Ellen Hertzmark

Poor dietary intake of vitamin B12 and folate before and during pregnancy has been associated with adverse birth outcomes. This relationship has not been rigorously evaluated in Tanzania. We performed secondary analyses of data collected during the perinatal study, a double‐blind trial that investigated the effect of vitamin supplements on perinatal outcomes in Tanzania between 2001 and 2004. In this analysis, we used log‐binomial models to investigate the adequacy of vitamin B12 and folate intake among 7633 mothers and the association of vitamin B12 and folate intake during pregnancy with low birth weight, preterm birth (PTB), small for gestational age and foetal death. Sixty‐seven percent of women had vitamin B12 intake below the recommended dietary allowances (RDAs) of 2.6 mcg for pregnant women, and 98% of women had folate intake below the RDA of 600 mcg for pregnant women. Compared with women in the lowest tertile of vitamin B12 intake women in the highest tertile were 26% less likely to have PTB (relative risk [RR] = 0.74, 95% confidence interval [CI]: 0.65, 0.84) and 36% less likely to have severe PTB (RR = 0.64, 95% CI: 0.50, 0.83). Compared with women in the lowest tertile of folate intake women in the highest tertile were 21% less likely to have PTB (RR = 0.79, 95% CI: 0.69, 0.89) and 21% less likely to have severe PTB (RR = 0.79, 95% CI: 0.69, 0.89). The provision of an adequate supply of these nutrients before and during pregnancy would improve pregnancy outcomes in Tanzania.

The prevalence of adverse birth outcomes is highest in resource-limited settings such as sub-Saharan Africa. Maternal consumption of diets with adequate nutrients during pregnancy may protect against these adverse outcomes. The objective was to determine the association between maternal dietary consumption of animal source foods (ASFs) and the risk of adverse birth outcomes among HIV-negative pregnant women in Tanzania. Using dietary intake data from 7564 HIV-negative pregnant women, we used Poisson regression with the empirical variance (generalized estimating equation) to estimate the RR of adverse birth outcomes—preterm birth, very preterm birth, small for gestational age (SGA), low birth weight (LBW), stillbirth, and neonatal death—for higher and lower frequency of ASF intake. Median daily dietary intake of animal protein was 17 g (IQR: 1–48 g). Higher frequency of ASF protein intake was associated with lower risk of neonatal death (quartile 4 compared with quartile 1; RR: 0.59; 95% CI: 0.38, 0.90; P-trend = 0.01). Higher fish intake was associated with lower risk of very preterm birth (high tertile compared with low; RR: 0.76; 95% CI: 0.58, 0.99; P-trend = 0.02). Any meat intake was protective of preterm birth (RR: 0.73; 95% CI: 0.65, 0.82; P < 0.001), very preterm birth (P < 0.001), LBW (P < 0.001), and neonatal death (P = 0.01) but was associated with increased risk of SGA (RR:1.19; 95% CI: 1.01, 1.36; P = 0.04). Any egg intake was protective of very preterm birth (RR: 0.50; 95% CI: 0.31, 0.83; P = 0.01) as compared with no egg intake. Finally, any dairy intake was associated with lower risk of preterm birth (RR: 0.82; 95% CI: 0.68, 0.98; P = 0.03) and very preterm birth (RR: 0.53; 95% CI: 0.34, 0.84; P = 0.01). Higher frequency of dietary intake of ASF is associated with lower risk of adverse birth outcomes in urban Tanzania. Promoting prenatal dietary intake of ASF may improve birth outcomes in this region and similar resource-limited settings

