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W2186441219 abstract "Special CommunicationSerum Zinc in Infants and Preschool Children in the Jeddah Area: Effect of Diet and Diarrhea in Relation to Growth Suhad M. BahijriPhD Suhad M. Bahijri Search for more papers by this author Published Online:1 Sep 2001https://doi.org/10.5144/0256-4947.2001.324SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionZinc is known to influence cell division, growth and development,1 as well as sexual maturation.2 It is also needed as a membrane stabilizer,3 and is essential for the integrity of the immune system.4 In fact, more than 100 enzymes require zinc as a cofactor, and it seems to be involved in the proper storage and release of insulin, growth and repair of tissues, wound healing, the ability to taste food, the production of prostaglandins, mineralization of bone, blood clotting, the function of vitamin A, and the functions of the thyroid hormones.5,6Nutritional zinc deficiency was first documented in the Middle East in 1963,7 and in the following two decades, reports from Iran, Egypt, Turkey, Portugal, Morocco, Yugoslavia and other developing countries, as well as the United States9 and Canada,10 have shown that nutritional zinc deficiency is fairly prevalent throughout the world. These reports do not represent actual incidence of zinc deficiency worldwide, but reflect awareness in diagnosing overt cases only. Hence, zinc deficiency could be prevalent in other countries but remain undiagnosed.An important predisposing factor for zinc deficiency is the extensive use of cereal protein which limits the availability of zinc due to high phosphate and phytate content.11 The recommended dietary allowance of the Food and Nutrition Board12 and the National Academy of Sciences in the United States is 15 mg/day for adult males and 12 mg/day for adult females, with higher recommended levels during pregnancy and lactation. Requirements for infants and children are relatively high in relation to body size because of increased requirements for physical growth.13The best sources for zinc in the diet are meat and fish,14 and the bioavailability of zinc from animal products is considered to be greater than that from plants. Diarrhea is associated with zinc deficiency15,16 and low serum zinc concentration.17 Suggestions have been made that growth retardation commonly seen in children in developing countries is related to a nutritional deficiency of zinc.5,18,19 In a recent study conducted in the Western region of Saudi Arabia,20 the range of serum zinc of all studied ages including infants and adults was found to be 0.5–13.9 μmol/L, which is lower than the international standard of 7.65–22.95 μmol/L. The study included very few infants and children, and made no attempt to relate low levels to growth. However, it draws the attention to the possible existence of zinc deficiency among infants and children in this area of the world. We therefore undertook this study to investigate the prevalence of zinc deficiency (reflected in low-serum zinc) in our infant and preschool children population, and to see whether such a deficiency is a cause of retarded growth in our region. We studied the relationship between serum zinc and height for age, as well as the causes of deficiency, i.e., whether it was due to inadequate intake or to increased loss in diarrhea. This will help in formulating strategy and making recommendations to health authorities and pediatricians with respect to the need for zinc supplementation, and the identification of groups of infants and children most susceptible to zinc deficiency and who are likely to benefit from such supplementation.Subjects and MethodsA total of 935 healthy infants and preschool children aged 4–72 months with no internal disorders were selected randomly from nurseries, kindergartens, welfare centers, and vaccination clinics. The principles of random selection were used in choosing the subjects.21 Care was taken to ensure that all districts in the Jeddah area as well as all socioeconomic classes were covered.22 Subjects were included in the study only if their parents gave free informed consent, were of Saudi origin or Arabic speaking, and had been resident in the country for at least five years. The Research Committee at the university approved the study protocol.Of the 935 subjects, blood samples were obtained from 728. Various anthropometric measurements (weight, height, head circumference, mid-upper arm circumference, chest circumference and skin fold thickness) of the subjects were taken according to international guidelines23 by the same person, but only height and weight were used in the study. Recumbent length was taken for children of up to two years of age using a measuring table (SR