Isabel Madzorera, Mia M. Blakstad, Alexandra L. Bellows, Chelsey R. Canavan, Dominic Mosha, Sabri Bromage, Ramadhani A. Noor, Patrick Webb, Shibani Ghosh, Joyce Kinabo, Honorati Masanja, and Wafaie W. Fawzi. Forthcoming. “Food crop diversity, women’s income-earning activities and distance to markets in relation to maternal dietary quality in Tanzania.” Journal of Nutrition.
Sabri Bromage and Davaasambuu Ganmaa. 10/12/2020. “Recent study finds key nutrient inadequacies and overweight to be widespread among Mongolian adults nationwide.” IKON. Publisher's Version English Монгол
Sabri Bromage, Tselmen Daria, Rebecca L. Lander, Soninkhishig Tsolmon, Lisa A. Houghton, Enkhjargal Tserennadmid, Nyamjargal Gombo, Rosalind S. Gibson, and Davaasambuu Ganmaa. 5/22/2020. “Diet and Nutrition Status of Mongolian Adults.” Nutrients, 12, 5, Pp. 1514. Publisher's VersionAbstract

(1) Background: Aspects of the Mongolian food supply, including high availability of animal-source foods and few plant foods, are plausibly associated with disease in the population. Data on Mongolian diets are lacking, and these risks are poorly quantified. The purpose of this study was to provide a multifaceted nutritional analysis of the modern Mongolian diet. (2) Methods: The study population consisted of 167 male and 167 female healthy non-pregnant urban and nomadic adults (22–55 years) randomly selected from lists of residents in 8 regions. From 2011–2016, 3-day weighed diet records and serum were collected twice from each participant in summer and winter; anthropometry was collected once from each participant. Serum was analyzed for biomarkers, and nutrient intake computed using purpose-built food composition data and adjusted for within-person variation. Exploratory dietary patterns were derived and analyzed for associations with diet and nutrition measurements. (3) Results: We collected 1838 of an expected 1986 diet records (92.5%), 610/658 serum samples (92.7%), and 315/334 height and weight measurements (94.3%). Sixty-one percent of men and 51% of women were overweight or obese. Consumption of red meat, refined grains, and whole-fat dairy was high, while that of fruits, non-tuberous vegetables, eggs, nuts and seeds, fish and poultry, and whole grains was low. Dairy and red meat were more consumed in summer and winter, respectively. Dietary inadequacy of 10 of 21 assessed nutrients, including fiber, folate, and vitamin D were >50% prevalent, while protein, zinc, and vitamin B12 inadequacy were low. Biochemical evidence of iron and vitamin A deficiency was also low. Three dietary patterns (Urban, Transitional, Nomadic) explained 41% of variation in food consumption. The Urban pattern was positively associated with BMI in multivariate analysis. (4) Conclusions: Results indicate a high prevalence of key dietary inadequacies and overweight among Mongolian adults. Prior studies by our group have suggested that expanded supplementation and food fortification would be effective in addressing micronutrient inadequacies; these strategies should be coupled with measures to mitigate the growing burden of chronic disease.

Simone Passarelli, Sabri Bromage, Anne Marie Darling, Jia‐Sheng Wang, Said Aboud, Ferdinand Mugusi, Jeffrey K. Griffiths, and Wafaie Fawzi. 12/11/2019. “Aflatoxin exposure in utero and birth and growth outcomes in Tanzania.” Maternal & Child Nutrition, Pp. e12917. Publisher's VersionAbstract

Some evidence suggests that aflatoxin may contribute to the high prevalence of stunting observed in low‐income countries. Whereas several studies have been conducted in West Africa, fewer exist in East Africa and even fewer in nonagricultural contexts. We analyzed serum samples from 400 iron‐replete, nonanemic pregnant women from a cohort in Dar es Salaam, Tanzania to determine the extent and magnitude of exposure to aflatoxin and to study the relationship between levels of aflatoxin exposure in utero and infant birth and growth outcomes. Ninety‐nine percent of women had detectable concentrations of aflatoxin B1‐lysine (AFB1‐lysine), with a median level of 1.4‐pg/mg albumin, indicating a much lower level compared to studies of rural populations in sub‐Saharan Africa. Our results do not show a statistically significant relationship between AFB1‐lysine levels and birth weight, small for gestational age, or prematurity. We observe a small statistically significant reduction in gestational age at delivery (0.47 weeks; 95% CI: −0.86, −0.07) as the natural log of AFB1‐lysine levels increases by 1 unit of pg/mg of albumin, after controlling for potential confounders. Among a nonrandom set of infants who had measurements for placental weight, haemoglobin at delivery, and follow‐up z‐score measurements, we find no association between aflatoxin plasma concentrations and these variables. These findings suggest a high prevalence of chronic low‐level exposure to aflatoxin, though its effect on birth outcomes in this population remains unclear. Our research adds to a growing body of literature finding mixed associations between aflatoxins on pregnancy outcomes and child growth.