Context The association between weight change and mortality among participants with incident type 2 diabetes (T2D) was unclear. Objective To examine above association and evaluate the impact of lifestyle on it. Methods This prospective analysis included 11 262 incident T2D patients from Nurses’ Health Study and Health Professionals Follow-up Study. We assessed weight change bracketing T2D diagnosis in relation to mortality. We also examined potential effect modification by a healthy lifestyle consisting of high-quality diet, regular physical activity, nonsmoking status, and moderate alcohol consumption. Results On average, T2D patients lost 2.3 kg during a 2-year time window spanning the T2D diagnosis, and body weight increased afterwards following a trajectory similar to that of nondiabetics. Compared with patients with a stable weight, T2D patients who lost ≥10% body weight had a 21% (95% CI, 9%-35%) increased all-cause mortality. Lifestyle significantly modified these associations: the hazard ratios (95% CIs) of all-cause mortality comparing ≥10% weight loss with stable weight were 1.63 (1.26-2.09) among participants with a deteriorated lifestyle, 1.27 (1.11-1.46) for a stable lifestyle, and 1.02 (0.81-1.27) for an improved lifestyle (P_interaction < 0.001). Major weight loss was associated with increased cause-specific mortality and similar effect modifications by lifestyle were also observed. Conclusion Significant weight loss upon T2D incidence was associated with increased mortality, although improved lifestyle quality abolished these associations. These results highlight the role of adopting a healthy lifestyle for newly diagnosed T2D patients, especially among those who might lose weight unintentionally, and improving long-term survival.

Preterm birth (PTB), small for gestational age (SGA), and low birth weight (LBW) are risk factors for morbidity and mortality among infants. High-quality maternal diets during pregnancy may protect against these adverse birth outcomes. The aim of this study was to prospectively examine the association of maternal dietary diversity and quality during pregnancy with birth outcomes among women in Dar es Salaam, Tanzania. We analyzed data from 7553 HIV-negative pregnant women enrolled in a multivitamin trial at 12-27 weeks of gestation. Dietary intake was assessed using 24-h dietary recalls. Dietary diversity scores (DDS; range: 0-10) were computed as the number of food groups consumed by women, using FAO's Minimum Dietary Diversity for Women index. The Prime Diet Quality Score (PDQS; range: 0-42) assessed maternal diet quality based on consumption of 21 healthy and unhealthy food groups. Log binomial regression methods were used to assess associations of DDS and PDQS with PTB, SGA, LBW, and fetal loss. In the previous 24 h, 99.9% of all women had consumed cereal and staples, 57.9% meats, 4.7% eggs, and 0.5% nuts and seeds. Median DDS was 3.0 (IQR: 2.5-3.5). For the PDQS, all women consumed ≥4 servings/wk of green leafy vegetables and refined grains. Higher DDS was associated with lower risk of SGA (RR highest compared with lowest quintile: 0.74; 95% CI: 0.62, 0.89). Higher PDQS was associated with lower risk of PTB (RR highest compared with lowest quintile: 0.55; 95% CI: 0.46, 0.66), LBW (RR: 0.53; 95% CI: 0.40, 0.70), and fetal loss (RR: 0.53; 95% CI, 0.34, 0.82). PDQS was inversely associated with PTB, LBW, and fetal loss, and DDS was inversely associated with SGA. These findings suggest that in addition to dietary diversity, diet quality should be considered as important in understanding dietary risk factors for poor birth outcomes.This trial was registered at clinicaltrials.gov as NCT00197548.

Hematological status may predict HIV disease progression and mortality among adults initiating highly active antiretroviral therapy (HAART). We aimed to examine the relation of anemia and iron status at HAART initiation with survival and morbidity outcomes. We conducted a case-cohort study of 570 HIV-infected adults initiating HAART who were enrolled in a trial of multivitamins in Tanzania. Hemoglobin, serum ferritin, and hepcidin concentrations were assessed at HAART initiation and participants were followed up monthly. We adjusted serum ferritin for inflammation using a regression correction method to characterize hematological status. Cox proportional hazards models were used to estimate HRs for mortality and incident clinical outcomes. We found an 83% prevalence of anemia, 15% prevalence of iron deficiency anemia, and 66% prevalence of anemia of chronic diseases (ACD). The prevalence of elevated iron was 33% and 19% had iron deficiency (ID). After multivariate adjustment, severe anemia (HR: 2.57; 95% CI: 1.49, 4.45) and ACD (HR: 4.71; 95% CI: 2.91, 7.62) were associated with increased risk of mortality as compared with nonanemic participants. In addition, both ID (HR: 2.65; 95% CI: 1.08, 7.78) and elevated iron (HR: 2.83; 95% CI: 2.10, 3.82) were associated with increased risk of mortality as compared with normal iron concentrations. Severe anemia and elevated iron concentrations were associated with incident wasting and >10% weight loss (P values <0.05). Anemia and both ID and elevated iron were associated with increased mortality among HIV-infected adults initiating HAART. Safety and efficacy studies including anemia etiology, timing of HAART initiation, and dose of iron supplementation among HIV patients appear warranted. This trial was registered at clinicaltrials.gov as NCT00383669.

