KEITH WEST: OK.
We'd ask folks to take
your seat, please.
And I'd like to
point out that there
are some excellent
posters on display
outside in the gallery area.
Please take time to see them.
Dr. Kerry Schulze gathered
faculty and students
and collaborators
to submit posters
so that we can have a display
of the kinds of things going
on here that don't
necessarily get highlighted
during the presentation.
So we have a great
lineup this afternoon.
Don't go anywhere.
Hope you're rested.
You've drunk your tea or coffee.
We're going to lead off
with Professor Robert Black.
Bob, you'll notice
that the rat appeared.
I don't know how it happened.
But he's really cute.
So we have Professor
Robert Black,
who is our Department
of International Health
chair for a very
short period of time,
only 27 years, during
which the department
grew from four faculty
to well over 100 faculty,
and has worked tirelessly on
trying to pull the world's
data together about what we know
about these kinds of problems.
So Professor--
ROBERT BLACK: Thank you, Keith.
First, if I had known that
I was going to start off
with what the nutrition
community got right and got
wrong, and if I realized that
McCollum's rat was looking
at me from his
peripheral vision,
I would have put in
a couple of slides.
But I will tell a
small story before I
get into the Lancet
series and the findings
related to vitamins
and minerals.
It wasn't only vitamins that
the McCollum lab was working on,
it was actually
minerals as well.
And they were looking
up into the 1930s
for essential elements that
were important in nutrition.
And they started
working on zinc.
And I have worked on zinc,
although that's not largely
the focus of my talk today.
And the first paper
by that laboratory,
by a graduate student
and EV McCollum,
said zinc is not an
essential nutrient.
It's ubiquitous.
It's really not
something that would
be necessary to
consider in the diet,
because it's in all the diets.
And really, what
happened is they
were trying to use
deficient diets,
but they didn't have a
sufficiently deficient diet
or environment,
including the cages.
And they really didn't
create zine deficiency.
And there were
subsequent publications.
And then they did
actually get it right
and published that
zinc was essential.
Not the first
publication on it, but--
so it is this story.
But there's another
part to the story
also that early on, it was
thought that it was only
severe zinc deficiency that
was a cause of ill health
or perhaps mortality.
And until very recently, the
last couple of decades, that
was really the presumption.
But it was really through
epidemiology and through trials
that it was recognized that even
milder forms of what you might
call subclinical without overt
clinical manifestations of zinc
deficiency did result
in serious consequences
for infectious
disease, particularly.
So that's my little
digression about zinc.
I couldn't resist.
So we in 2008 published a series
of papers on maternal and child
nutrition in the
journal The Lancet.
And just this year, this
summer, did an update,
a five-year update
of that series
in this set of
publications, four papers
and a call-to-action comment.
And I'm not going to go through
the details of the papers.
I'm going to really focus just
on some of the aspects related
to vitamins and minerals
in what we said as part
of the overall conclusion.
So it may be a
little bit disjointed
in the sense that
it doesn't have
the total set of information
that we were working with.
But I will say we--
just for the sake of the
framing of the entire series--
we were looking in
this set of papers
at the consequences across the
life course, so in this case,
reshaping this framework that
was developed a long time back
by UNICEF as a framework
for under-nutrition
or for stunting.
We turned that around to say we
wanted a framework for actions
to achieve optimal fetal
and child nutrition
and development.
So it's much more encompassing.
But it includes, then,
the consequences,
which I'm going to talk
about briefly, then
the nutrition-specific
interventions,
so the kinds of things
that you would think
of as obvious examples to
improve nutrition supplements,
fortification, approved diet,
breastfeeding, et cetera.
And those interventions work at
this level, the more proximate
level, of determinants of
the optimal fetal growth
and nutrition.
But we also in this series
looked at these other sectors
and programs, for example, in
agriculture, social protection,
social safety nets, education,
water, and sanitation,
so the other aspects that
also have relationships
to nutrition.
Looked at the evidence
to what extent
did they affect maternal
and child nutrition.
And then finally at this
most underlying level
of determinants of the
context in countries,
we actually looked at how to
build an enabling environment
to improve nutrition.
So just to say, there's
much more involved
in this series than the
little bits I will show you.
Klaus already showed this table.
And I don't want to dwell on it.
I will say, though, that
even at a global level,
there is a very substantial
deficiency remaining
of these four important
micronutrients, vitamin A.
And I think important
to recognize here
is compiling the data on
a population deficiency,
there is still a high prevalence
of it in spite of the fact
that there is a very
substantial effort going on
to deliver high-dose
vitamin A supplements.
And those supplements have,
as I think Al alluded to,
were presented as far
as they've attributed
deaths that have likely been
averted by the supplementation
programs.
We may through the programs have
reduced the mortality burden.
Certainly, it looks like there
is a reduction of the eye
disease xerophthalmia.
But we have not corrected
the underlying dietary
deficiencies.
So without the
supplement programs,
those conditions, ill-health
conditions, will likely return.
So it is to say
that there is a need
to persist in the programs.
New estimates done around
the time before the series,
actually, on iodine deficiency--
so a lot of issues around
what it means to have urinary
iodine in school children
below this threshold.
Nonetheless, in certain
areas of the world,
is likely there are still
consequences of this.
The milder degrees
of iodine deficiency,
especially in areas such as
Europe, which doesn't really--
many countries don't have
iodized salt, still debated
how much effect that has.
Perhaps there is some,
as recently published
in England on
cognitive impairment.
Zinc deficiency-- we used
a dietary assessment.
And the estimates
here-- and it varies.
The prevalence of likely
zinc-deficient diets
varies by region but
overall, about 17%.
And then some new estimates
we did for the series
on the importance of
iron deficiency anemia,
both in children and
in pregnant women.
So moderately high prevalences
across all the regions,
actually, in both
these age groups.
So some conclusions related
to some particular vitamins
and minerals--
one is that we redid
some analyses related
to anemia as a risk factor
for maternal deaths.
Most likely the deaths
that are associated
are those due to hemorrhage.
So when a woman
starts anemic, she
may have higher risk of death.
The hemorrhage is the leading
cause of maternal deaths.
And our estimate is that about
a quarter of those deaths
you might attribute to or at
least there's a strong risk
relationship with anemia.
Likewise, calcium
deficiency increases
the risk of preeclampsia.
And preeclampsia and
eclampsia are currently
the second-leading cause of
maternal death, so about 19%
of those deaths.
So we have said,
and I think it's
clear from the evidence,
that addressing
these deficiencies would have
benefits for maternal health.
For micronutrient
deficiencies in children,
you saw earlier the entire
range of micronutrients.
We didn't deal with all
of those in this series.
We really focused on
the ones with the most
demonstrated health effects.
And the first
statement is very clear
that deficiencies of
vitamin A and zinc
adversely affect child
health and survival.
And I'll show the attributed
deaths in a moment.
And the deficiencies
of iodine and iron,
primarily, are risk factors
for or contributors to children
not reaching full
developmental potential,
so cognitive impairment.
And as I already mentioned,
and Al did as well,
continuing to
address the vitamin
A deficiency would be necessary.
And what I'm showing is
the health consequences
of vitamin A deficiency.
At this point, the
marginal benefit
of now reaching additional
children who are not
being reached by
vitamin A supplements so
that the number is much less
because of the programs that do
exist.
So this is the
overall table that we
published in the series.
And I don't have time
to go into all of these.
But I would highlight that
we, in the new analyses,
gave a lot more weight to fetal
growth restriction as assessed
by small for gestational
age, so maternal nutrition,
under-nutrition as one
factor contributing
to poor fetal growth
and development.
And then being born small
for gestational age,
we're attributing about 800,000
deaths to that condition,
not prematurity.
I'm not talking about low
birth weight under 2,500 grams.