Sergey Yegorov, Sabri Bromage, Ninjin Boldbaatar, and Davaasambuu Ganmaa. 10/23/2019. “Effects of Vitamin D Supplementation and Seasonality on Circulating Cytokines in Adolescents: Analysis of Data From a Feasibility Trial in Mongolia.” Frontiers in Nutrition, 6, 166, Pp. 1-6. Publisher's VersionAbstract

Vitamin D deficiency is prevalent in human populations and has been linked to immune dysfunction. Here we explored the effects of cholecalciferol supplementation on circulating cytokines in severely vitamin D deficient [blood 25(OH)D << 30 nmol/L] adolescents aged 12–15 from Mongolia. The study included 28 children receiving 800 IU daily cholecalciferol for 6 months spanning winter and spring, and 30 children receiving placebo during the same period. The levels of 25(OH)D were assessed at baseline, 3 and 6 months. Twenty-one cytokines were measured in serum at baseline and at 6 months. Changes in 25(OH)D and cytokines were assessed using paired parametric tests. The median blood 25(OH)D concentration at baseline was 13.7 nmol/L (IQR = 10.0–21.7). Supplementation tripled blood 25(OH)D levels (p < 0.001) and was associated with elevated interleukin (IL)-6 (p = 0.043). The placebo group had reduced macrophage inflammatory protein (MIP)-1α (p = 0.007) and IL-8 (p = 0.034) at 6 months. Although limited by a small sample size, these findings suggest that cholecalciferol supplementation and seasonality may impact systemic immunity in adolescents, identifying chemokines as potentially important biomarkers of vitamin D status in this Northeast Asian population. Larger clinical trials are warranted to validate these results.

Nurun Nahar Naila, Prasenjit Mondal, Sabri Bromage, M. Munirul Islam, M. Mamun Huda, Mohammad Sohel Shomik, Dinesh Mondal, Wafaie Fawzi, and Tahmeed Ahmed. 7/2019. “Home Fortification of Rice With Lime, A Novel Potential Way to Reduce Calcium Deficiency in Bangladesh.” Food and Nutrition Bulletin. Publisher's VersionAbstract


In order to improve the calcium status, fortified rice should have acceptable organoleptic properties of that food.


We aimed to assess whether home fortification of rice with slaked lime can increase calcium content of the rice and whether this fortified rice is well tolerated in a nutritionally at-risk population.


This experimental study measured the calcium content of rice cooked with different concentration of lime and assessed the acceptability of fortified rice among 400 women and children. Each participant received fortified rice with one of five concentrations of lime (0, 2.5, 5, 7.5 or 10 gm per 500 gm of rice), with or without additional foods (lentil soup or fried green papaya). All participants were asked to score the organoleptic qualities in hedonic scale.


Analysis showed, rice calcium content increased in dose response manner with increased lime amount during cooking (76.03, 205.58, 427.55, 614.29 and 811.23 mg/kg for given lime concentrations). Acceptability of meal was greater when additional foods were served with rice at all lime concentrations. In both groups, 7.5M arm reported highest overall acceptability (children, 6.25; women 6.10). This study found significant association between overall acceptability (different concentrations of lime mixed rice; with/without additional foods) and between groups (women vs. children) (p value = < 0.001) where as no association was found within groups.


Lime-fortified-rice can be feasible considering the calcium uptake of rice and organoleptic character. Further research on bioavailability can establish a solid foundation which will support designing of an effective intervention to reduce calcium deficiency in this population.