Zinc and vitamin A supplementation have both been shown to affect iron status, hemoglobin (Hb) concentration, and anemia in animal and human studies. However, evidence on their combined use in pregnancy, in the context of iron-folic acid (IFA) supplementation, remains limited. This study determined the effects of prenatal zinc, vitamin A, and iron supplementation on maternal hematologic and micronutrient status at delivery in Tanzania. We analyzed 2 large randomized controlled trials, using generalized estimating equations, and examined the effect of daily zinc (25 mg) and vitamin A (2500 IU) supplementation starting in the first trimester of pregnancy compared with placebo (n = 2500), and separately evaluated the safety and efficacy of daily iron (60 mg) supplementation among iron-replete pregnant women (n = 1500). Blood samples from baseline and delivery were tested for Hb, serum ferritin, soluble transferrin receptor, plasma zinc, and zinc protoporphyrin. Zinc and vitamin A supplementation were associated with lower Hb concentrations at delivery of -0.26 g/dL (95% CI: -0.50, -0.02 g/dL) and -0.25 g/dL (95% CI: -0.49, -0.01 g/dL), respectively. Vitamin A increased mean ferritin concentrations at delivery (14.3 μg/L, 95% CI: 1.84, 29.11 μg/L), but was associated with increased risk of severe anemia (RR: 1.41; 95% CI: 1.06, 1.88). Among women who were iron replete at baseline, iron supplementation reduced the risk of iron depletion at delivery by 47% (RR: 0.53; 95% CI: 0.43, 0.65). There was no effect of zinc or iron supplements on plasma zinc concentrations. Our findings support existing WHO guidelines on prenatal iron, vitamin A, and zinc supplementation among pregnant women. In this setting, scaling uptake of prenatal iron supplements is warranted, but prenatal zinc and vitamin A supplementation did not benefit maternal hematologic status at delivery. In settings where vitamin A deficiency is endemic, the efficacy and safety of the WHO recommended prenatal vitamin A supplementation require further evaluation.

We examined the incidence of herpes zoster (HZ) before and after the initiation of antiretroviral therapy (ART), and risk factors for HZ among human immunodeficiency virus (HIV)-infected individuals in Tanzania. A cohort study was conducted among HIV-positive individuals enrolled in HIV care and treatment clinics in Dar es Salaam, Tanzania. A Cox proportional hazard model was used to examine the effect of ART on the risk of HZ after adjusting for sociodemographics and time-varying clinical and nutritional factors. Among 72,670 HIV-positive individuals, 2,312 incident cases of HZ (3.2%) occurred during the median follow-up of 15 months (interquartile range: 3–35). The incidence rate of HZ significantly declined from 48.9 (95% confidence interval [CI] = 46.7–51.0) per 1,000 person-years before ART to 3.7 (95% CI = 3.3–4.1) per 1,000 person-years after the initiation of ART (P < 0.001). The risk of HZ declined with longer duration on ART. Low CD4 cell count, older age, female sex, district of Dar es Salaam, and year of enrollment were independently associated with the risk of HZ in the multivariate analysis. Low body mass index and anemia were not associated with the risk of HZ. The risk of HZ substantially declined after ART initiation in this large cohort of HIV-infected individuals. Earlier initiation of ART could reduce the risk of HZ and other opportunistic infections among HIV-infected individuals in sub-Saharan Africa.