I'm talking about
specifically being
small for gestational age.
So it really puts us back to
put a major focus on pregnancy,
and as we've said, perhaps
the pre-conception period
or adolescent period
where nutrition needs
to be considered to improve
the health of girls and women
but also to improve
fetal growth.
Other estimates here for
stunting, underweight, et
cetera--
the zinc deficiency and
vitamin A deficiency sees here,
this is the attributed
deaths at this point
in children under five, although
not the entire age group
for each.
And then overall--
and this is a figure
you may have heard-- when
we use the methods that
allow us to combine these,
not simply add them but look
at the joint distributions
and not double counting,
we come out with about 45% of
all child deaths attributed
to under-nutrition in
one form or another,
including suboptimal
breastfeeding.
And so this summarizes
that 45%, as I said.
That's about 3 million
deaths a year out
of the almost 7 million deaths.
And deficiencies of
vitamin A and zinc
account for about 300,000
of those currently.
We looked at interventions
in the second paper
of the series, the
nutrition-specific
interventions.
And this is the plot
of how many deaths
would be averted
by scale-up to 90%,
cover each of those
interventions.
A very large number
from treatment
of severe acute malnutrition
with mostly community-based
interventions to provide
ready-to-use therapeutic foods
but also preventive
zinc supplementation
and preventive vitamin A
supplementation down here.
But again, at the time when
programs for supplementation
are already very extensive
for vitamin A and virtually
no programs for zinc
supplementation.
Let me go on quickly.
We looked at the effective
v packages of interventions.
As you can see, micronutrients
play an important part
in most of these.
I'm going to show
data in a moment
on maternal multiple
micronutrient supplements
but also calcium
supplementation to mothers
at risk of low intake.
Salt iodization, that's another
important and now widely used
intervention.
Critical importance, as we
pointed out in the 2008 series,
to the time in
pregnancy but also
the first two years of life, the
1,000 days, a critical period
for interventions, both for
breastfeeding and complementary
feeding.
And then for micronutrient
supplementation
as another package that we
looked at vitamin A and zinc.
And then the treatment of severe
and moderate malnutrition.
So I'll just show here the
effect of these packages.
And this is the
number of lives saved
from implementing the packages.
And then interestingly,
we did a full costing
of the scale-up of
these interventions.
And I think by any measure,
this cost per life saved is--
these are very
cost-effective or very low
cost per life saved compared
to many other interventions.
And in fact, all of these
are highly cost effective.
I said I would show
a little information
on the multiple
micronutrients in pregnancy,
because we wanted
to look particularly
at the effect on small
for gestational age.
So as I said, we
now have evidence
of more importance to the
fetal growth restriction.
And that importance, actually,
is not only for mortality.
I should also add--
I didn't put it in the slide--
but Parul Christian here
did some very nice
analyses related
to the effect of being small
for gestational age on stunting
and the attribution of
about 20% of global stunting
to fetal growth, so stunting
at 24 months of age.
But actually in some
parts of the world--
India that has 47%
of all births being
small for gestational age,
the attribution of SGA
or fetal growth restriction
to stunting is more like 35%,
so a fair amount of
regional variation.
But so what do we do about it?
So what interventions
do we have that
can affect being small
for gestational age
and reduce the risk of it?
Well, one is multiple
micronutrients in pregnancy.
These trials are in comparison
to iron and folic acid,
which, of course, is the
currently recommended
supplement during pregnancy.
And these trials, actually,
in this standard forest
plot of all the trials,
show an overall effect here.
And I'll just go on to this one,
which you can see more easily.
So there is an effect
on low birth weight.
But importantly, we were
trying to distinguish
between the effect on being
small for gestational age
or pre-term.
And there's not the same studies
in each of these analyses,
but I think from that
previous meta analysis plot,
you can see that there is
a 11% reduction in being
small for gestational
age with the use
of multiple micronutrients,
even in comparison
to just iron and folic acid.
And there's also a small
but seriously significant
reduction in the risk
of pre-term births
and pre-term birth
complications.
Pre-term birth, by our
estimates we do with WHO,
is now the second-leading
cause of death in the world.
So even a small
percent reduction
can be a very major
benefit for survival.
Now, I'm cheating a little bit.
Because Keith wanted me to
put in a little bit of what
we have done on
zinc supplementation
for young children
with acute diarrhea.
We didn't deal with this
in The Lancet series.
We've dealt with it in
lots of other publications,
and in fact, in another
series of papers
we published early
this year on diarrhea
and pneumonia in The Lancet.
So it is part of a
Lancet series, just not
the nutrition series.
But it actually-- this is
the beginning of the story.
For me, at least, this
is the first publication
on the use of zinc
supplements in young children
for the treatment of diarrhea,
a study we did in India.
Sunil Sazawal was my
doctoral student at the time.
What we showed in this
RCT was a 23% reduction
in diarrhea duration.
There are other effects I
don't have time to go into.
But just for interest,
I wanted to show this
because it comes from a
recent analysis we've done.
And it just shows,
in a way, how much
is out there that
we may not know
and the power of the
electronic searches.
So we did the trial, published
it in the New England
Journal back 20 years ago.
Been another 14 trials
that I'm calling here
the non-Chinese trials.
So what we knew about
the world literature
until earlier this year and what
basically the recommendation
was based on for use of
zinc were these trials.
And they essentially
confirmed what
we showed in the first
study, a reduction
by 22% in the duration-- there
were various measures of that--
but the episodes lasting
more than three days or more
than seven days.
But then we actually learned
through some colleagues
through collaboration
in China that there
were a number of trials done
in China mostly in last five
years.
We thought, OK, we'll
find a few more trials.
And we'll put them
in the meta analysis.
And there are now
electronic databases
of Chinese-published studies.
And fortunately, not
that I speak Chinese,
but we have faculty,
we have students,
and we have collaborators in
China who can read these papers
and can do the
literature searches.
To my astonishment, we
ended up with 89 trials
done in China, all of zinc--
comparative trials,
randomized controlled trials.
None of them were
placebo-controlled.
They decided not
to use placebos.
Couldn't find placebos.
But they were generally
methodologically sound.
And the interesting thing
is, with these trials,
they find the same thing.
And there's actually a
whole set of these trials
that was done very specifically
in rotavirus diarrhea.
So all these trials
were just general.
We didn't know the etiology.
This set of trials
here I call episodes.
They were just general etiology.
But a sizable number, 29
trials, were done specifically
in rotavirus diarrhea.
So rotavirus diarrhea,
as you may know,
is the most severe,
most likely fatal cause
of diarrhea in the world.
So remarkable
evidence that confirms
very much what the other
global literature has shown.
And the global treatment
policy by WHO and UNICEF
was set in 2004.
And it does recommend zinc
supplementation during diarrhea
to shorten the duration
and reduce the severity.
So I'm finishing with this.
The conclusion is that
for pregnant women,
providing multiple
micronutrient supplements
has benefits on maternal
health and mortality
and improved fetal growth and
reduction of pre-term births.
We also talk about the need
for more research, really,
on the pre-conception and
adolescent care issues
to know how much we can improve
nutrition and ultimately
fetal growth as well.
For children, this series
reemphasizes and re-affirms
the statement that
we really should
be focusing very strongly
on the 1,000 days
from conception to
the second birthday.
And this includes the importance
of these micronutrients.
Of course, it's not the only
period for vitamin A or zinc,
for that matter.
But it's a period of great
importance for growth.
And it's also a very
high mortality period.
And then as I said, zinc
for treatment of diarrhea
is another aspect that is
part of the recommendation.
Scale-up has been slow,
but it's picking up
in a number of countries now.
I'll end with that.
Thank you.
[APPLAUSE]
KEITH WEST: We're going to
do questions [INAUDIBLE]..