Sabri Bromage, Davaasambuu Enkhmaa, Tsedmaa Baatar, Gantsetseg Garmaa, Gary Bradwin, Buyandelger Yondonsambuu, Tuul Sengee, Enkhtuya Jamts, Narmandakh Suldsuren, Thomas F. McElrath, David E. Cantonwine, Robert N. Hoover, Rebecca Troisi, and Davaasambuu Ganmaa. 7/2019. “Comparison of seasonal serum 25-hydroxyvitamin D concentrations among pregnant women in Mongolia and Boston.” Journal of Steroid Biochemistry and Molecular Biology, 193, Pp. 105427. Publisher's VersionAbstract

Adequate vitamin D status during pregnancy is important for developing fetal bone strength and density and may play a role in preventing a range of skeletal and non-skeletal diseases in both mothers and children. We previously identified Mongolian women of reproductive age to have the lowest vitamin D levels yet observed in any population globally, which renders this population uniquely important in vitamin D research. In this study, we measured the seasonal distribution of 25-hydroxyvitamin D (25(OH)D) concentration in 390 healthy third trimester pregnant women living in urban and rural Mongolia using DiaSorin LIAISON and compared this distribution to that of 206 third trimester women living in Boston, USA. Also, we analyzed seasonally-independent associations between (25(OH)D) levels and selected predictors in both groups using quantile regression. Mean 25(OH)D levels were significantly higher and less seasonal in Boston (seasonal range: 27.1 ± 7.0–31.5 ± 7.7 ng/ml) than in Mongolia (seasonal range: 11.2 ± 3.9–19.2 ± 6.7 ng/ml). Adjusting for month of blood draw, higher 25(OH)D levels were significantly associated with older age, lower gravidity, lower BMI, and lack of a college or university degree among Boston participants, however, only gravidity was robust to multivariable adjustment. No assessed characteristics were independently predictive in Mongolia, likely due to universally low 25(OH)D levels and a resulting lack of between-person variation. In conclusion, vitamin D status among pregnant Mongolians is severely depressed throughout the year and should be addressed through fortification and supplementation, while in the U.S., deficiency is associated with specific characteristics targetable through supplementation.

    Pi-I D. Lin, Sabri Bromage, Md. Golam Mostofa, Mohammad Rahman, Joseph Allen, Emily Oken, Molly L. Kile, and David C. Christiani. 2/6/2019. “Mediating role of arsenic in the relationship between diet and pregnancy outcomes: prospective birth cohort in Bangladesh.” Environmental Health, 18, 10, Pp. 1-13. Publisher's VersionAbstract


    Epidemiological evidence suggests that arsenic (As) exposure during pregnancy may reduce infant birth weight. One significant source of As exposure is diet; thus, As may indirectly affect infant growth by mediating the effect of maternal diet on birth weight (BW). This study evaluated the potential mediating effect of As in the relationship between maternal diet and BW, gestational age (GA), and gestational weight gain (GWG).


    The study used a prospective birth cohort in Bangladesh that captured the dietary habits of 1057 pregnant women through validated semi-quantitative food frequency questionnaires. We applied a causal mediation model with counterfactual approach and performed analyses with and without adjustment for total energy intake. Other potential confounders captured by self-report questionnaire were exposure to secondhand tobacco smoke, betel nut chewing, maternal age, education level, household income level, physical activity level during pregnancy, and daily hours spent cooking over open fire.


    No association was found between maternal toenail As and BW. Higher absolute and energy-adjusted protein, fat and fiber intakes were associated with higher toenail As and lower GA and GWG, while higher absolute and energy-adjusted carbohydrate intake was associated with lower toenail As and greater GA and GWG. Mediation analysis showed significant natural indirect effects by toenail As in the relationships between absolute fat, carbohydrate and fiber intake with GA. Specifically, 3% (95% CI: 1–6%) of the association between carbohydrate intake and GA was mediated by change in toenail As, 6% (95% CI: 1–9%) for absolute fat intake and 10% (95% CI: 4–13%) for absolute fiber intake. After adjusting for total energy, no significant mediating effect was observed, suggesting the mediating effect might be due to measurement error or that absolute amount of As exposure rather than the amount in relationship to total energy intake was a more important factor to consider when understanding the negative implication of As on fetal growth.


    The mediating effect of As in the relationship between maternal diet and birth outcome was small and might be due to measurement error.