Scales by SR Instruments Inc.) and standard techniques. The weight of the subjects was measured at the same time. Standing height was taken for older children by using Detecto anthropometer (Cardinal Scale Manufacturing Company), which measured weight at the same time. Measurements of height were to the nearest 0.1 cm. The weight was measured to the nearest 0.01 kg in infants and small children, and to the nearest 0.05 kg in older children. The scales were checked regularly against standard weights. Uncooperative children were weighed while being held in their mother’s arms, then the mother was weighed separately and subtraction used to obtain the child’s weight.Using the concept of weight for height,24,25 the subjects were classified according to their grade of wasting. Those with values greater than 90% of standard26 were classified as grade 0, while those with values ranging from 80%–90% of standard were classified as grade 1, and those with values of 70%–80% of standard, and <70% of standard, were classified as grades 2 and 3, respectively.The age of the subject was calculated to the nearest month from their birth records. Using the concept of height for age, the subjects were classified according to their grade of stunting. Those with values greater than 95% of standard26 were classified as grade 0, while those with values ranging between 90%–95% were classified as grade 1, and those with values of 85%–90% and <85% were classified as grades 2 and 3, respectively. Medical history of past illnesses, with special emphasis on diarrheal attacks and their duration, was taken for each subject.The subjects’ diets were assessed by means of diet history and food-frequency questionnaires, as well as 24-hour recall method administered by personal interview. The 24-hour dietary recalls were repeated three days later and an average of the two recalls taken. Other information collected was used to validate the 24-hour recalls. Total calories consumed per day, protein, calcium, iron, vitamin A and vitamin C intakes were calculated for each subject using the nutrient values given in various food composition bulletins,27–30 as well as information on packets of ready-made food.A siliconized 21-gauge minicath intravenous catheter was inserted into an antecubital vein, and blood was drawn into trace element-free evacuated tube (Becton Dickinson, Rutherford, US). Serum was separated by the use of disposable sterile pipettes and stored at −20°C for subsequent analysis.All glassware used in preparation of serum samples for zinc analysis was washed with mild detergent and rinsed with distilled double-deionized water (dddH2O). Washed glassware was placed in a 20% nitric acid bath (BHD, England) for 48 hours and then rinsed with several volumes of dddH2O. Rinsed glassware was placed in a covered polyethylene drying basket until dry, then stored in sealed plastic bags prior to use.Serum zinc was assayed by flame atomic absorption spectrophotometer (Perkin Elmer 503 Spectrophotometer), utilizing an air acetylene flame, hollow cathode lamp (Perkin Elmer) as light source, and procedures recommended by the manufacturer and based on standard techniques.31,32 A calibration curve was prepared using readings from five working standards taken from a reference standard (May Baker Zinc Standard 1000 ppm) diluted by glycerol (reagent grade) and aspirated into the atomic absorption spectrophotometer.Results were expressed as mean±SD. Data were analyzed by comparing means of groups or categories using Students’s unpaired t-test Significance was assigned at P<0.05.ResultsSerum zinc levels for the sample as a whole and for the various age groups are presented in Table 1. This distribution of values is illustrated in Figure 1. A total of 488 values (67% of whole sample) lie within ±1SD of the calculated mean, while 706 values (97% of sample) lie within ±2SD of the calculated mean, thus satisfying the empirical rule for normal distribution. The values were similarly distributed when divided into subgroups according to age (distribution not illustrated). Therefore, the means of the different subgroups were compared statistically. The mean of the 6–12-month age group decreased significantly (P<0.05) compared to the younger age group, then remained unchanged in the next two age groups (i.e., until 36 months). The mean of the oldest age group increased significantly (P<0.01) compared to the previous three groups and became not significantly different to the mean of the youngest age group, but the range was much wider. Many subjects in all the age groups had zinc levels below the cutoff point of 10.4 μmol/L frequently cited in the literature.10,33 This might be due to the incidence of various grades of stunting and wasting in our population (Table 