I think we have lots
of grist for the mill.
We'll have hopefully
a vigorous discussion.
We've reserved time
at the end of the day
for an open dialogue.
So hold your questions
if we haven't
been able to accommodate
them right now.
We're going to switch
gears a little bit.
And Dr. Harry Dawson is going to
address this issue of well, OK,
micronutrients have
a variety effects.
Looks like they reduce
infection, so forth.
How?
What are the mechanisms?
Dr. Dawson is a
nutritional immunologist
working in genomics.
He's at the Genomics and
Immunology Laboratory
at the USDA in Beltsville.
He's on the faculty of the
Department of International
Health and thinks about
mechanisms all the time.
So Harry, please come on
up and address this sort
of facet of this diamond.
HARRY DAWSON: Well, I'll
say that just to start off,
Keith had said to me I've got
about 14 minutes and 50 seconds
to give you, the how
of this equation here.
So I'm going to be broad
and not necessarily deep.
I've got a couple
of slides that we've
made for a recent
workshop that was convened
last November by
the BON Project,
looking at the needs for
the research in nutrition
and immunology.
So for something this big,
where do you start at?
There are so many nutrients.
There are so many parts
of the immune response
that have been shown to be
responsive to nutrition.
And I think Dr.
Ames had mentioned
40 essential nutrients.
If you consider 2,500
or so food components
that may qualify as bioactives,
it's really a daunting task.
There are thousands and
thousands of articles.
So where did you start at?
Well, you start in
the very beginning.
So I don't know this
literature as well as I should
and certainly as well as some
of the people in this room.
But if you go back to the
original papers of Wolbech
and Howell, they
describe some defects
in what is the immune system
of the rat, a chemically
insensitive,
non-secretory epithelium,
basically a spleen that was
devoid of lymphoid cells
and the missing thymus.
So I could probably say,
well, that explains it all.
I think Dr. Sommer had said,
what they knew back then,
we could stop here
and say, that's great.
Because now we know we have
impaired innate immunity,
a barrier function, and we have
impaired cellular or adaptive
immunity.
And we don't need to
do anything past 1925.
Well, there are some
indications back then
and debate in the literature
whether, in fact, that rat
model was actually reflective
of human deficiency.
Do you see children
with no thymus gland
that are vitamin A deficient?
And I would submit to you now,
even to this day, I think--
and this is my own ax to grind--
that over-reliance on rodent
models has set--
there have been some
very important findings
in those models.
But when you go
looking for things
that you find in the rodent and
try to find them in the human,
you don't necessarily
find the same thing.
So let me just orient
you to this slide.
This is one of four
slides that we originally
prepared for a course
that Dr. [INAUDIBLE]
and I teach here at the school.
And it was to give the
students essentially
a summary of zeitgeist,
some feeling of what
micronutrients do
relative to each
other and also relative
to different mechanisms
that may or may not
have been established.
So along the side here,
we have basic indicators
of innate immunity.
We have a qualitative,
not a quantitative,
score about whether or
not the mechanism has
been well-established.
And let me just explain what
our inclusion criteria is.
There has to be good evidence
that there is, in fact,
a deficiency established.
And there has to be
some sort of evidence
either at the cellular level or
at least a tissue level where
we can assign a
specific mechanism,
and by a specific mechanism in
these very broad categories.
So if you see your nutrient of
interest up here, that's great.
We had to stop someplace.
These are the ones that are
the focus of the BON Project
and coincidentally happened
to be the most immunologically
active, at least from a
literature standpoint.
So if you take a
look over here, we
have a positive control, which
is protein energy malnutrition
in its various forms.
It's pretty devastating
to the immune response,
the innate immune response.
And it's very likely that this
is just not protein energy
malnutrition but all the
nutrients and utilizations
are affected here.
But it's a strong
positive control.
We have vitamin A,
vitamin D, and zinc,
which we've just heard about.
They cause significant
amount of mortality
from infectious diseases.
Not so much maybe
with vitamin D yet,
but they are still
working out whether
or not to call
somebody deficient
based on certain plasma levels.
So we'll leave it at that.
So you can see here
that barrier function
is impaired by vitamin A and
by zinc and by vitamin D. Zinc
deficiency, mostly
barrier function.
Selenium-- there have
been some good models.
I think somebody mentioned
earlier that there was a virus
infection.
I think Dr. Ames mentioned
the virus infection models.
So there's some
impaired immunity there.
I highlighted
these two, I guess,
nutrients in the macrophage
function together.
I checked with Dr.
Checkley last night
to see what he was
going to present.
He was going to present
vitamin A in the lung.
So this is actually-- this study
violates the convention which
I just said.
These are alveolar macrophages
that we isolate from our pigs.
And the experiment's
pretty simple.
You put these cells in
culture for 24 hours
with retinoic acid.
And then we sequence
all the transcripts
that come off of it
by deep sequencing
so that we get couple of
50, 60 million sequences off
of these cells.
And then we compare
them, what was induced,
what was repressed.
And we do pathway analysis.
This is a standard, I guess
genomics, routine now.
And the number-one canonical
pathway that's actually present
is, in fact, the vitamin
D receptor pathway.
And I don't want you to get
lost in the alphabet soup here.
But this stands out.
In ingenuity pathway
analysis they
say, vitamin D receptor and
inflammation interaction.
So the number-one canonical
pathway for vitamin A
turns out to be
vitamin D. And I think
that Dr. Checkley made some
inference to the two of them
being important together.
Again, the lung
macrophage is probably
a very significant source
of retinoic acid in lung,
also a significant source of
vitamin D. It was originally
thought that calcification
in the lungs that happened
during tuberculosis was,
in fact, the macrophages
making vitamin D
and calcification
occurring in situ.
Now, these are the human
data for the same parameters.
You'll notice a
couple of things.
The strength of the
association goes down.
A larger number of
question marks come up.
There aren't that
many studies out there
that really have looked at
mechanism at any great degree.
The trends are very similar.
There's barrier function
impairment with vitamin A
and vitamin D and zinc.
And I have highlighted here
just two specific examples
I'm going to show you for humans
related to barrier function
and macrophage
function together.
So we'll kill two
birds with one stone.
This is the gut or
any other epithelium.
There is a functional
barrier consisting of mucus,
anti-microbial peptides.
This is a pattern recognition
receptor or toll like receptor.
During normal
immune homeostasis,
this is all in balance.
But you get dysregulated
production of any one or more
of these molecules, then you get
micro dysbiosis, inflammation,
perhaps bacterial
translocation that occurs.
These particular
antimicrobial peptides
are an interesting species.
This is something that happens
in humans and humans only.
There is-- oops.
Sorry.
What happened?
I turned it off.
There you go.
There's a step here
that happened on our way
to being human.
During the normal course
of swapping DNA out,
a vitamin D response element
got inserted into the beginning
of this anti-microbial peptide.
So this only occurs in
humans, no other animals.
So what we have here are
pathogens binding to the toll
like receptors stimulating
pro-inflammatory cytokines,
which turns on vitamin
D synthesis by CYP21B1.
Vitamin D becoming
active, binding
to the vitamin D
receptor, making
this anti-microbial peptides.
At the same time, the macrophage
is taking these pathogens up.
They go into these
autophagosomes.
The antimicrobial peptides
bind to the outside of viruses,
fungi, bacteria, poke
holes in them-- well,
we think that happens--
and kill them.
So it's a very
important mechanism.
There's a recent science
paper that just illustrates
this in different
immune settings
that I didn't want
to talk about,
because it's pretty detailed.
So does this thing
happen in humans?
That happens in cell culture.
So what evidence do we
have that this is related
to human vitamin D status?
Well, this is a very
recent research note
that was published that shows--
ignore this.
