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          Abstract

          Dear Editor: We thank Rahman and Ireen for their interest in our recent publication (1). Indeed, we had been surprised to find that the prevalence of anemia was lower than expected in this study site in Bangladesh (2). The control group prevalence in our study was 17.4%, just more than half the 33% prevalence reported in the National Micronutrient Status Survey published in 2013 (3) and substantially lower than the 48.8% prevalence that we found in Kenya (2). We agree with the sentiment in the letter that groundwater iron concentrations are an important contributor to population iron status in Bangladesh, but we are not convinced that this is the reason for the unexpectedly low prevalence of anemia in our study compared with that in other areas of Bangladesh. Because it was shown previously that iron status is correlated with groundwater iron concentration (4), we had purposefully selected an area with low groundwater iron concentrations (5). According to the Bangladesh National Hydrochemical Survey, the majority of groundwater iron concentrations should have been <2 mg/L in our study area, which we illustrated in Supplemental Figure 1. Indeed, median groundwater iron concentration measured in the study area prior to the start of the intervention trial was 0.91 mg/L (IQR: 0.36–2.01 mg/L) (6). Iron deficiency did appear to be a problem in our study area. The prevalence of iron deficiency was 41% (inflammation corrected ferritin <12 µg/L or serum soluble transferrin receptor >8.3 mg/L), which was reduced by 40–60% in the 2 nutrition intervention groups. We have struggled to explain the unexpectedly low prevalence of anemia in this area compared with that of the national survey (3), which included sampling from regions that had much higher groundwater iron concentrations. One possibility that we had considered was that our blood sampling methods differed from those used in the survey, which we erroneously stated had used capillary blood sampling. However, Rahman and Ireen have correctly noted that we did in fact use the same method of venous blood sampling. Nevertheless, it is apparent from our study as well as from the national survey that micronutrient deficiencies are a problem in Bangladesh, regardless of the prevalence of anemia, and that the prevalence likely varies regionally. We recommend that investigators measure groundwater iron concentrations in future studies of iron or other micronutrient interventions.

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          Iron status of women is associated with the iron concentration of potable groundwater in rural Bangladesh.

          Women of reproductive age are at a high risk of iron deficiency, often as a result of diets low in bioavailable iron. In some settings, the iron content of domestic groundwater sources is high, yet its contribution to iron intake and status has not been examined. In a rural Bangladeshi population of women deficient in dietary iron, we evaluated the association between groundwater iron intake and iron status. In 2008, participants (n = 209 with complete data) were visited to collect data on 7-d food frequency, 7-d morbidity history, 24-h drinking water intake, and rice preparation, and to measure the groundwater iron concentration. Blood was collected to assess iron and infection status. Plasma ferritin (μg/L) and body iron (mg/kg) concentrations were [median (IQR)] 67 (46, 99) and 10.4 ± 2.6, respectively, and the prevalence of iron deficiency (ferritin < 12 μg/L) was 0%. Daily iron intake from water [42 mg (18, 71)] was positively correlated with plasma ferritin (r = 0.36) and total body iron (r = 0.35) (P < 0.001 for both). In adjusted linear regression analyses, plasma ferritin increased by 6.1% (95% CI: 3.8, 8.4%) and body iron by 0.3 mg/kg (0.2, 0.4) for every 10-mg increase in iron intake from water (P < 0.001). In this rural area of northern Bangladesh, women of reproductive age had no iron deficiency likely attributable to iron consumed from drinking groundwater, which contributed substantially to dietary intake. These findings suggest that iron intake from water should be included in dietary assessments in such settings.
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            Effects of lipid-based nutrient supplements and infant and young child feeding counseling with or without improved water, sanitation, and hygiene (WASH) on anemia and micronutrient status: results from 2 cluster-randomized trials in Kenya and Bangladesh