    Ulziijargal Gurjav, Munkhzaya Ankhbat, Gantungalag Ganbaatar, Khulan Batjargal, Batbayar Ochirbat, Delgerekh Baigal, Badamtsetseg Jargalsaikhan, Oyunsuren Munkhjargal, Sunjidmaa Bolormaa, Narankhuu Yansanjav, Narangerel Luvsanyandan, Gantserseg Dorj, Naranzul Dambaa, Sabri Bromage, and Davaasambuu Ganmaa. 1/24/2019. “Vitamin D deficiency is associated with tuberculosis infection among household contacts in Ulaanbaatar, Mongolia.” International Journal of Tuberculosis and Lung Disease, 23, 8, Pp. 919–923. Publisher's VersionAbstract

    BACKGROUND: Vitamin D deficiency (VDD) is a known risk factor for tuberculous infection. We investigated if VDD is a risk factor for tuberculous infection among the household contacts (HHCs) of patients with tuberculosis (TB) in Mongolia.

    MATERIALS AND METHOD: All HHCs of TB patients diagnosed in Khan-Uul District, Mongolia, were enrolled. The serum level of 25-hydroxyvitamin D [25(OH)D] was detected and TB infection determined using QuantiFERON-TB Gold Plus (QFT-Plus). A tuberculin skin test (TST) reading .10 mm was considered to be positive. Epidemiological and bacteriological data were collected from routine surveillance of the National Tuberculosis Programme.

    RESULTS: Among study participants, 48.2% (135/285) were QFT-Plus-positive. Of QFT-positive HHCs, 77.0% (104/135) were TST-positive and the overall concordance of tests was low (j 0.374, P , 0.001). A low serum level of 25(OH)D was an independent predictor for QFT-Plus positivity (P , 0.001). CD8þ T-cell stimulation measured by QFT-Plus had borderline association with the serum level of 25(OH)D (P ¼ 0.089).

    CONCLUSION: We showed a high rate of TB infection among HHCs in Mongolia. QFT-Plus could decrease the number of people requiring TB preventive treatment, in addition to aiding detection of new TB infection. A low serum level of vitamin D was an independent predictor of TB infection, but not a predictor of stimulation of CD8þ T cells.

    KEY WORDS: VDD; latent tuberculous infection; CD8þ T-cell stimulation; tuberculin skin test

    Sabri Bromage, Enkhmaa Gonchigsumlaa, Margaret Traeger, Bayarbat Magsar, Qifan Wang, Jorick Bater, Hewei Li, and Davaasambuu Ganmaa. 1/19/2019. “Awareness and Attitudes Regarding Industrial Food Fortification in Mongolia and Harbin.” Nutrients, 11, Pp. 201. Publisher's VersionAbstract

    This study assessed awareness and attitudes regarding industrial food fortification among adults in urban and rural Mongolia, and the city of Harbin, China. Between 2014 and 2017, surveys were collected from healthy men and women aged 18 years (182 Harbin residents and 129 urban and rural Mongolians participating in a nationwide nutrition survey in Mongolia). Survey reproducibility was assessed among 69 Mongolian participants to whom it was administered twice (summer and winter). Findings revealed that only 19% of rural and 30% of urban Mongolians, and 48% of Harbin residents were aware that industrial fortification is practiced in their countries. For most food groups evaluated, at least half of Mongolians and less than half of Harbin residents thought fortification was government-mandated (only the addition of iodine with salt is actually mandated in both countries). Fifty-five percent of rural and urban Mongolians favored mandatory fortification of foods, 14% disapproved of it, and 31% were uncertain (compared with 25%, 38%, and 37% respectively in Harbin). Upon learning that the primary purpose of adding vitamin D to milk is to prevent rickets, 75% of Mongolians but only 18% of Harbin residents favored mandatory fortification, while 42% of Harbin residents favored voluntary fortification (compared with <10% of Mongolians). In conclusion, in Mongolia and Harbin, awareness and understanding of food fortification is low, as is receptivity toward mandatory fortification. Health promotion and social marketing should be designed to create an enabling environment for increasing supply and demand of fortified foods, in support of upcoming program implementation in Mongolia and potential future legislation in northeern China.

    Davaasambuu Ganmaa, Polyna Khudyakov, Uyanga Buyanjargal, Badamtsetseg Jargalsaikhan, Delgerekh Baigal, Oyunsuren Munkhjargal, Narankhuu Yansan, Sunjidmaa Bolormaa, Enkhsaikhan Lkhagvasuren, Christopher T Sempos, Sabri Bromage, Zhenqiang Wu, Batbayar Ochirbat, Batbaatar Gunchin, and Adrian R Martineau. 11/27/2018. “Prevalence and determinants of QuantiFERON-diagnosed tuberculosis infection in 9,810 Mongolian schoolchildren.” Clinical Infectious Disease. Publisher's VersionAbstract


    There is controversy regarding the potential influence of vitamin D deficiency, exposure to environmental tobacco smoke, BCG vaccination, season and body habitus on susceptibility to Mycobacterium tuberculosis (MTB) infection.


