007) Preschool children's eating behaviours are related to dietary adequacy and body weight. Eur J Clin Nutr 61: 846–855.
    1. Nicklas TA, Hayes D, American Dietetic A (2008) Position of the American Dietetic Association: nutrition guidance for healthy children ages 2 to 11 years. J Am Diet Assoc 108: 1038–1044, 1046–1037
    1. Benton D (2008) Micronutrient status, cognition and behavioral problems in childhood. Eur J Nutr 47 Suppl 3: 38–50. 10.1007/s00394-008-3004-9
    1. Pollitt E, Leibel RL (1976) Iron deficiency and behavior. J Pediatr 88: 372–381.
    1. Oski FA (1979) The nonhematologic manifestations of iron deficiency. Am J Dis Child 133: 315–322.
    1. Baker-Henningham H, Hamadani JD, Huda SN, Grantham-McGregor SM (2009) Undernourished children have different temperaments than better-nourished children in rural Bangladesh. J Nutr 139: 1765–1771. 10.3945/jn.109.106294
    1. Vaghri Z, Wong H, Barr SI, Chapman GE, Hertzman C (2011) Associations of socio-demographic and behavioral variables with hair zinc of Vancouver preschoolers. Biol Trace Elem Res 143: 1398–1412. 10.1007/s12011-011-8999-8
    1. Hambidge KM, Hambidge C, Jacobs M, Baum JD (1972) Low levels of zinc in hair, anorexia, poor growth, and hypogeusia in children. Pediatr Res 6: 868–874.
    1. Bates JE, Freeland CA, Lounsbury ML (1979) Measurement of infant difficultness. Child Dev 50: 794–803.
    1. Pollitt E, Saco-Pollitt C, Leibel RL, Viteri FE (1986) Iron deficiency and behavioral development in infants and preschool children. Am J Clin Nutr 43: 555–565.
    1. Lozoff B, Brittenham GM (1987) Behavioral alterations in iron deficiency. Hematol Oncol Clin North Am 1: 449–464.
    1. Georgieff MK (2011) Long-term brain and behavioral consequences of early iron deficiency. Nutr Rev 69 Suppl 1: S43–48. 10.1111/j.1753-4887.2011.00432.x
    1. Lozoff B, Corapci F, Burden MJ, Kaciroti N, Angulo-Barroso R, et al. (2007) Preschool-aged children with iron deficiency anemia show altered affect and behavior. J Nutr 137: 683–689.
    1. Corapci F, Radan AE, Lozoff B (2006) Iron deficiency in infancy and mother-child interaction at 5 years. J Dev Behav Pediatr 27: 371–378.
    1. Armony-Sivan R, Kaplan-Estrin M, Jacobson SW, Lozoff B (2010) Iron-deficiency anemia in infancy and mother-infant interaction during feeding. J Dev Behav Pediatr 31: 326–332. 10.1097/DBP.0b013e3181dc525d
    1. Hurley KM, Surkan PJ, Black MM (2011) Maternal depression and child growth in developing countries: A focus on the post-natal period In: Preedy VR, editor. Handbook of Growth Monitoring and Health and Disease. London: Springer Publications.
    1. Dongre AR, Deshmukh PR, Garg BS (2011) Community-led initiative for control of anemia among children 6 to 35 months of age and unmarried adolescent girls in rural Wardha, India. Food Nutr Bull 32: 315–323.
    1. Parsons AG, Zhou SJ, Spurrier NJ, Makrides M (2008) Effect of iron supplementation during pregnancy on the behaviour of children at early school age: long-term follow-up of a randomised controlled trial. Br J Nutr 99: 1133–1139.
    1. Gupta S, Venkateswaran R, Gorenflo DW, Eyler AE (1999) Childhood iron deficiency anemia, maternal nutritional knowledge, and maternal feeding practices in a high-risk population. Prev Med 29: 152–156.
    1. Ashworth A, Morris SS, Lira PI, Grantham-McGregor SM (1998) Zinc supplementation, mental development and behaviour in low birth weight term infants in northeast Brazil. Eur J Clin Nutr 52: 223–227.
    1. Sazawal S, Bentley M, Black RE, Dhingra P, George S, et al. (1996) Effect of zinc supplementation on observed activity in low socioeconomic Indian preschool children. Pediatrics 98: 1132–1137.
    1. Bentley ME, Caulfield LE, Ram M, Santizo MC, Hurtado E, et al. (1997) Zinc supplementation affects the activity patterns of rural Guatemalan infants. J Nutr 127: 1333–1338.
    1. Kirksey A, Rahmanifar A, Wachs TD, McCabe GP, Bassily NS, et al. (1991) Determinants of pregnancy outcome and newborn behavior of a semirural Egyptian population. Am J Clin Nutr 54: 657–667.
    1. DiGirolamo AM, Ramirez-Zea M, Wang M, Flores-Ayala R, Martorell R, et al. (2010) Randomized trial of the effect of zinc supplementation on the mental health of school-age children in Guatemala. Am J Clin Nutr 92: 1241–1250. 10.3945/ajcn.2010.29686
    1. Lozoff B (2007) Iron deficiency and child development. Food Nutr Bull 28: S560–571.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa