Isabel Madzorera, Lindsay Jaacks, Robert Paarlberg, Anna Herforth, Sabri Bromage, Shibani Ghosh, Samuel Myers, William Masters, and Wafaie W. Fawzi. 5/2021. “Food systems as drivers of optimal nutrition and health – Complexities and opportunities for research and implementation.” Current Developments in Nutrition, 24, 5 (Suppl 3), Pp. nzab062. Publisher's VersionAbstract

The Sustainable Development Goals (SDGs) are intricately linked to food systems. Addressing challenges in food systems is key to meeting the SDGs in Africa and South Asia, where undernutrition and micronutrient deficiencies persist, alongside increased nutrition transition, overweight and obesity, and related chronic diseases. Suboptimal diets are a key risk factor for mortality and 3 billion people cannot afford a healthy diet; in addition, food systems are not prioritizing environmental sustainability. Optimizing food systems and increasing agricultural productivity beyond calories, to nutrient-rich vegetables and fruits, legumes, and livestock, and sustainable fishing, are required. Strengthening of research around food systems—on pathways, value chains, and development and validation of metrics of diet quality—is required. The development of new technology in crop management and pest control and addressing natural resource degradation is key. Engaging with the public and private sectors, outreach to donors and policymakers, and strengthening cross-disciplinary collaborations are imperative to improving food systems.

Rajesh Kumar Rai, Sabri Bromage, and Wafaie W. Fawzi. 3/3/2021. “Receipt of Weekly Iron Supplementation among Indian Children, 2005-2016.” Current Developments in Nutrition, Pp. nzab020. Publisher's VersionAbstract

Background: In response to India’s unacceptably high burden of anemia among children aged 6–59 mo, the central government introduced the National Iron Plus Initiative program which recommends an intervention of iron supplementation to mitigate anemia, especially iron deficiency anemia. Objective: The objective of this study was to examine the trend (between 2005–2006 and 2015–2016) in receiving weekly iron supplementation (WIS) among children aged 6–59 mo, and factors associated with receiving WIS during 2015–2016.

Methods: Two waves of the nationally representative cross-sectional National Family Health Survey (NFHS) data collected during 2005–2006 (NFHS-3) and 2015–2016 (NFHS-4) were used. The trend was measured using both rounds of datasets, whereas factors associated with WIS receipt were assessed from NFHS-4. The trend was assessed using a sample of 35,650 children from NFHS-3 and 202,227 children from NFHS-4. After exclusion of 8978 cases, a total of 199,110 children were included to analyze the factors associated with receiving WIS. Using appropriate sample weighting, unadjusted and adjusted (multivariate) logistic regression analyses were deployed. Application of the chi-squared test and checking for multicollinearity were also part of the analysis. The possibility of sample selection bias was tested.

Results: An increase of WIS receipt (from 4.6% in 2005–2006 to 26% in 2015–2016) was observed. Older children, children living in rural areas, children belonging to Scheduled Tribes, children of mothers with secondary education or higher, and children whose mothers had some mass media exposure had higher odds of receiving WIS. Children of fifth or higher birth order, children who were followers of Islam and Christianity, children from the richest economic group, noninstitutional birth of children, and children from high-focus group states were negatively associated with WIS receipt.

Conclusions: Despite improvement (between 2005–2006 and 2015–2016) in receiving WIS, coverage remains unacceptably low (in absolute terms). The suboptimum performance of WIS intervention demands further investigation.


Selma Gicevic, Emin Tahirovic, Sabri Bromage, and Walter Willett. 2/24/2021. “Diet quality and all-cause mortality among U.S. adults, estimated from NHANES, 2003-2008 .” Public Health Nutrition, Pp. 1-25. Publisher's VersionAbstract

Objective: We assessed the ability of the Prime Diet Quality Score (PDQS) to predict mortality in a United States (U.S.) population and compared its predictiveness with that of the Healthy Eating Index-2015 (HEI-2015).

Design: PDQS and HEI-2015 scores were derived using two 24-hour recalls and converted to quintiles. Mortality data were obtained from the 2015 Public-Use Linked Mortality File. Associations between diet quality and all-cause mortality were evaluated using multivariable Cox proportional hazards models, and predictive performance of the two metrics were compared using a Wald test of equality of coefficients with both scores in a single model. Finally, we evaluated associations between individual metric components and mortality.

Setting: A prospective analysis of the U.S. National Health and Nutrition Examination Survey (NHANES) data.

Participants: 5,525 participants from three survey cycles (2003-2008) in the NHANES aged 40 years and over.

Results: Over the 51,248 person-years of follow-up (mean: 9.2 years), 767 deaths were recorded. In multivariable models, hazard ratios between the highest and lowest quintiles of diet quality scores were 0.70 (95%CI: 0.51, 0.96, p-trend=0.03) for the PDQS, and 0.77 (95%CI: 0.57, 1.03, p-trend=0.20) for the HEI-2015. The PDQS and HEI-2015 were similarly good predictors of total mortality (p-difference=0.88).