The 75's supposed
to be over here--
that people who have a
low vitamin D status,
there's a pretty high
degree of correlation
between those antimicrobial
peptide in the blood
and vitamin D
status in the blood.
This study was done
a little bit earlier.
They didn't measure the protein,
because the assays weren't
all that good.
But they measured the
induction of this messenger RNA
after a challenge with a
toll like receptor ligand.
These are people that had
been prescreened for vitamin D
status.
Their vitamin D status
was less than 75.
That's why it's
over here, not here.
And they were given vitamin
D, 50,000 international units,
pretty large dose, twice
a week for five weeks.
After the end, they were
challenged with these toll
like receptor ligands.
And this is the messenger
RNA for this particular
antimicrobial peptide.
So we can say, at
least in this instance,
vitamin D status
has something to do
with the production
of this peptide.
And you certainly
get it in the blood.
Whether this occurs
at epithelial cells
remains to be demonstrated.
But it's a pretty
interesting mechanism.
So we switch our gears
to adaptive immunity.
I have basic three
functions here.
And again, these are
extraordinarily complex--
antigen presenting cell
function, T cell function,
and B cell function.
What stands out here are
very good animal models
for the nutrients
that we've discussed.
I'm going to focus on
the vitamin A and T and B
cell function in animal models.
There is an
exquisitely worked out
set of metabolic and
immunological parameters
that have been
worked out, probably
100 papers, mostly
consistent, that
show that vitamin A is
converted to retinoic acid
by a set of dendritic cells.
Used to be we thought that
it was restricted to the gut.
We do know that now other
tissues actually do this.
We've demonstrated this in
macrophages from the lungs.
In response to a
number of stimuli,
including retinoic acid,
they make vitamin A
into retinoic acid.
That retinoic acid is
responsible for differentiation
of plasma cells
and secretory IgA,
the differentiation of T
regulatory cells, which
help dampen
inflammation, homing of B
cells and T cells to the gut,
and stimulating the function
of gamma delta t-cells,
which reside in the gut.
This is fine and good.
We have not found
evidence for most
of these mechanisms in humans.
One can imagine trying to
biopsy gut immune tissue
and do these studies
in the population.
There are in vitro studies where
retinoic acid in combination
with different cytokines does
cause Treg induction in humans.
So that is something that does
translate over to species.
But we are really
looking for evidence
that those T regulatory cells
actually increase in humans
when they're given vitamin A.
So again, these
are human studies.
You notice the same trends.
The pluses are less plus.
And there's lots
of question marks.
So I decided to focus on
the T cell function here.
I wanted to use Dr. Amed
and Dr. Stevenson's paper
as an example of a
field trial where
people were given two
doses of vitamin A that
were classified as low.
They were given at
two and three weeks.
And five weeks, they
were vaccinated.
One week post-vaccinated,
the cells from their blood
were challenged in
[INAUDIBLE] culture
and cytokines were measured.
And one month post
[INAUDIBLE] vaccination, so
let me walk you through this.
There's an extraordinary
amount of data in this paper.
But I wanted to focus
on a couple of things.
So interleukin 5 is a
Th2-associated cytokine.
We associate it with B
cell differentiation.
But it's mostly associated
with allergic and asthmatic
responses.
And you can see
here that people who
had gotten the
vitamin A supplement
make a little bit
more and a lot more
after measuring these things
in culture for a while.
Interferon gamma,
which is responsible
for inflammatory responses and
immune responses to virus--
but we kind of see it
going down a little bit.
And even at the one
month post-vaccination,
we don't see a robust
Th1 response in response
to a vaccine against a virus.
I would say it's
not disappointing.
If you express these two
as a ratio of one another,
then you see significance
in the difference of that.
Notice of course the
heterogeneity of the data.
So there's precedent
for this, actually.
Just a year earlier
we published--
if you take t-cells
from humans in culture
and give them retinoic
acid and stimulate them,
within six hours they start
making all of the transcription
factors that are responsible
for Th2 differentiation.
And they make less
of the one that's
responsible for Th1
differentiation.
And then here interleukin
4 is our representative Th2
cytokine.
If you take it to the
protein level, on this site,
it's interleukin 4,
interleukin 5, interleukin 13,
a trio of cytokines that are
made that are Th2-induced
and interferon gamma,
which is our Th1.
If you give the
cells retinoic acid,
you get a uniform increase
in these cytokines.
And you get a decrease.
If you use a compound that
binds to one of the vitamin
A receptors, the retinoic
acid receptor alpha,
you get the same exact effect.
And if you use an
antagonist of that,
you get a reduction of it.
So we've taken a field
observation backwards in time
and related to the production
of transcription factors
and then eventually
as cells that are
making Th1 and Th2 cytokines.
So I'm being brief.
I'm within 14 minutes
and 30-some seconds.
The question is how do
they fight infection?
Well, a wholly
unsatisfactory answer
if you're expecting the big
payoff or the smoking gun
is that the jury is still out.
And there's lots of
reasons for this.
First and foremost, an
intervention trial's goal
is to prevent people from dying.
Accessibility to samples,
doing tests in the field,
you necessarily have to do
smaller numbers of people.
So your power is
going to be lost.
And in some ways, I
guess it may or may not
actually be important
to know mechanistically
what's going on.
So having said
that, I started off
by saying there's a vast
literature on nutrition
and immunity.
Very few immune-related
biomarkers
have emerged from
that literature
that have practical
applications in humans.
We do know that
individuals who have
vitamin A or zinc deficiency
die from infectious diseases.
But we don't really
know what goes on.
I purposely avoided
discussing zinc.
Vitamin A has six receptors.
Vitamin D has one.
Zinc has 2,000
transcription factors.
So I purposefully
avoided talking about it.
I think it's
necessarily complicated
and probably is going to be
the toughest one of all to try
to figure out.
There's people in this room
that have been pioneers
in the field of using omics and
proteomics, which we're going
to hear about, to help us
sort out what we can measure
in the field setting.
And there's some
thought that this
is going to improve our
ability to detect mechanism.
So I'll just be the
devil's advocate
and say that by measuring
so many things at one
time in a heterogeneous
population,
you actually may be making the
situation worse, in that you're
creating more noise
to overcome for things
that are likely to
change two to threefold.
So having said that, we've
done a couple of studies
with our human studies
facility, and we've
seen that with some
microarray data
from the blood that was there.
But nevertheless, I do
think this is promising.
The degree of effect--
why don't we see it?
Well, I mentioned
logistics and cost.
But how do we measure deficiency
for some of these nutrients?
For zinc and iron, we use
surrogates, for example.
You get an infection, zinc
changes, iron changes,
vitamin A changes.
So we need better tools
to measure the deficiency.
I group things
according to-- real
easy-- whether or not it was
the severity of deficiency.
Some of those studies
that I showed in there,
the animals were
practically dead.
And then some of them, they
were marginally deficient.
There are multiple
deficiencies that exist
and synergies that happen.
There's age-dependent
effects, genetics, and--
I'll throw this out--
possible epigenetic events.
I think Dr. Checkley had
referred to some epigenetics
in vitamin D work.
But there are some
precedent in the literature.
In animal studies, if you
mess with the zinc status,
you get effects that last
beyond the generation.
Either you supplement and have
immunosuppression that's goes
through three generations--
this has been reported
on multiple occasions.
I'm not a zinc expert.
I don't know how
to interpret these.
But that's something
you should be--
I guess something to think
about from a clinical trial
standpoint.
There are some studies
that show differential DNA
methylation in children
with vitamin A status.
And recently, very specific DNA
methylation site modifications
by people with different
vitamin D status.
And some interventional
studies with folic acid
show an increase in
whole genome methylation
with folic acid supplementation.