            ABSTRACT Background Anemia in young children is a global health problem. Risk factors include poor nutrient intake and poor water quality, sanitation, or hygiene. Objective We evaluated the effects of water quality, sanitation, handwashing, and nutrition interventions on micronutrient status and anemia among children in rural Kenya and Bangladesh. Design We nested substudies within 2 cluster-randomized controlled trials enrolling pregnant women and following their children for 2 y. These substudies included 4 groups: water, sanitation, and handwashing (WSH); nutrition (N), including lipid-based nutrient supplements (LNSs; ages 6–24 mo) and infant and young child feeding (IYCF) counseling; WSH+N; and control. Hemoglobin and micronutrient biomarkers were measured after 2 y of intervention and compared between groups using generalized linear models with robust SEs. Results In Kenya, 699 children were assessed at a mean ± SD age of 22.1 ± 1.8 mo, and in Bangladesh 1470 participants were measured at a mean ± SD age of 28.0 ± 1.9 mo. The control group anemia prevalences were 48.8% in Kenya and 17.4% in Bangladesh. There was a lower prevalence of anemia in the 2 N intervention groups in both Kenya [N: 36.2%; prevalence ratio (PR): 0.74; 95% CI: 0.58, 0.94; WSH+N: 27.3%; PR: 0.56; 95% CI: 0.42, 0.75] and Bangladesh (N: 8.7%; PR: 0.50; 95% CI: 0.32, 0.78; WSH+N: 7.9%, PR: 0.46; 95% CI: 0.29, 0.73). In both trials, the 2 N groups also had significantly lower prevalences of iron deficiency, iron deficiency anemia, and low vitamin B-12 and, in Kenya, a lower prevalence of folate and vitamin A deficiencies. In Bangladesh, the WSH group had a lower prevalence of anemia (12.8%; PR: 0.74; 95% CI: 0.54, 1.00) than the control group, whereas in Kenya, the WSH+N group had a lower prevalence of anemia than did the N group (PR: 0.75; 95% CI: 0.53, 1.07), but this was not significant (P = 0.102). Conclusions IYCF counseling with LNSs reduced the risks of anemia, iron deficiency, and low vitamin B-12. Effects on folate and vitamin A varied between studies. Improvements in WSH also reduced the risk of anemia in Bangladesh but did not provide added benefit over the nutrition-specific intervention. These trials were registered at clinicaltrials.gov as NCT01590095 (Bangladesh) and NCT01704105 (Kenya).
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              Effect of Groundwater Iron on Residual Chlorine in Water Treated with Sodium Dichloroisocyanurate Tablets in Rural Bangladesh

              Abstract. We assessed the ability of sodium dichloroisocyanurate (NaDCC) to provide adequate chlorine residual when used to treat groundwater with variable iron concentration. We randomly selected 654 tube wells from nine subdistricts in central Bangladesh to measure groundwater iron concentration and corresponding residual-free chlorine after treating 10 L of groundwater with a 33-mg-NaDCC tablet. We assessed geographical variations of iron concentration using the Kruskal–Wallis test and examined the relationships between the iron concentrations and chlorine residual by quantile regression. We also assessed whether user-reported iron taste in water and staining of storage vessels can capture the presence of iron greater than 3 mg/L (the World Health Organization threshold). The median iron concentration among measured wells was 0.91 (interquartile range [IQR]: 0.36–2.01) mg/L and free residual chlorine was 1.3 (IQR: 0.6–1.7) mg/L. The groundwater iron content varied even within small geographical regions. The median free residual chlorine decreased by 0.29 mg/L (95% confidence interval: 0.27, 0.33, P 3 mg/L iron in water. Similar findings were observed for user-reported iron taste in water. Our findings reconfirm that chlorination of groundwater that contains iron may result in low-level or no residual. User reports of no iron taste or no staining of storage containers can be used to identify low-iron tube wells suitable for chlorination. Furthermore, research is needed to develop a color-graded visual scale for iron staining that corresponds to different iron concentrations in water.
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                Author and article information

                Journal
                Am J Clin Nutr
                Am. J. Clin. Nutr
                ajcn
                The American Journal of Clinical Nutrition
                Oxford University Press
                0002-9165
                1938-3207
                August 2019
                16 May 2019
                16 May 2019
                : 110
                : 2
                : 520
                Affiliations
                [1 ]From the Department of Nutrition, University of California, Davis, Davis, CA
                [2 ]Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA
                [3 ]International Center for Diarrheal Disease Research, Dhaka, Bangladesh
                [4 ]Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA
                Author notes
                Article
                nqz055
                10.1093/ajcn/nqz055
                6669049
                31095285
                b26ba81a-af07-414f-b891-25686143e1f0
                Copyright © American Society for Nutrition 2019.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

                Page count
                Pages: 1
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                Categories
                Letter to the Editor

                Nutrition & Dietetics
                Nutrition & Dietetics

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