    We conducted a cross-sectional analysis to identify determinants of a positive QuantiFERON®-TB Gold (QFT) assay result in children aged 6-13 years attending 18 schools in Ulaanbaatar, Mongolia. Data relating to potential risk factors for MTB infection were collected by questionnaire, physical examination and determination of serum 25-hydroxyvitamin D (25[OH]D) concentrations. Risk ratios were calculated using generalized estimating equations with adjustment for potential confounders, and population attributable fractions (PAFs) were calculated for modifiable risk factors identified.


    946/9,810 (9.6%) participants had a positive QFT result. QFT-positivity was independently associated with household exposure to pulmonary TB (adjusted risk ratio [aRR] 4.75, 95% CI 4.13-5.46, P<0.001; PAF 13.1%, 95% CI 11.1%-15.0%), vitamin D deficiency (aRR 1.23, 95% CI 1.08-1.40, P=0.002; PAF 5.7%, 1.9%-9.3%), exposure to environmental tobacco smoke (one indoor smoker, aRR 1.19, 95% CI 1.04-1.35; two or more indoor smokers, aRR 1.30, 95% CI 1.02-1.64; P for trend, 0.006; PAF 7.2%, 95% CI 2.2%-12.0%) and increasing age (aRR per additional year 1.14, 95% CI 1.10-1.19, P<0.001). No statistically significant independent association was seen for presence of a BCG scar, season of sampling or body mass index.


    Our findings underline the importance of contact tracing in TB-exposed households as a strategy to identify MTB-infected children. Vitamin D deficiency and exposure to environmental tobacco smoke may be modifiable risk factors for MTB infection.

    Choongwon Jeong, Shevan Wilkin, Tsend Amgalantugs, Abigail S. Bouwman, William Timothy Treal Taylor, Richard W. Hagan, Sabri Bromage, Soninkhishig Tsolmon, Christian Trachsel, Jonas Grossmann, Judith Littleton, Cheryl A. Makarewicz, John Krigbaum, Marta Burri, Ashley Scott, Ganmaa Davaasambuu, Joshua Wright, Franziska Irmer, Erdene Myagmar, Nicole Boivin, Martine Robbeets, Frank J. Rühli, Johannes Krause, Bruno Frohlich, Jessica Hendy, and Christina Warinner. 11/5/2018. “Bronze Age population dynamics and the rise of dairy pastoralism on the eastern Eurasian steppe.” PNAS. Publisher's VersionAbstract

    Recent paleogenomic studies have shown that migrations of Western steppe herders (WSH) beginning in the Eneolithic (ca. 3300–2700 BCE) profoundly transformed the genes and cultures of Europe and central Asia. Compared with Europe, however, the eastern extent of this WSH expansion is not well defined. Here we present genomic and proteomic data from 22 directly dated Late Bronze Age burials putatively associated with early pastoralism in northern Mongolia (ca. 1380–975 BCE). Genome-wide analysis reveals that they are largely descended from a population represented by Early Bronze Age hunter-gatherers in the Baikal region, with only a limited contribution (∼7%) of WSH ancestry. At the same time, however, mass spectrometry analysis of dental calculus provides direct protein evidence of bovine, sheep, and goat milk consumption in seven of nine individuals. No individuals showed molecular evidence of lactase persistence, and only one individual exhibited evidence of >10% WSH ancestry, despite the presence of WSH populations in the nearby Altai-Sayan region for more than a millennium. Unlike the spread of Neolithic farming in Europe and the expansion of Bronze Age pastoralism on the Western steppe, our results indicate that ruminant dairy pastoralism was adopted on the Eastern steppe by local hunter-gatherers through a process of cultural transmission and minimal genetic exchange with outside groups.