So having said that, this
is [INAUDIBLE] I think
Dr. West wanted to
me avoid but I'm
going throw in here
in the last thing.
So the nutrients
by themselves, they
exist in single deficiency.
But how complicated
and how mechanistic
can we get with data?
Now I'm going to just
rely on cell culture.
So this is a gene
called FOXP3, which
is responsible for T regulatory
cell differentiation in mice
and in humans.
It has a bunch of sites
in the promoter region.
It had these CpG
islands that are
folic acid dependent
for their methylation.
We have a whole bunch of
transcription factors that
either bind to the promoter
or enhancer regions
that have zinc.
We have a vitamin A responsive
element here in the promoter
and in the enhancer.
And we have a good old vitamin
D responsive element in there.
So one can imagine if you are
marginal in zinc, folic acid,
vitamin A, and vitamin
D at the same time,
that there may be
some synergy that's
involved in the regulation
of this particular gene.
So I think that's
my payoff slide.
And I think I'm
finished at this point.
So if there's time I'll
entertain any questions.
[APPLAUSE]
KEITH WEST: I think
we actually do have
time for one or two questions.
HARRY DAWSON: Where
are my helpers?
AUDIENCE: [INAUDIBLE]
AUDIENCE: Really
enjoyed your talk.
I wonder whether
you would comment
on the relationship
between vitamin
D and an innate immune
response effectors.
And I wonder whether
there's a difference
between the various types
of innate immune effectors,
for instance, those that
are sort of reinforcing
the barrier in [INAUDIBLE].
You might expect them to
be positively regulated
by vitamin D. But
[INAUDIBLE],, danger signals,
might be negatively correlated
with vitamin D status.
So when you dig the
data in that fashion,
do you find that differential?
Or is everybody
that sort of relates
to innate immunity
positively regulated?
HARRY DAWSON: So
let me, I believe,
summarize your question.
I believe it relates to the
relationship between vitamin
A and vitamin D and
interactions in innate immunity.
Is that what I--
AUDIENCE: Really, vitamin D and
effectors with innate immunity.
HARRY DAWSON: Well,
it's kind of tough,
because the pharmaceutical
industry, many years ago,
developed non-calcemic
analogs of vitamin D
to treat autoimmune diseases.
They are hellaciously
immunosuppressive when
given in high doses.
So having said that,
there is the potential,
if you dampen the
immune response enough,
that you essentially
open yourself
up to being more susceptible
to an infectious agent.
And I think the fact that
these enzymes are regulated
by cytokines, I
think the body knows
what it's doing
with its own vitamin
D. I think if you provide 1,25
hydroxyvitamin D to people,
you may be bypassing those
regulatory mechanisms.
And that's where you may
be getting in trouble.
Thank you, Keith.
KEITH WEST: Thank
you very much, Harry.
That was exactly at the level
that I could understand.
We're going to switch gears.
And we talk a lot about
under-nourished, under-served
populations.
But North America has
nutrition problems as well.
And probably no one has thought
about this more than Dr. Regan
Bailey at the Office
of Dietary Supplements
at the National
Institutes of Health.
Regan is a nutritional
epidemiologist.
Some of you may know her because
she runs the Mary Frances
Picciano Dietary Supplement
Research Seminar every May
that hundreds of
people go to, including
a number of our students.
Regan is going to talk to us
about trends in micronutrient
intake and status, what's
going on in the United States
in 14 minutes.
Regan?
REGAN BAILEY: It's
not easy to summarize
five years of your research
in such a short time.
But for Keith, I
will give it a try.
It's a true honor to be
part of this group today.
And I've really enjoyed
all the previous talks.
And because we've talked a lot
about some of these concepts,
we can go through the
background of my presentation
rather quickly.
In saying that whether it's
an intake or concentration
distribution for a nutrient,
too much or too little
is going to put
individuals at risk.
And so if you believe
this sort of paradigm
that I'm putting forward
and flip it on its head,
you can see where
the food nutrition
board, the dietary
reference intakes stem from.
And I'm going to focus on
this part of the distribution.
So below the EAR, I will
call it the Estimated Average
Requirement, and
this is the cut point
that is used for population
or group-level data
in which there's a high
prevalence for inadequacy.
We don't say there's
deficiency below this.
It's a high prevalence
for inadequacy.
And in order to assess who's
at risk in any group, what
you want is a usual intake.
You don't want to look at a
one-day snapshot of someone's
intake and classify
them as at risk or not,
because we know that dietary
recommendations are intended
to be met over time.
You don't necessarily have to
have your vitamin C at x amount
every single day.
But overall,
long-term average, are
you meeting that requirement?
And as I mentioned,
this is what's
necessary for
characterizing those tails
of the distribution.
Who's at risk?
The problem is that
usual intakes are not
directly observable.
We know that self-reported
dietary assessment
methods are fraught with error.
And if we ignore this
measurement error,
we have biased estimates.
However, there are statistical
modeling techniques
that are available to us to
help reduce some of this bias.
And in general, the
approach that is used
is multiple daily
reports are collected.
And you separate the within- and
the between-person variability
to establish usual intake.
So the within-person
variability is
what makes me different on day
one from myself on day two.
So once we take that
individual variability out,
that's how we get
our usual intakes.
And the data that I
will be presenting today
all come from the National
Health and Nutrition
Examination Survey, which
has a host of information
on health and nutritional
factors in the US.
But I will be
focusing specifically
on the diet and supplements.
We saw this slide earlier today.
This is a very broad brush
stroke of the US population,
so looking at everyone
older than the age of two.
If we just looked at the
percent of this population that
would have intakes below
the EAR from nutrients
that are naturally
occurring in foods,
we would see a
pretty grim picture.
In the US, though, we have
mandatory and voluntary
fortification and enrichment.
And you see that this
lowers the percent who
would be considered
at risk substantially
for some nutrients.
Specifically for folic acid,
you can see this big drop.
But not so much when we
look at the minerals,
because with the
exception of iron,
there's not much mandatory
or voluntary fortification
of our food supply.
But not only do we want
to look at usual intakes,
we need to look at
total nutrient intake.
So nutrients can also
come from supplements
and also from both
over-the-counter and
prescription medications.
And this is particularly
salient in the US context
where we have a high proportion
of individuals in specific age
groups that use dietary
supplements containing
nutrients.
And so if we only look at
nutrient intakes from foods,
we're really underestimating
nutrient exposure, particularly
for nutrients that
are not ubiquitous
in foods, like vitamin
D. And while we're not
going to be talking
about upper limits
today, for some of
the upper limits
are only for
supplemental sources,
like magnesium and folic acid.
So let's dive right into the
data on infants, toddlers,
children, adolescents,
and teens,
who I'll just call children
for the sake of ease.
So in the purple
bars, we're going
to look at children who do
not use dietary supplements
and the percent who would
be considered at risk.
And this is for two- to
eight-year-olds specifically.
And in the blue bars are the
same estimates for children
who use dietary supplements.
So you can see a
big drop for things
like vitamin D and vitamin E.
In this age group,
we saw no difference
in the percent at risk
for users and non-users
for a whole host of nutrients.
And that's simply because
the diets of this age group
are pretty good, by and large.
There was 0% inadequacy to
begin with for these nutrients.
So adding supplements
didn't help lower
the prevalence of inadequacy.
Moving on to our slightly
older children, nine-
to 13-year-olds, we can see
that there are a few more
micronutrients here with
differences between users
and non-users with that same
trend in vitamin D and E
emerging.
Children nine to
13 in general were
doing pretty good for iron,
B-12, selenium, copper, folate,
and B-6.
But it's important
to note that even
among those children
in this age group who
are using a dietary supplement,
calcium and vitamin D
intake still remain low.
And finally moving
on to our teenagers.