2), indicating malnutrition, which is reported to be associated with low levels of zinc.34,35 Moreover, some subjects had suffered from moderate or severe attacks of acute diarrhea less than three weeks before the date of sample collection, which could have led to low serum zinc levels.15–17FIGURE 1 Distribution of serum zinc levels in the whole collected sample.Download FigureTable 1 Serum zinc levels (mean±SD) for various age groups in μmol/L.Age (months)No. of samplesMean±SDNo. of samples <10.4 μmol/L4–<61159.36±2.84646–<121658.74±2.0513212–<241618.62±2.0713024–<36888.00±2.467136–<721999.44±3.75116All samples7288.91±45513Table 2 Distribution of normal and below normal subjects in the different age groups.Age (months)No. of subjects with grade zero stunting and wasting (normal)No. of wasted subjectsNo. of stunted subjectsNo. of wasted and stunted subjects4–<6(n=154)94 (61.0)*38 (24.7)20 (12.9)2 (1.3)6–<12 (n=202)95 (47.0)70 (34.7)25 (12.4)12 (5.9)12–<24 (n=219)83 (37.9)55 (25.1)35 (16.0)46 (21.0)24–<36 (n=93)38 (40.9)14 (15.0)13 (14.0)28 (30.1)36–<72 (n=267)101 (37.8)34 (12.7)73 (26.5)59 (22.0)*percentage of subjects in age group.The cause of low serum zinc levels was investigated by comparing the anthropometric measurements of the concerned subjects to their calculated dietary intakes and a review of their medical history. In the youngest age group, 24 subjects with serum zinc of < 10.4 μmol/L had either very low levels (<75% of RDA for calories and <54% of RDA36 for protein and other calculated nutrients), being dependent on breast milk mainly, with very little homemade mashed fruits, vegetables and rice (all low in zinc). Two of them were stunted and wasted, 13 were wasted and nine were stunted. The remaining 40 subjects with low serum zinc apparently received adequate dietary intakes of calories and other calculated nutrients but suffered from recent moderate or severe diarrheal attacks causing wasting in 25 of them, while the remaining 15 had normal anthropometric measurements. No significant difference in dietary intakes or pattern was noted between these subjects and others with higher serum zinc, being mostly dependent on breast milk, bottled infant milk and various home- and ready-made foods.In the second age group, 18 subjects with low serum zinc had either very low or low dietary intakes, being still dependent mainly on breast milk. Twelve subjects were stunted and wasted and six were stunted. The remaining subjects with low serum zinc had apparently adequate dietary intakes with respect to total calories, protein and other calculated nutrients, but had suffered recent moderate-to-severe attacks of diarrhea, leading to various grades of wasting in 70 of them. No significant difference was noted in dietary intakes between those subjects and the ones with higher zinc levels. Thus, it seems that in subjects <12 months of age, low serum zinc is more associated with incidence of diarrhea rather than low dietary intake.In the group aged 12–<24 months, the unsuccessful attempt to change from infant foods, including ready-made formulas to semi-solid and solid foods led to a high percentage of subjects with low dietary intakes with respect to calories and all calculated nutrients. Almost all subjects with low serum zinc had low dietary intake reflected on anthropometric measurement with various grades of stunting and wasting (46 subjects were stunted and wasted, 28 were stunted, and 52 were wasted). Diarrhea must also have contributed to the low levels of zinc, as 38 of the wasted subjects, 23 wasted and stunted subjects, as well as the remaining four subjects with normal anthropometric measurements had had recent attacks of diarrhea ranging from moderate to severe.As the subjects passed the two-year mark, the adequacy of the diet decreased further and seemed to be behind the low serum zinc. Of the 71 subjects with low serum zinc, five had very low intakes (all were wasted and stunted), 50 had low intakes (23 were wasted and stunted, 13 were stunted, and 14 were wasted, with recent diarrheal attacks in 13), and 16 with normal anthropometric measurements seemed to receive adequate dietary intakes with respect to calories and all calculated nutrients, but the intake of zinc could not be determined, and 11 of them had had recent attacks of diarrhea ranging from mild to severe.The link between inadequacy of diet and low serum zinc levels appears more in the oldest group. Of 116 subjects with low serum zinc, six had very low intakes (all stunted and wasted) and 110 had low intakes with respect to calories and all calculated nutrients (53 were stunted and wasted, 37 stunted and 20 wasted, with recent attacks of diarrhea in 14). To investigate whether low zinc levels were related to anthropometric measurement, the