    Ryan S.D. Calder, Sabri Bromage, and Elsie M. Sunderland. 9/7/2018. “Risk Tradeoffs Associated with Traditional Food Advisories for Labrador Inuit.” Environmental Research. Publisher's VersionAbstract

    The traditional Inuit diet includes wild birds, fish and marine mammals, which can contain high concentrations of the neurotoxicant methylmercury (MeHg). Hydroelectric development may increase MeHg concentrations in traditional foods. Consumption advisories are often used to mitigate such risks and can result in reduced intake of traditional foods. Data from a dietary survey, MeHg exposure assessment and risk analysis for individuals in three Inuit communities in Labrador, Canada (n = 1,145) in 2014 indicate reducing traditional food intake is likely to exacerbate deficiencies in n-3 polyunsaturated fatty acids and vitamins B12 and B2. Traditional foods accounted for < 5% of per-capita calories but up to 70% of nutrients consumed. Although consumption advisories could lower neurodevelopmental risks associated with an increase in MeHg exposure (90th-percentile ∆IQ = −0.12 vs. −0.34), they may lead to greater risks of cardiovascular mortality (90th-percentile increase: +58% to +116% vs. +25%) and cancer mortality (90th-percentile increase +2% to +4% vs. no increase). Conversely, greater consumption of locally caught salmon mostly unaffected by hydroelectric flooding would lower all these risks (90th-percentile ∆IQ = +0.4; cardiovascular risk: –45%; cancer risk: –1.4%). We thus conclude that continued consumption of traditional foods is essential for Inuit health in these communities.

    Rajesh K. Rai, Lindsay M. Jaacks, Sabri Bromage, Anamitra Barik, Wafaie W. Fawzi, and Abhijit Chowdhury. 8/30/2018. “Prospective cohort study of overweight and obesity among rural Indian adults: sociodemographic predictors of prevalence, incidence and remission.” BMJ Open, 8, 8, Pp. e021363. Publisher's VersionAbstract


    To assess sociodemographic predictors of prevalence, incidence and remission of overweight including obesity among adults (aged ≥18 years) in rural Eastern India.


    Prospective cohort study.


    Birbhum Health and Demographic Surveillance System, West Bengal, India.


    Self-weighted sample of 24 115 adults (men: 10915, women: 13200) enrolled in 2008 were followed up for body mass index (BMI) reassessment in 2017.


    Measured BMI was categorised as: underweight (<18.5 kg/m2), normal weight (18.5-22.9 kg/m2) and overweight including obesity (≥23 kg/m2; hereinafter overweight). Incident overweight was defined as transition from normal weight in 2008 to overweight in 2017, whereas if overweight individuals in 2008 measured normal BMI in 2017, it was classified as remission from overweight.


    In 2008, 10.1% of men and 14.6% of women were overweight, whereas 17.3% of men and 24.7% of women were overweight in 2017. At the same time, in 2017, 35.6% of men and 33.3% of women were underweight. Incident overweight was 19.0% among men and 27.2% among women, whereas remission among men was higher (15.4%) than women (11.5%). Women were more likely to be overweight in 2008 and to experience incident overweight than men. For men and women, education level and wealth were positively associated with prevalence and incidence of overweight. Remission from overweight was less likely in Sainthia, a business hub in the district, as compared with Mohammad Bazar, a more rural area.


    A nutrition transition to higher risk of overweight is evident in this rural setting in India, especially among women and individuals with high socioeconomic status. At the same time, a high prevalence of underweight persists, resulting in a significant double burden. Culturally sensitive interventions that address both ends of the malnutrition spectrum should be prioritised.

    Sabri Bromage, Davaasambuu Ganmaa, Janet W. Rich-Edwards, Bernard Rosner, Jorick Bater, and Wafaie W. Fawzi. 8/2/2018. “Projected effectiveness of mandatory industrial fortification of wheat flour, milk, and edible oil with multiple micronutrients among Mongolian adults.” PLoS One, 13, 8, Pp. e0201230. Publisher's VersionAbstract

    Industrial fortification of wheat flour is a potentially effective strategy for addressing micronutrient deficiencies in Mongolia, given its ubiquitous consumption and centralized production. However, Mongolia has not mandated fortification of any foods except for salt with iodine. This study modeled the effectiveness and safety of mandatory industrial fortification of wheat flour alone and in combination with edible oil and milk in reducing the prevalence of multiple micronutrient intake deficiencies among healthy non-pregnant adults in Mongolia. Six days of diet records (3 summer, 3 winter) were collected from 320 urban and rural adults across the country and analyzed for food and nutrient consumption using a purpose-built food composition table, and the Intake Monitoring and Planning Program (IMAPP) was used to project the effects of fortification on summer and winter bioavailable micronutrient intake and intake deficiency under different fortification guidelines within population subgroups defined by urban or rural locality and sex. Projections showed that flour fortification would be effective in reducing intake deficiencies of thiamin and folate, while marginal benefits of fortification with iron and riboflavin would be smaller given these nutrients' higher baseline consumption, and fortification with zinc, niacin, and vitamin B12 may be unnecessary. Fortification of flour, oil, and milk with vitamins A, D, and E at levels suggested by international guidelines would substantially reduce vitamin A intake deficiency and would increase vitamin D intake considerably, with the greatest benefits elicited by flour fortification and smaller benefits by additionally fortifying oil and milk. These results support mandatory industrial fortification of wheat flour, edible oil, and milk with iron, thiamin, riboflavin, folate, and vitamins A, D, and E in Mongolia. Considerations will be necessary to ensure the fortification of these nutrients is also effective for children, for whom the potential benefit of zinc, niacin, and vitamin B12 fortification should be assessed.