I had to put it on two slides,
because their diets are
terrible--
not terrible, but relative
to the younger children.
And we can see the
prevalence of inadequacies
here for a number of minerals
in a similar trend observed
for the vitamin.
So to summarize
this age group, we
did see a higher prevalence
of nutrient inadequacies
than in younger children.
And this is a group for which
supplement use is the lowest.
And so among this group,
teens who use a supplement
really confer a benefit, but
there's a very low prevalence
of use in this group.
So finally, I'll talk really
briefly about the adult data.
We published a series of papers.
We know that people who use
supplements are different than
people who don't.
We know they tend to be older.
They're more likely to
be white, have higher
educational attainment, have
more physical activity, less
smoking, and moderate
alcohol consumption.
So we were interested in looking
at why are these people using
supplements then?
Are their nutrient
intakes falling short?
Are they using them
for added protection?
And I'll tell you,
the diet quality
of adults who use supplements is
already much better than those
who don't use supplements.
So they're already
adding to intakes
that are by and large adequate
for a number of vitamins
and minerals.
So I'll show you the
differences here.
So this side has set up
just slightly differently
than the ones before.
And the blue bars are adults
who don't use a supplement,
the percent who have intakes
below the EAR, quite high.
In the red bars, we're looking
at users, but just their food.
We're not even looking
at their supplements yet.
You can see that
they have a lower
prevalence of inadequacies.
And then of course, when
we add the supplements,
you see the decrease there.
And this slide is set up the
same way for selected vitamins.
And I wanted to pull
out calcium in females
to make the point that
the prevalence of use
of a supplement really
makes a difference.
So women tend to have a high
usage of calcium supplements.
And you can see
the big differences
across all age groups for who's
meeting the recommendations,
particularly salient here if
you look at these older women.
Older women-- I
don't mean older,
I mean in terms of this--
anyway, women over
the age of 50,
nearly 90% would be inadequate,
have inadequate intakes.
But even so, 30% with
the use of supplements
still aren't meeting
the calcium guidelines.
So to summarize
what I've presented,
adult users tend to have higher
vitamin and mineral intakes
from their food sources alone.
We did not find
this in children.
We found the diet quality among
users and non-users in children
was similar.
Supplements help all
age groups meet the EAR
for almost every micronutrient
with the exception
of potassium.
And that's because potassium
is not ubiquitously found
in dietary supplements.
But it's particularly
important for things.
We saw the big drops for
vitamin D and for vitamin E.
Now, I started with
a broad brush stroke,
and I want to end with
a broad brush stroke.
So adding users and
non-users all in one big pot,
and what would be the prevalence
of inadequacies in the US?
And I have them here arranged
by their relative frequency.
And it's important to note
that this is dietary data.
There is also data that is
available for biomarkers.
And when we examined
biomarker data,
we see a much lower prevalence
than 70% when we look
at the total US population.
It's still there.
But there are discrepancies
between dietary intake
and biomarkers of
nutrient status.
So I just want to
point that out.
The data that I have
presented to you
that our team has
worked on aligns closely
with the dietary guidelines
for Americans for calcium
and vitamin D. As I
mentioned, potassium is not
found in dietary supplements and
remains a nutrient of concern
in the US as well
as dietary fiber
as well as iron,
folate, and B-12
within specific age, gender,
or life stage groups.
So that's all I have to say.
And I'd be happy to have any
questions if anyone has any.
Thank you.
[APPLAUSE]
KEITH WEST: Thank you, Regan.
That was a great talk.
And you are on time.
And we have time for questions.
REGAN BAILEY: Everybody
looks so sleepy.
We could do a dance.
AUDIENCE: I'm not asleep.
Have you considered
iodine in your analyses?
REGAN BAILEY: There's no
database for dietary iodine.
So we haven't been able
to examine that yet.
It's something
we're interested in.
There's an iodine
initiative in our office,
at the Office of
Dietary Supplements now.
And so that's
definitely on our minds.
AUDIENCE: You said that children
are meeting their nutrition
requirements overall.
But then you're also hearing
about how kids are now
developing diabetes younger and
younger and the obesity rate's
going up for younger kids.
So what kind of explains
those two factors?
REGAN BAILEY: Well,
I don't want you
to take home the message that
the diets of children are OK.
The diets of
children two to eight
are the most nutritionally
adequate among all children.
And so these are looking
at dietary intakes
relative to the
standard reference.
This is from the National
Health and Nutrition Examination
Survey, so it's
nationally representative.
It's not looking at
high-risk groups.
It's not looking at obese
children or diabetic children.
There would be people
in the sample that
have those conditions, but it's
not looking at the higher risk
groups.
AUDIENCE: So vitamin
D is a bit special,
because we get most
of it from sun.
But they supplemented milk,
but it was the wrong food.
They put too little in.
And 75% of African Americans
are lactose intolerant,
along with 50 million
other people in the US.
So it really wasn't
the right thing.
Now, I guess they're putting
some in orange juice.
But if you eat a lot of
fish, you can get some.
REGAN BAILEY: Now, I think
that's an important point.
And I think that the
dietary reference intakes
are set assuming that this
is the requirement from diet,
not factoring in sun exposure.
And I also think
that in the report
they mentioned that
African Americans are
most likely to have different
calcium and vitamin D
economy than European
descent and because we
see lower vitamin D,
serum vitamin D levels,
but we don't see the
problems with bone health
parameters, certainly
different diseases, yes.
AUDIENCE: But in autism if
you correct for social class,
blacks have twice the rate
of having autistic kids.
So there it is showing up.
And Somalis who just
[INAUDIBLE] to Minneapolis
have five times the rate
of the local population.
So I wouldn't say that means
genetic differences necessarily
negate--
REGAN BAILEY: Oh, no.
I wasn't trying to say that--
I am simply
suggesting that there
is data to support there's
a differential vitamin
D and calcium economy.
That's all.
AUDIENCE: How much
is the higher rate
of deficiencies in elderly
simply due to lower food intake
and less exercise?
REGAN BAILEY: Yes.
There is definitely a
precipitous decrease
in total calorie
intakes with aging.
And so it's tougher to meet your
requirements with less food,
unless you're
taking a supplement
or really trying to have
a high quality diet.
KEITH WEST: Just one
question, and then we'll
move on to our next speaker.
It seems like, in some
respects, those who need
the supplements more are not--
they're not accessible to them.
Or they're not taking them.
Do you have any ideas on how
to correct that imbalance?
How do we find, motivate,
evidence-based supplementation
for those groups whose
diets really are poor?
REGAN BAILEY: Yeah.
That's a great question.
And I would like to hear
what DSM in the audience
has to say about that.
How can we target those who
need the supplements the most?
Because in the US, it's
definitely the worried well
that we're seeing, at
least from our data.
KEITH WEST: Maybe in
our open dialogue.
REGAN BAILEY: Thank you.
[APPLAUSE]
KEITH WEST: Thank
you, Dr. Bailey.
That was a great talk.
In the context of trying
to cover lots of bases
but not exhaustively
by any means,
we're going to
shift gears again.
And Dr. Parul Christian is going
to speak to us about evidence
emerging on the
effects of early life
developmental nutrition
exposures, malnutrition,
micronutrient deficiencies,
and what may be effects
later on in offspring.
Parul is a professor in the
Department of International
Health, a close colleague.
She's worked a
great deal in Nepal,
in Bangladesh conducting trials.
She's leading studies in
Malawi and in Mozambique
on child feeding
evaluation and is
going to give us this
perspective today.
Thank you.
PARUL CHRISTIAN: Thank
you very much, Keith.
And I'm delighted to be
presenting today in front
of this wonderful audience.
And thank you for
hanging in there.
I know it's pretty
late in the day.
