Analí Castellanos-Gutiérrez, Sonia Rodríguez-Ramírez, Sabri Bromage, Teresa T Fung, Yanping Li, Shilpa N Bhupathiraju, Megan Deitchler, Walter Willett, and Carolina Batis. 2021. “Performance of the Global Diet Quality Score with Nutrition and Health Outcomes in Mexico with 24-h Recall and FFQ Data.” J Nutr, 151, Supplement_2, Pp. 143S-151S. Publisher's VersionAbstract
BACKGROUND: The Global Diet Quality Score (GDQS) is intended as a simple global diet quality metric feasible in low- and middle-income countries facing the double burden of malnutrition. OBJECTIVE: The aim of this study was to evaluate the performance of the GDQS with markers of nutrient adequacy and chronic disease in nonpregnant nonlactating (NPNL) Mexican women of reproductive age and to compare it with the Alternate Healthy Eating Index-2010 (AHEI-2010) and the Minimum Dietary Diversity for Women (MDD-W). METHODS: We included NPNL women aged 15 to 49 y from the Mexican National Health and Nutrition Surveys (2012 and 2016) with 24-h recall (n = 2542) or a FFQ (n = 4975) (separate samples). We evaluated the correlation of the GDQS with the energy-adjusted intake of several nutrients and evaluated its association with health parameters using covariate-adjusted linear regression models. RESULTS: The GDQS was positively correlated with the intake of calcium, folate, iron, vitamin A, vitamin B-12, zinc, fiber, protein, and total fat (rho = 0.09 to 0.38, P < 0.05) and was inversely correlated with the intake of added sugar (rho = -0.37 and -0.38, P < 0.05) using both instruments, and with total fat, SFA, and MUFA only with 24-h recall data (rho = -0.06 to -0.16, P < 0.05). The GDQS was inversely associated with serum ferritin, BMI, waist circumference, and serum total and LDL cholesterol using FFQ data (P < 0.05), and was positively associated with serum folate using 24-h recall data (P < 0.05). Similar correlations and associations were observed with the MDD-W (only with micronutrients) and the AHEI-2010 (only with chronic disease-related nutrients and health markers). CONCLUSIONS: In comparison to other diet metrics, the GDQS can capture both dimensions of nutrient adequacy and health markers related to the risk of chronic disease. The performance of the GDQS was satisfactory with either 24-h recall or FFQ.
Jorick Bater, Sabri Bromage, Tuyatsetseg Jambal, Enkhjargal Tsendjav, Enkhsaikhan Lkhagvasuren, Yanjmaa Jutmann, Adrian R. Martineau, and Davaasambuu Ganmaa. 2021. “Prevalence and Determinants of Vitamin D Deficiency in 9595 Mongolian Schoolchildren: A Cross-Sectional Study.” Nutrients, 13, 11. Publisher's VersionAbstract
Population-based data relating to vitamin D status of children in Northeast Asia are lacking. We conducted a cross-sectional study to determine the prevalence and determinants of vitamin D deficiency in 9595 schoolchildren aged 6–13 years in Ulaanbaatar (UB), the capital city of Mongolia. Risk factors for vitamin D deficiency were collected by questionnaire, and serum 25-hydroxyvitamin D (25[OH]D) concentrations were measured using an enzyme-linked fluorescent assay, standardized and categorized as deficient (25[OH]D <10 ng/mL) or not. Odds ratios for associations between independent variables and risk of vitamin D deficiency were calculated using multivariate analysis with adjustment for potential confounders. The prevalence of vitamins D deficiency was 40.6% (95% CI 39.7% to 41.6%). It was independently associated with female gender (adjusted odds ratio [aOR] for girls vs. boys 1.23, 95% CI 1.11–1.35), month of sampling (aORs for December–February vs. June–November 5.28 [4.53–6.15], March–May vs. June–November 14.85 [12.46–17.74]), lower levels of parental education (P for trend <0.001), lower frequency of egg consumption (P for trend <0.001), active tuberculosis (aOR 1.40 [1.03–1.94]), household smoking (aOR 1.13 [1.02 to1.25]), and shorter time outdoors (P for trend <0.001). We report a very high prevalence of vitamin D deficiency among Mongolian schoolchildren, which requires addressing as a public health priority.