Conclusion: Among U.S. adults, better diet quality measured by the PDQS was associated with reduced risk of all-cause mortality. Given that the PDQS is simpler to calculate than the HEI-2015, it should be evaluated further for use as a diet quality metric globally.

Keywords: Healthy Eating Index-2015; NHANES; Prime Diet Quality Score; all-cause mortality; diet quality metrics.

Selma Gicevic, Yuchan Mou, Sabri Bromage, Teresa T Fung, and Walter C Willett. 2/15/2021. “Development and evaluation of a novel diet quality screener for global use: evaluation in a sample of U.S. women.” Journal of the Academy of Nutrition and Dietetics. Publisher's VersionAbstract


Valid and efficient tools for measuring and tracking diet quality globally are lacking.


The objective of the study was to develop and evaluate a new tool for rapid and cost-efficient diet quality assessment.


Two screener versions were designed using Prime Diet Quality Score (PDQS), one in a 24-hour recall (PDQS-24HR) and another in a 30-day (PDQS-30D) food frequency format. Participants completed two 24-hour diet recalls using the Automated Self-Administered 24-hour Dietary Assessment Tool (ASA24) and 2 web-based diet quality questionnaires 7 to 30 days apart in April and May 2019. Both dichotomous/trichotomous and granular scoring versions were tried for each screener.


The study included 290 nonpregnant, nonlactating US women (mean age ± standard deviation 41 ± 11 years) recruited via Amazon Mechanical Turk.

Main outcome measures

The main outcome measures were Spearman rank correlation coefficients and linear regression beta-coefficients between ASA24 nutrient intakes from foods and beverages and PDQS values.

Statistical analyses performed

The Spearman rank correlation and linear regression were used to evaluate associations of the PDQS values with ASA24 nutrient intakes from food, both crude and energy-adjusted. Correlations were de-attenuated for within-person variation in 24-hour recalls. Wolfe’s test was used to compare correlations of the 2 screening instruments (PDQS-24HR and PDQS-30D) with the ASA24. Associations between the ASA24 Healthy Eating Index 2015 and the PDQS values were also evaluated.


Positive, statistically significant rank correlations between the PDQS-24HR values and energy-adjusted nutrients from ASA24 for fiber (r = 0.53), magnesium (r = 0.51), potassium (r = 0.48), vitamin E (r = 0.40), folate (r = 0.37), vitamin C (r = 0.36), vitamin A (r = 0.33), vitamin B6 (r = 0.31), zinc (r = 0.25), and iron (r = 0.21); and inverse correlations for saturated fatty acids (r = –0.19), carbohydrates (r = –0.22), and added sugar (r = –0.34) were observed. Correlations of nutrient intakes assessed by ASA24 with the PDQS-30D were not significantly different from those with the PDQS-24HR. Positive, statistically significant correlations between the ASA24 Healthy Eating Index 2015 and the PDQS-24HR (r = 0.61) and the PDQS-30D (r = 0.60) were also found.


The results of an initial evaluation of the PDQS-based diet quality screeners are promising. Correlations and associations between the PDQS values and nutrient intakes were of acceptable strength and in the expected directions, and the PDQS values had moderately strong correlations with the total Healthy Eating Index 2015 score. Future work should include evaluating the screeners in other population groups, including men, and piloting it across low- and middle-income countries.

Ajibola I. Abioye, Sabri Bromage, and Wafaie W. Fawzi. 1/19/2021. “Effect of micronutrient supplements on influenza and other respiratory tract infections among adults: A systematic review and meta-analysis.” BMJ Global Health, 6, Pp. e003176. Publisher's VersionAbstract

Acute respiratory tract infections (ARIs) are a leading cause of ill-health and death globally. Individual or multiple micronutrients have been shown to modulate immune function and affect the risk and severity of a number of infectious diseases. We systematically reviewed the evidence on the impact of micronutrient supplements to reduce the occurrence of ARIs and shorten the duration of ARI symptoms among adults. Random effects meta-analyses were conducted to estimate the pooled effects of vitamin D, vitamin C, zinc and multiple micronutrient supplementation (MMS) on the occurrence of ARIs and the duration of ARI symptoms. Vitamin D supplementation reduced the risk of ARI (risk ratio (RR)=0.97; 95% CI 0.94 to 1.00; p=0.028) and shortened the duration of symptoms (per cent difference: −6% (95% CI −9% to −2%; p=0.003)). The RR of vitamin D to prevent ARI was farther from the null when diagnosis was based on clinical diagnosis or laboratory testing, compared with self-report and when the loading dose was <60 000 IU. Vitamin C supplementation reduced the risk of ARIs (RR=0.96; 95% CI 0.93 to 0.99; p=0.01) and shortened the duration of symptoms (per cent difference: −9% (95% CI −16% to −2%; p=0.014)). The effect of vitamin C on preventing ARI was stronger among men and in middle-income countries, compared with women and high-income countries, respectively. Zinc supplementation did not reduce the risk of ARIs but shortened the duration of symptoms substantially (per cent difference: −47% (95% CI −73% to −21%; p=0.0004)). Our synthesis of global evidence from randomised controlled trials indicates that micronutrient supplements including zinc, vitamins C and D, and multiple micronutrient supplements may be modestly effective in preventing ARIs and improving their clinical course. Further research is warranted to better understand the effectiveness that individual or multiple micronutrients have on SARS-CoV-2 infection and treatment outcomes.