mean zinc level and the standard deviation was calculated for subjects with grade 0 wasting and stunting (i.e., considered to be normal), as well as for subjects with wasting only, with stunting only or with stunting and wasting together. The results are presented in Table 3.Table 3 Serum zinc in subjects with normal and below normal anthropometric measurements (mean±SD) in μmol/L.Age (months)Subjects with grade zero stunting and wastingSubjects with various grades of wastingSubjects with various grades of stuntingSubjects with stunting and wasting4–<612.5±1.55 (n=55)6.95±1.65 (n=38)11.92±1.95 (n=20)3.63 and 3.96 (n=2)6–<1210.95±0.93 (n=58)6.51±1.02 (n=70)10.73±1.04 (n=15)6.31±0.82 (n=12)12–<2411.43±0.65 (n=35)6.32±0.93 (n=52)9.14±0.62 (n=28)5.97±0.76 (n=46)24–<3611.27±0.86 (n=33)6.63±0.76 (n=14)6.37±0.85 (n=13)5.73±0.64 (n=28)36–7212.83±1.21 (n=83)6.47±0.97 (n=20)6.63±0.78 (n=37)5.14±1.57 (n=59)For the youngest age group, the lowest levels of serum zinc were found in two wasted and stunted subjects, but low levels were found in subjects with and without stunting or wasting. The mean levels of subjects with various grades of wasting was significantly lower than the mean of subjects considered to have normal anthropometric measurements (P<1×10−5), and the mean of subjects with various grades of stunting (P<1×10−4). However, no significant decrease in the mean was found due to stunting. From the medical history, it was found that stunting in this group of subjects was associated with prematurity or being small for date at birth, while wasting was associated with low dietary intake or diarrhea.Similarly in the group aged 6–12 months, the mean levels of serum zinc in subjects suffering from wasting or wasting and stunting were not significantly different, but were significantly decreased when compared to the mean of subjects having 0 grade wasting and stunting (P<1×10−6 in both cases). On the other hand, the mean of subjects with stunting did not differ significantly from the mean of subjects with normal anthropometric measurements, and was significantly higher than the mean of subjects with wasting or wasting and stunting (P<5×10−6 in both cases). Stunting in this group was more associated with premature birth or previous frequent attacks of diarrhea, while wasting was associated with low dietary intake or recent diarrheal attacks.The situation was different in the group aged 12–<24 months. The mean serum zinc for the wasted and stunted subjects was significantly lower than the means of other categories in this group. However, the mean for subjects with normal anthropometric measurements was significantly higher than the mean of wasted subjects (P<1×10−6) and the mean of stunted subjects (P<0.001). Wasting and stunting, as well as stunting, were associated with low dietary intakes and previous frequent attacks of diarrhea, while wasting was found to be associated with low dietary intakes and recent attacks of diarrhea.In the group aged 24–<36 months, the lowest serum zinc mean was that of the wasted and stunted subjects, being significantly lower than the means of the other categories in this age group. However, the means of the wasted subjects, and those of the stunted subjects did not differ from each other, and both were significantly lower than the mean of subjects with normal anthropometric measurements (P<0.001 in both cases). Wasting and stunting in this age group seem to be associated with low dietary intakes mainly. Recent attacks of diarrhea were noted in only a few wasted or wasted and stunted subjects. Similarly, in the group of subjects over three years of age, the lowest mean serum zinc was found in the category of wasted and stunted subjects. The mean of wasted subjects and the mean of stunted subjects did not differ from each other, both being significantly lower than the mean of subjects with no grade of wasting or stunting (P<1×10−5). Below-normal anthropometric measurements in this age group seem to be mainly associated with low dietary intake.Age seemed to have an effect on the mean serum zinc level in subjects with normal anthropometric measurements. The mean of the second age group was significantly lower than the mean of the youngest age group (P<0.01). A significant increase in the mean was noted in the next age group (P<0.05), and the mean remained unchanged in the group aged 24–37 months, then increased again (P<0.005) to make it not significantly different to the mean of the youngest age group. This was a slightly different pattern to what was found when the means in Table 1 were compared with each other. However, the change in mean seems to be related to dietary changes as the subjects grew older. The normal unsupplemented powdered milk after six months of age seems to be the main