As Keith mentioned, I'm going
to be talking a little bit
about our work that
is derived from some
of the randomized
controlled trials
that we have been
doing in Nepal.
And previous
speakers have alluded
to the early life and
the developmental period
as being critical.
And there was mention
of programming.
There was mention of
transgenerational effects.
And so I'm going to
show you some emerging
evidence with regard
to long-term impact
of micronutrients, especially
interventions of micronutrients
on outcomes of interest.
So I wanted to
start with the point
that the fetal life is a
critical period of development
in humans.
And of course, the
embryonic period
is particularly vulnerable to
teratogenic effects, et cetera.
But throughout the fetal
period, nutritional deprivation
can lead to dysfunction.
And I'm going to be focusing on
interventions of micronutrients
during this critical period
of fetal development.
Of course, the
supplementation is indirectly
done through maternal
supplementation
during pregnancy.
So just to give
you a perspective
on what we look at generally
in these kinds of studies.
Our outcomes tend to be
more short term in nature.
And when we look at
long-term effects, of course,
we are talking
about at later ages
when we look at
effects of the impact
the short-term
consequences may have
had on certain systems,
certain organs,
such as the central nervous
system or the growth
and accretion of
muscle mass or body
composition in the short
term, which can then manifest
into effects on the immune
function [INAUDIBLE] capacity
later in life.
And then within the
group of effects,
which is termed as
metabolic programming,
you can see that happening
in the short term
during the period of
deprivation, which
can have, then, long-lasting
effects on outcomes
of diabetes, obesity, and
coronary heart disease, et
cetera in adulthood
and in old age.
This is a conceptual
framework that
was derived from a
literature review
that I conducted with
then my doctoral student.
Now she is assistant professor
at UC Davis, Christine Stewart.
And this is just to look
at where is the evidence
to suggest that micronutrient
deficiency in the mother,
especially during pregnancy,
can have these effects on organs
and systems.
And we were able to
find some evidence
to show that there is a link.
Most of this literature is
derived from animal studies.
But there are some
observational human studies
which have also shown that
maternal micronutrient
deficiency through restricted
fetal growth and development
can have a range of effects
across various organ systems.
And then specific micronutrients
are implicated in this.
And so renal function,
cardiovascular function,
the development of
pancreas and beta cells,
pulmonary function as well as
how body composition occurs
over the course of life
can all be influenced
by specific
micronutrients leading
to increased risk of chronic
disease, cardiometabolic risk.
And so today I'm going
to talk about some
of these specific nutrients,
largely because we've
done these intervention
studies using micronutrients
and supplements
that are listed here
but now looking at not
just short-term outcomes.
The original trials
were actually
designed to look at
the immediate outcomes.
But in this
presentation, I'm going
to focus on long-term
survival, on long-term growth,
cognitive development
and function,
cardiometabolic health, to
some degree immune function,
and lung function.
And so I'll take you to
our study site in Nepal.
We have been
operational in this area
and have a research site
since the past 25 years.
In fact, this year we are
celebrating the 25th year
of this research site.
And in 2006 and
2008 we conducted
a very large
cross-sectional survey
of all our existing
cohorts from trials
that had been conducted
previously over the previous 15
years or so.
So when you think
about Nepal, you
think about the
Himalayas, the mountains.
And you can, if
you're fortunate,
get a good glimpse of them
from the Kathmandu valley.
But our study area is located
in the flat plains of Nepal
in the southern part of
Nepal adjacent to India.
It's a very
agrarian, rural area,
where a lot of rice
and corn and grown.
And this is a typical
kind of environment
where small mothers give birth
to small babies who are raised
and grow up as
kids with stunting.
And as adolescents, also, they
are nutritionally lacking.
And so this is our field site.
Our study is called the
Nepal Nutrition intervention
Project-Sarlahi because
it's located in the Sarlahi
district, in short, NNIPS.
And these are the cohorts
that I'm going to talk about.
The first one is a child vitamin
A supplementation trial cohort.
I'm not going to speak much
about this, because this
doesn't address the intervention
period, the fetal period that I
was referring to.
So I'm going to focus on the two
trials, the NNIPS two and three
studies, in which maternal
supplementation was
done in the context of
randomized control trials.
And then, as I
said, the follow-up
was done simultaneously
for all the cohorts.
And we did a whole range
of field-based, home-based
measurements in young
children at different ages
depending on the
age of the cohort.
And we took blood
pressure measurements.
We did waist circumference
measurements.
Blood drawing was
done in a subsample.
A full anthropometry, et
cetera, was also conducted.
The blood was processed
and in part analyzed
in the field itself
with lipid profiles
being assessed,
glucose, HbA1c being
measured in fasting blood.
And we also collected
fasting urine
to look at albumin-creatinine
ratio for kidney function.
And so I'll talk about
first the vitamin
A trial, which was a randomized
control trial of weekly vitamin
A and beta carotene
supplementation to women
of reproductive age.
So this study was
done among all women,
irrespective of whether
they were pregnant or not.
So a lot of them received the
supplements pre-conceptionally
into their pregnancy.
And this study was done
between '93 and '97.
And the children at
the time of the follow
up were nine to 12 years of age.
And we looked at these
outcomes in those children.
And Will Checkley already
presented some of these data.
But we actually did
this work in the field
with hand-held spirometers,
so that was pretty exciting.
And the training that it
required was pretty intensive.
But in this study, maternal
vitamin supplementation,
as to be expected, raised
serum retinol levels.
And with increase in serum
retinol levels in the mothers,
lung function was
improved using FEV1.
And so this is the data
that Will presented.
So I won't talk much about
it, except to say that vitamin
A supplementation in
the moms increased lung
volume in the offspring at
nine to 13 years of age.
And these are the
median differences
between the vitamin A group
and the placebo group.
One of our doctoral
students also
looked at vitamin A
status and immune system
development in the same cohort.
And so she looked
at B1a lymphocytes,
which has natural antibodies.
And B1a lymphocytes
are [INAUDIBLE]----
they produce most of
the natural antibodies.
And these arise from an early
wave of progenitor cells
that are unique to fetal life.
And in mice
experiments, vitamin A
has been shown to regulate
early lymphopoiesis.
And in deficiency during
this critical fetal period,
vitamin deficiency compromises
B1 cell populations.
So these natural antibodies,
which she measured,
they protect against bacterial
pathogens and oxidative damage.
And therefore, they may have
an impact both on the infant's
host resistance and
development but also
long-term chronic disease risk.
And what she found was
that the supplementation
in the mom, the vitamin
A supplementation,
increased this population,
this concentration
of natural antibodies
in the offspring
at 9 to 13 years of age.
And you see the same
relationship in maternal serum
retinol and
concentration of NAb.
We looked at blood pressure,
high blood pressure,
in these children as well.
And here what I'm showing
is that overall, it
did not seem that either
of the two supplements,
Vitamin A or beta carotene,
had an impact on high blood
pressure.
But among children who had
high waist circumference,
there seemed to be a protective
effect after supplementation
on high blood pressure.
Moving on, we did another trial,
also in the same population.
This study was done
to actually address
one of the questions
that came up
earlier on, which was why do we
do only single micronutrients?
We actually wanted to look at
the outcome of birth weight.
And we wanted to see
which micronutrients
were most limiting and critical
in this environment where
there were multiple
micronutrient deficiencies.
And we went after
the ones that we
thought were most important,
folic acid, folic acid, iron,
folic acid, iron, and zinc.
And then we also had a multiple
micronutrient supplement
in this five-arm trial.
All the women got vitamin A
because our previous study
had shown a benefit of vitamin
A to moms in pregnancy.
So one of the first things-- and
this is actually the same trial
that--
I should remind
Scott [INAUDIBLE]
about that-- this is the trial
that you had come to visit.
And the babies were being born
at that time in 2006 and '08.
