nutrition and health: suboptimal thiamin status is common in cambodian women of childbearing age

Suboptimal thiamin status is common in Cambodian women of childbearing age

Whitfield, KC, Liu, Y, Karakochuk, CD, Talukder, A, Kroeun, H, Kevanna, O, Kitts, DD, Li-Chan, ECY, McLean, J, Green TJ

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Presented at the International Food Security Dialogue 2014

Enhancing Food Production, Gender Equity and Nutritional Security in a Changing World

Under-nutrition measures for women and children in Africa and Asia

The Fish on Farms project is being jointly conducted by the University of

British Columbia (UBC) and Helen Keller International (HKI), with technical assistance from World Fish, in Prey Veng Province, Cambodia.

This randomized control trial investigates an integrated Homestead Food Production models in relation to poverty, gender empowerment, and food

and nutrition security, particularly among women and children. 

This is the first project known to rigorously measure the effectiveness of different models of Homestead Food Production at reducing undernutrition

using biochemical and anthropometric measurements.

University of British Columbia Ministry of Health, Cambodia Dr. Tim Green, Associate Professor, Human Nutrition Ministry of Planning, Cambodia Dr. Judy McLean, Assistant Professor, Human Nutrition Dr. Susan Barr, Professor, Human Nutrition Dr. Larry Lynd, Professor & Director, Collaboration for Outcomes Research & Evaluation Dr. Tony Farrell, Professor, Centre for Aquaculture and Environmental Research Dr. David Kitts, Professor, Food Science & Associate Dean of Research Dr. Ian Forster, Centre for Aquaculture and Environmental Research Jen Foley, Fish on Farms Program Coordinator

Helen Keller International - Cambodia Graduate Students Dr. Zaman Talukder Kyly Whitfield (PhD, Nutrition) Mr. Hou Kroeun Crystal Karakochuk (PhD, Nutrition) Ms. Ly Sokhoing Vashti Verbowski (MSc, Nutrition) Field Research Team Pardis Lakzadeh (MSc, Public Health)

Jeff Tang (BSc, Science)

Karen People of Mae La Refugee Camp

•  Thai-Burmese border; settled in 1986

•  High infant mortality rate unrelated to major killers •  diarrhea and respiratory illness

•  Between 1987 – 1990, infantile beriberi caused 40% of all infant deaths

McGready et al 2001; Luxemburger et al 2003; Stuetz et al 2012

Background: Thiamin •  Vitamin B1 •  Thiamin diphosphate (TDP)

plays major role in carbohydrate metabolism •  Pentose-Phosphate Pathway •  Kreb’s Cycle

•  Modulates neuronal and neuro-muscular transmissions

Images from: Beltramo, E (2011)

Infantile beriberi •  Stems from thiamin (vitamin B1)

deficiency

•  Symptoms •  signs of right-sided heart failure •  rapid breathing •  generalized edema •  distinctive, hoarse cry

•  Presents around 3 months of age •  Infant AI: 0.2 mg/day

•  AI based on [breast milk thiamin] from apparently replete women

•  Root cause: maternal thiamin deficiency

Thiamin deficiency

© Kyly Whitfield 2012

Rationale

Research question

What is the current level of thiamin

deficiency among women of childbearing age (20-45y) in rural and urban Cambodia?

© Kyly Whitfield 2013

Regional (urban/rural) n=160 per region

16 villages per region

10 women per village

Protocol

Purposeful Selection

Random Selection: Lists

Random Selection: Draw

Protocol

© Kyly Whitfield 2013

© Kyly Whitfield 2013

© Kyly Whitfield 2013

Protocol

© Kyly Whitfield 2014

Results

Phnom Penh (n=146)

Prey Veng (n=156)

Vancouver (n=50)

Age (years; mean±SD) 32.6 ± 7.2 35.1 ± 6.3 26.4 ± 4.6

Body Mass Index (kg/m2; mean±SD) 23.4 ± 4.1 21.6 ± 2.9 22.4 ± 3.8

Ethnicity Khmer Caucasian Non-Caucasian

146 (100%)

- -

156 (100%)

- -

-

34 (68%) 16 (32%)

Thiamin deficiency cut-offs

Thiamin Deficiency Status Thiamin Diphosphate (TDP; nmol/L)

Sufficient > 90 Marginally Deficient 70 - 90

Deficient < 70

•  Measured using high performance liquid chromatography (HPLC)

61%

41%

84%

27%

35%

12% 12%

24%

4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Phnom Penh (urban Cambodia)

Prey Veng (rural Cambodia)

Vancouver (urban Canada)

Results

59% 39%

n=146 n=156 n=50

Results

Population Mean TDP ± SD (nmol/L)

Range (nmol/L)

Phnom Penh (urban Cambodia) 100 ± 28 40 - 195

Prey Veng (rural Cambodia) 87 ± 26 38 - 191

Vancouver (urban Canada) 128 ± 38 42 - 213

What next?

© Kyly Whitfield 2013

Randomized Control Trial

Rationale

Need to improve maternal thiamin status to decrease the incidence of infantile beriberi

Infantile Beriberi

•  change dietary behaviours •  supplementation •  food fortification

Overall Objective

Develop a thiamin-fortified product that, when

consumed by women of childbearing age, increases

thiamin in women’s blood to a level consistent with a low

risk of infantile beriberi.

© Kyly Whitfield 2013

Fortified fish sauce

Protocol

Best option? There are many condiments that could be fortified

Results

Fish Paste Number of Participants % Purchase fish paste at market 144 of 320 45%

No brand 144 of 144 100%

Salt Number of Participants % Purchase salt at market 319 of 320 99%

No brand 173 of 319 54%

Fish Sauce Number of Participants % Purchase fish sauce market 202 of 320 63%

No brand 26 of 202 13%

Intervention

© Kyly Whitfield 2013

Fish Sauce Fortification

© Kyly Whitfield 2013

© Kyly Whitfield 2013

Fish Sauce Fortification

© Kyly Whitfield 2013

© Kyly Whitfield 2013

Randomized Control Trial

6 month, 3 armed, double blind randomized control trial

Intervention A:

8 mg/mL thiamin fortified fish sauce

Intervention B:

2 mg/mL thiamin fortified fish sauce

Control:

Placebo fish sauce

Intervention Arms: RCT

Placebo

Intervention © Kyly Whitfield 2013

Potential Significance

•  Potential to significantly decrease thiamin deficiency in Cambodia, which in turn will lower the risk of infantile beriberi

•  Possibility of scaling up the production and distribution of

fortified product throughout Cambodia •  Potential for multiple micronutrient fortification; for example:

riboflavin

Thank you!