cause of decreased mean serum zinc in the second age group, especially since subjects in this age group have not started to eat food naturally rich in zinc (e.g., meat, liver, nuts). With the inclusion of such foods, as the children grew older the mean increased gradually, returning to the same level when the children were younger and were receiving zinc-supplemented infant formulas.DiscussionThe mean serum zinc level seems to be affected by the age of subjects, whether it is calculated for all subjects as in Table 1, or for subjects with normal and below normal anthropometric measurements, as in Table 3. This was noted in an earlier report on serum zinc levels of individuals in the same area of the country.20 However, our calculated means in Tables 1 and 3 are higher than the earlier reported means for subjects above one year of age, and close to the mean for the younger subjects. Two factors are likely to cause the noted changes with age; the first is the dietary intake that changes as the infant grows, and the second is the incidence of diarrhea. The relative importance of these two factors differ with age. In the youngest two age groups (i.e., subjects <12 months of age), diarrhea seems to be the main cause of low serum zinc in the majority of subjects, since dietary intake was similar in most subjects with low and high zinc levels. However, as the subjects grew older, the incidence of diarrhea decreased, and the effect of diet became more important. In the group aged 12–<24 months, both diarrheal attacks and inadequate diet seem to be of equal importance in causing low serum zinc levels.Low zinc status, reflected in low serum zinc, seems to have a negative effect on the growth of young children in this area of the world. Loss of dietary zinc, combined with poor absorption due to diarrhea, led to an association between low zinc levels and wasting in the subjects less than one year of age, but no effect on height was noted at this stage. As the children grew older, continued low zinc status started to affect their height, and low levels of serum zinc were associated with stunting.Zinc supplement studies in India37 and Bangladesh38 found a significant reduction in the duration and severity of episodes of acute diarrhea in infants, especially those with low tissue zinc levels.37 Therefore, it seems imperative to recommend zinc supplements to infants suffering from repeated attacks of diarrhea, in the hope of improving the immunocompetence of these infants, thus minimizing the effects of these attack, or even preventing them altogether, as some studies indicate,39 especially in children with lower plasma zinc. In fact, it might be advisable to recommend zinc supplements to all infants above four months of age, especially those depending solely on breast milk with very little addition of low zinc-containing foods. This may be necessary in order to improve their immunocompetence, and prevent or reduce the incidence of various childhood infectious diseases such as diarrhea and respiratory tract infections, as reported in various studies.39–41 This is also applicable to children above 1 year of age, as many of them had low serum zinc levels and suffered from various grades of stunting and/or wasting. Zinc deficiency might not be the limiting factor in this group of studied children, as a large percentage of them had low dietary intake, however, zinc supplementation of such children might improve their appetite, dietary intake and absorptions, as previously reported,42 in addition to improving their immunocompetence, thus leading to improved nutritional status. Furthermore, children with below-normal anthropometric measurements and with low zinc status have been reported to show improved growth following zinc supplementation.10,18,33 Therefore, it is likely that young children would benefit from a combination of zinc supplementation and increased dietary intake, which might lead to normalization of their anthropometric measurements more quickly than if a general increased dietary intake was recommended by itself.In summary, the result of this work shows a high incidence of low serum zinc levels among Jeddah-area infants and young preschool children, which is associated with diarrhea and wasting in the first two years of life, and generally low dietary intake, wasting and/or stunting in older children. Zinc supplementation is recommended for certain categories of subjects to improve appetite and hence dietary intake, immunocompetence, and anthropometric measurements. 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W2186441219 title "Serum Zinc in Infants and Preschool Children in the Jeddah Area: Effect of Diet and Diarrhea in Relation to Growth" @default.
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