    Sabri Bromage, Bernard Rosner, Janet W. Rich-Edwards, Davaasambuu Ganmaa, Soninkhishig Tsolmon, Zuunnast Tserendejid, Tseye-Oidov Odbayar, Margaret Traeger, and Wafaie W. Fawzi. 5/31/2018. “Comparison of Methods for Estimating Dietary Food and Nutrient Intakes and Intake Densities from Household Consumption and Expenditure Data in Mongolia.” Nutrients, 10, 6, Pp. E703. Publisher's VersionAbstract

    Household consumption and expenditure surveys are frequently conducted around the world and they usually include data on household food consumption, but their applicability to nutrition research is limited by their collection at the household level. Using data from Mongolia, this study evaluated four approaches for estimating diet from household surveys: direct inference from per-capita household consumption; disaggregation of household consumption using a statistical method and the "adult male equivalent" method, and direct prediction of dietary intake. Per-capita household consumption overestimated dietary energy in single- and multi-person households by factors of 2.63 and 1.89, respectively. Performance of disaggregation methods was variable across two household surveys analyzed, while the statistical method exhibited less bias in estimating intake densities (per 100 kcal) of most dietary components in both of the surveys. Increasingly complex prediction models explained 54% to 72% of in-sample variation in dietary energy, with consistent benefits incurred by inclusion of basic dietary measurements. In conclusion, in Mongolia and elsewhere, differences in how household and dietary measurements are recorded make their comparison challenging. Validity of disaggregation methods depends on household survey characteristics and the dietary components that are considered. Relatively precise prediction models of dietary intake can be achieved by integrating basic dietary assessment into household surveys.

    Sabri Bromage. 5/2018. “Epidemiology of Dietary and Micronutrient Deficiencies in Mongolia.” ScD Dissertation. Publisher's Version PDF
    Rajesh K. Rai, Wafaie W. Fawzi, Sabri Bromage, Anamitra Barik, and Abhijit Chowdhury. 3/2018. “Underweight among rural Indian adults: burden, and predictors of incidence and recovery.” Public Health Nutrition, 21, 4, Pp. 669-678. Publisher's VersionAbstract


    To study the magnitude and predictors of underweight, incident underweight and recovery from underweight among rural Indian adults.


    Prospective cohort study. Each participant's BMI was measured in 2008 and 2012 and categorized as underweight (BMI<18·5 kg/m2), normal (BMI=18·5-22·9 kg/m2) or overweight/obese (BMI ≥23·0 kg/m2). Incident underweight was defined as a transition from normal weight or overweight/obese in 2008 to underweight in 2012, and recovery from underweight as a transition from underweight in 2008 to normal weight in 2012. Bivariate and multivariable logistic regression analyses were employed.


    The Birbhum Health and Demographic Surveillance System, West Bengal, India.


    Predominantly rural individuals (n 6732) aged ≥18 years enrolled in 2008 were followed up in 2012.


    In 2008, the prevalence of underweight was 46·5 %. From 2008 to 2012, 25·8 % of underweight persons transitioned to normal BMI, 12·9 % of normal-weight persons became underweight and 0·1 % of overweight/obese persons became underweight. Multivariable models reveal that people aged 25-49 years, educated and wealthier people, and non-smokers had lower odds of underweight in 2008 and lower odds of incident underweight. Odds of recovery from underweight were lower among people aged ≥36 years and higher among educated (Grade 6 or higher) individuals.


    The current study highlights a high incidence of underweight and important risk factors and modifiable predictors of underweight in rural India, which may inform the design of local nutrition interventions.