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. 11/26/2020. “Food crop diversity, women’s income-earning activities and distance to markets in relation to maternal dietary quality in Tanzania.” Journal of Nutrition. Publisher's VersionAbstract

Background: Women's dietary diversity and quality are limited in low- and middle-income countries (LMICs). Nutrition-sensitive interventions that promote food crop diversity and women's access to income could improve diets and address the double burden of malnutrition in LMICs.

Objectives: We examined the associations among food crop diversity and women's income-earning activities with women's diet quality, as well as effect modification by access to markets, in the context of small-holder food production in rural Tanzania.

Methods: Data from a cross-sectional study of 880 women from Rufiji, Tanzania, were analyzed. Women's dietary intake was assessed using a food frequency questionnaire. The prime diet quality score (PDQS; 21 food groups; range, 0-42), a unique diet-quality metric for women that captures the healthy and unhealthy aspects of diet, was computed. Generalized estimating equation linear models were used to evaluate the associations of food crop diversity and women's income-earning activities with PDQS, while controlling for socio-economic factors.

Results: Maternal overweight (24.3%) and obesity (13.1%) were high. The median PDQS was 19 (IQR, 17-21). Households produced 2.0 food crops (SD ± 1.0) yearly. Food crop diversity was positively associated with PDQS (P < 0.001), but the association was strengthened by proximity to markets (P for interaction = 0.02). For women living close (<1.1 km) to markets, producing 1 additional food crop was associated with a 0.67 (95% CI, 0.22-1.12) increase in PDQS, versus a 0.40 (95% CI, 0.24-0.57) increase for women living farther away. The PDQS increased with women's salaried employment (estimate, 0.96; 95% CI, 0.26-1.67).

Conclusions: Household food production may interact with access to markets for sales and purchases, while nonfarm income also improves women's diet quality in rural Tanzania. Programs to improve women's diet quality should consider improving market access and women's access to income (source of empowerment), in addition to diversifying production.

Keywords: PDQS; Tanzania; distance to market; food crop diversity; food systems; market food diversity; maternal diet quality; prime diet quality score; production diversity; women's access to income.

Nerges Mistry, Elena C. Hemler, Yatin Dholakia, Sabri Bromage, Anupam Shukla, Prachi Dev, Laxmi Govekar, Pranita Tipre, Daksha Shah, Salmaan A. Keshavjee, and Wafaie W. Fawzi. 11/12/2020. “Protocol for a case-control study of vitamin D status, adult multidrug-resistant tuberculosis disease and tuberculosis infection in Mumbai, India.” BMJ Open, 10, 11, Pp. e039935. Publisher's VersionAbstract


Introduction: Vitamin D status may be an important determinant of multidrug-resistant tuberculosis (MDR-TB) infection, progression to disease and treatment outcomes. Novel and potentially cost-effective therapies such as vitamin D supplementation are needed to stem the tide of TB and MDR-TB globally, particularly in India, a country that accounts for the largest fraction of the world's TB incidence and MDR-TB incidence, and where vitamin D deficiency is endemic. While vitamin D has shown some promise in the treatment of MDR-TB, its role in the context of MDR-TB infection and progression to disease is largely unknown.

Methods and analysis: Through a case-control study in Mumbai, India, we aim to examine associations between vitamin D status and active MDR-TB and to investigate vitamin D status and TB infection among controls. Cases are adult outpatient pulmonary patients with MDR-TB recruited from two public TB clinics. Controls are recruited from the cases' household contacts and from non-respiratory departments of the facilities where cases were recruited. Cases and controls are assessed for serum 25-hydroxyvitamin D concentration, nutrient intake, diet quality, anthropometry and other relevant clinical and sociodemographic parameters. Controls undergo additional clinical assessments to rule out active TB and laboratory assessments to determine presence of TB infection. Statistical analysis investigates associations between vitamin D status and active MDR-TB and between vitamin D status and TB infection among controls, accounting for potential confounding effects of diet, anthropometry and other covariates.

Ethics and dissemination: This study has been approved by Harvard T.H. Chan School of Public Health Institutional Review Board; Foundation for Medical Research Institutional Research Ethics Committee and Health Ministry's Screening Committee of the Indian Council for Medical Research. Permission was granted by the Municipal Corporation of Greater Mumbai, India, a collaborating partner on this research. Outcomes will be disseminated through publication and scientific presentation.

Trial registration number: NCT04342598.

Keywords: epidemiology; nutrition & dietetics; public health; tuberculosis.


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.