Mourad Moursi, Sabri Bromage, Teresa T Fung, Sheila Isanaka, Mika Matsuzaki, Carolina Batis, Analí Castellanos-Gutiérrez, Erick Angulo, Nick Birk, Shilpa N Bhupathiraju, Yuna He, Yanping Li, Wafaie Fawzi, Armen Danielyan, Sachit Thapa, Liseteli Ndiyoi, Marieke Vossenaar, Alexandra Bellows, Joanne E Arsenault, Walter C Willett, and Megan Deitchler. 2021. “There's an App for That: Development of an Application to Operationalize the Global Diet Quality Score.” J Nutr, 151, Supplement_2, Pp. 176S-184S. Publisher's VersionAbstract
BACKGROUND: The global diet quality score (GDQS) is a simple, standardized metric appropriate for population-based measurement of diet quality globally. OBJECTIVES: We aimed to operationalize data collection by modifying the quantity of consumption cutoffs originally developed for the GDQS food groups and to statistically evaluate the performance of the operationalized GDQS relative to the original GDQS against nutrient adequacy and noncommunicable disease (NCD)-related outcomes. METHODS: The GDQS application uses a 24-h open-recall to collect a full list of all foods consumed during the previous day or night, and automatically classifies them into corresponding GDQS food group. Respondents use a set of 10 cubes in a range of predetermined sizes to determine if the quantity consumed per GDQS food group was below, or equal to or above food group-specific cutoffs established in grams. Because there is only a total of 10 cubes but as many as 54 cutoffs for the GDQS food groups, the operationalized cutoffs differ slightly from the original GDQS cutoffs. RESULTS: A secondary analysis using 5 cross-sectional datasets comparing the GDQS with the original and operationalized cutoffs showed that the operationalized GDQS remained strongly correlated with nutrient adequacy and was equally sensitive to anthropometric and other clinical measures of NCD risk. In a secondary analysis of a longitudinal cohort study of Mexican teachers, there were no differences between the 2 modalities with the beta coefficients per 1 SD change in the original and operationalized GDQS scores being nearly identical for weight gain (-0.37 and -0.36, respectively, P < 0.001 for linear trend for both models) and of the same clinical order of magnitude for waist circumference (-0.52 and -0.44, respectively, P < 0.001 for linear trend for both models). CONCLUSION: The operationalized GDQS cutoffs did not change the performance of the GDQS and therefore are recommended for use to collect GDQS data in the future.
Mika Matsuzaki, Nick Birk, Sabri Bromage, Liza Bowen, Carolina Batis, Teresa T Fung, Yanping Li, Meir J Stampfer, Megan Deitchler, Walter C Willett, Wafaie W Fawzi, Sanjay Kinra, and Shilpa N Bhupathiraju. 2021. “Validation of Global Diet Quality Score Among Nonpregnant Women of Reproductive Age in India: Findings from the Andhra Pradesh Children and Parents Study (APCAPS) and the Indian Migration Study (IMS).” J Nutr, 151, Supplement_2, Pp. 101S-109S. Publisher's VersionAbstract
BACKGROUND: In India, there is a need to monitor population-level trends in changes in diet quality in relation to both undernutrition and noncommunicable diseases. OBJECTIVES: We conducted a study to validate a novel diet quality score in southern India. METHODS: We included data from 3041 nonpregnant women of reproductive age (15-49 years) from 2 studies in India. Diet was assessed using a validated food frequency questionnaire (FFQ). The Global Diet Quality Score (GDQS) was calculated from 25 food groups (16 healthy; 9 unhealthy), with points for each group based on the frequency and quantity of items consumed in each group. We used Spearman correlations to examine correlations between the GDQS and several nutrient intakes of concern. We examined associations between the GDQS [overall, healthy (GDQS+), and unhealthy (GDQS-) submetrics] and overall nutrient adequacy, micro- and macronutrients, body mass index (BMI), midupper arm circumference, hemoglobin, blood pressure, high density lipoprotein (HDL), and total cholesterol (TC). RESULTS: The mean GDQS was 23 points (SD, 3.6; maximum, 46.5). In energy-adjusted models, positive associations were found between the overall GDQS and GDQS+ and intakes of calcium, fiber, folate, iron, monounsaturated fatty acid (MUFA), protein, polyunsaturated fatty acid (PUFA), saturated fatty acid (SFA), total fat, and zinc (ρ = 0.12-0.39; P < 0.001). Quintile analyses showed that the GDQS was associated with better nutrient adequacy. At the same time, the GDQS was associated with higher TC, lower HDL, and higher BMI. We found no associations between the GDQS and hypertension. CONCLUSIONS: The GDQS was a useful tool for reflecting overall nutrient adequacy and some lipid measures. Future studies are needed to refine the GDQS for populations who consume large amounts of unhealthy foods, like refined grains, along with healthy foods included in the GDQS.
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.

    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.