    Davaasambuu Ganmaa, Baatar Munkhzul, Wafaie W. Fawzi, Donna Spiegelman, Walter C. Willett, Purev Bayasgalan, Erkhembayar Baasansuren, Burneebaatar Buyankhishig, Sereeter Oyun-Erdene, David A. Jolliffe, Theodoros Xenakis, Sabri Bromage, Barry R. Bloom, and Adrian R. Martineau. 9/1/2017. “High-Dose Vitamin D3 during Tuberculosis Treatment in Mongolia. A Randomized Controlled Trial.” American Journal of Respiratory and Critical Care Medicine, 196, 5, Pp. 628-637. Publisher's VersionAbstract


    Existing trials of adjunctive vitamin D in the treatment of pulmonary tuberculosis (PTB) are variously limited by small sample sizes, inadequate dosing regimens, and high baseline vitamin D status among participants. Comprehensive analyses of the effects of genetic variation in the vitamin D pathway on response to vitamin D supplementation are lacking.


    To determine the effect of high-dose vitamin D3 on response to antimicrobial therapy for PTB and to evaluate the influence of single-nucleotide polymorphisms (SNPs) in vitamin D pathway genes on response to adjunctive vitamin D3.


    We conducted a clinical trial in 390 adults with PTB in Ulaanbaatar, Mongolia, who were randomized to receive four biweekly doses of 3.5 mg (140,000 IU) vitamin D3 (n = 190) or placebo (n = 200) during intensive-phase antituberculosis treatment.


    The intervention elevated 8-week serum 25-hydroxyvitamin D concentrations (154.5 nmol/L vs. 15.2 nmol/L in active vs. placebo arms, respectively; 95% confidence interval for difference, 125.9-154.7 nmol/L; P < 0.001) but did not influence time to sputum culture conversion overall (adjusted hazard ratio, 1.09; 95% confidence interval, 0.86-1.36; P = 0.48). Adjunctive vitamin D3 accelerated sputum culture conversion in patients with one or more minor alleles for SNPs in genes encoding the vitamin D receptor (rs4334089, rs11568820) and 25-hydroxyvitamin D 1α-hydroxylase (CYP27B1: rs4646536) (adjusted hazard ratio ≥ 1.47; P for interaction ≤ 0.02).


    Vitamin D3 did not influence time to sputum culture conversion in the study population overall. Effects of the intervention were modified by SNPs in VDR and CYP27B1. Clinical trial registered with (NCT01657656).

    Sabri Bromage, Tselmen Daria, Gary Bradwin, Michael F. Holick, and Davaasambuu Ganmaa. 9/2017. “Validation of summer and winter ELISA measurements of serum 25-hydroxyvitamin D concentrations in Mongolia.” Asia Pacific Journal of Clinical Nutrition, 26, 6, Pp. 987-993. Publisher's VersionAbstract


    Assay cost, quality, and availability pose challenges for vitamin D surveys in limited resource settings. This study aimed to validate an inexpensive vitamin D assay (ELISA) under real-world conditions in Mongolia, the northernmost developing country, to characterize the assay's usefulness and inform the design of epidemiologic studies in similar regions.


    We collected paired summer and winter serum samples from 120 men and women (aged 20-57 years) in urban and rural Mongolia, analyzed each sample for 25(OH)D concentration using both Immunodiagnostic Systems ELISA and DiaSorin LIAISON 25(OH)D TOTAL, and compared the assays using multiple statistics. LIAISON was itself validated by participation in the DEQAS program.


    Correlation and agreement between assays were higher in summer (Pearson's correlation=0.60, Spearman's rank correlation=0.67, Lin's concordance correlation=0.56) than winter (rP=0.37, rS=0.43, rC=0.33), although ELISA less accurately assigned subjects to sufficiency categories in summer (percent agreement=44%) than winter (58%), during the latter of which most subjects were deficient ([25(OH)D] categories used: >75 nmol/L (optimal), 50-75 nmol/L (adequate), 25-50 nmol/L (inadequate), <25 nmol/L (deficient)). Compared with LIAISON, ELISA tended to indicate higher vitamin D status in both seasons (mean paired difference: 7.0 nmol/L (95% CI: 3.5-10.5) in summer, 5.2 nmol/L (95% CI: 2.9-7.5) in winter).


    ELISA proved useful for measuring and ranking subjects' vitamin D status in Mongolia during summer, but levels were too low in winter to sensitively discriminate between subjects, and ELISA overestimated status in both seasons. These findings have implications for the timing and interpretation, respectively, of vitamin D surveys in highly deficient populations.