These kids were now seven
to nine years of age.
And so we followed their
long-term survival.
And what you can see here is--
this is a blue line
is the control line.
So it's good that
it's at the bottom.
This is a survival curve.
All the other groups did better
in terms of long-term survival
of the children.
But the group that did
the best was actually
the iron and folic
acid group, and not
the multiple
micronutrient group.
When we looked at outcomes
of blood pressure and insulin
resistance, we found no
differences between groups.
They're all identical in
terms of their levels of blood
pressure and markers
of insulin resistance.
But we did look
at this condition
called metabolic
syndrome, which is defined
as three or more conditions of
cardiometabolic risk coexisting
together.
And in that definition
of metabolic syndrome,
we were able to show that the
folic acid supplement actually
significantly reduced the
risk of MS in this study.
None of the other three
groups did the same thing.
And then a
microalbuminuria, which
is a marker for kidney
function, was examined.
And again, folic
acid alone or when
it was given with iron
and zinc significantly
reduced the risk of
microalbuminuria.
Prenatal zinc
supplementation, actually--
so the combination of, again,
iron, folic acid, and zinc,
had a significant
impact on linear growth.
Height was higher in
children whose mothers
had received that supplement
at seven years of age.
And they also had
lower adiposity.
So their tricep skin folds
and subscapular skin folds
were smaller.
And their total arm
fat area was smaller.
And cognition was one of the
outcomes in this study as well.
This was another
study funded by NIH
in which we followed
the groups of children
whose mothers had received
the various combinations
of micronutrients.
And we did a whole
battery of tests on them
to look at general
intelligence, motor function,
executive function, and
fine motor function.
And for this outcome,
what we found was,
again, iron and
folic acid seemed
to have the most benefit for
the whole range of functions
that we had looked at, whereas
the other combinations did not
seem to have that effect.
And just to emphasize that
the critical window for brain
development and
function might actually
be the fetal period,
because we were also
able to follow a separate
cohort of children who
as preschoolers had
participated in a trial
and had received iron
and folic acid or zinc
or the combination of
two versus a placebo.
And in this cohort, we
were not able to show
any difference between groups
with child supplementation
on these same outcomes of
cognition and motor function.
So just to quickly summarize
the findings with regard
to maternal vitamin
A supplementation--
as I mentioned-- I showed you
it increased lung function
and volume, although
we do need to know
what the long-term impact
on pulmonary health
would be of this finding.
Overall, there was no
impact on prevalence
of high blood pressure.
But it reduced the odds
of high blood pressure
in the kids that may be at
higher risk with high waist
circumference.
And vitamin A enhanced the
natural antibody concentrations
of preadolescent children.
This again likely
reflects a greater number
of the Nab secreting B1A cells.
Folic acid, zinc, and iron
effects are summarized here.
Folic acid reduced
cardiometabolic risk
and improved kidney function in
the offspring and reduced child
mortality, long-term
child mortality and also
improved aspects of
intellectual function,
including executive
function as assessed
by looking at working memory
and inhibitory control as well
as fine motor functioning.
Zinc supplementation improved
post-natal child growth
and reduced adiposity.
The evidence for
multiple micronutrient
was quite limited across
these various combinations
of micronutrients we tested.
I just want to end with
a couple of thoughts
for future direction.
Cohorts that we followed
were still quite young.
And so they were
not likely to have
a very high
cardiometabolic risk,
especially in this environment,
which was very undernourished.
There's very little evidence
of overweight or obesity.
I showed you in that first
slide that the critical period
of time in the fetal period
is really the early pregnancy
period.
And there are very few
studies which have actually
looked at pre-conceptional or
early pregnancy interventions.
And there is a lot of evidence
from animal and epigenetic
studies in humans even showing
that the pre-conceptual period
may be very important
to evaluate.
And then there are
very few trials
like this which have looked
at maternal interventions
and followed cohorts
of their offspring
to look at these kinds
of longer-term outcomes.
And so these are clearly
needed more in many contexts.
And this is our staff
who I have to thank
for all the incredible
work they continue to do.
Thank you.
[APPLAUSE]
KEITH WEST: Thank
you very much, Parul.
You're on time.
And we have time
for a few questions.
AUDIENCE: That was a
very interesting talk.
I was surprised by the
multiple vitamins and minerals.
Why wasn't it at least as good
as the folic acid and zinc?
PARUL CHRISTIAN: So I think
that this is a Professor Ames
question.
Because we've been struggling
with this for a number of years
now.
It's these combinations-- you
were talking about the two
pluses, the irons, the zincs,
the coppers, the calciums
all together.
And so with birth weight,
which was our primary outcome,
we had seen that as well,
that iron and folic acid
improved birth weight.
But with zinc added
to the combination,
the birth weight
effect was removed.
And so that was puzzling.
And then the multiple
micronutrient
actually improved birth weight
after that negative inhibitory
effect of zinc was--
so I think, the
nutrient-nutrient interactions
are, at least from this work,
are important to look at.
There's much more we
know about iron and zinc.
But with a number of
these other ones--
there are 15 nutrients in the
multiple micronutrient pills.
So I think that we need to do
some smaller, really elegant
studies to just look at
the interaction effects
that we see in--
in animal models,
you don't do that.
You kind of remove--
you create deficiency of
one nutrient at a time.
Yes?
[INAUDIBLE]
AUDIENCE: It's just the minerals
interfere with each other.
So iron and zinc [INAUDIBLE]
the transporters sometimes
[INAUDIBLE].
So you just have
to be very careful.
If you get too much of
one mineral, [INAUDIBLE]..
PARUL CHRISTIAN:
I think also what
is more deficient in an
environment may be important.
So the context, as people
were alluding to that,
might be part of it.
This was a very
iron-deficient environment.
In a previous
study, we had shown
about 60%, 65% prevalence
of iron deficiency
anemia in pregnancy.
So that might be another
thing to consider.
AUDIENCE: Parul,
I have a question
related to the antibodies
that were generated.
I had discussed it
with Amanda when
she was doing her PhD thesis
that one can interpret
the presence of self
antibodies seven or eight years
after delivery as a bad thing,
because autoimmune disease
is often accompanied
by auto antibodies.
So any thoughts on that?
Or is that unfair to ask you?
PARUL CHRISTIAN: Well,
I'm not prepared to answer
that question.
I'm sure Amanda, if she's
listening to this in Zambia,
would be the right
person to ask.
I learned from her work
about the potential
for even looking at something
like natural antibodies
later in life as an
outcome of fetal exposure.
So I'll let you and
her figure it out.
AUDIENCE: Thanks, Parul.
You partially answered
my question already,
so I'll twist it a
little bit and ask you
about what your reflections
are on the policy implications
of the work you just presented.
Particularly I find I've
always found it a little hard
myself to understand
and take away
when you have one nutrient
that's good for one thing
but it's not good
for something else,
but that other nutrient's
really good for this,
and how do you sort
through that and figure out
what the right policy
recommendation is?
Do you just choose the outcome
you're most interested in?
Tell me what you
think about that.
PARUL CHRISTIAN: Yeah.
So I think I'm glad Regan
presented just before I did,
because what are
we doing in the US
to me is maybe an example
of what can be done,
which is to try and address
the micronutrient deficiency
and looking at diets and looking
at biochemical indicators
to see what is deficient.
We kind of tend to
think about where
there going to be a huge
public health impact?
That's what's really driven
policy and recommendations
and programs.
But maybe we have
advanced to a stage
where can start
thinking about reducing
micronutrient deficiency
for its own sake.
And I was pretty convinced
with what Professor Ames was
talking about earlier.
There's so many things that we
may need these micronutrients
for that we don't even assess.
We just assessed a few things.
And you're finding some
effects and some differences.
It's a hard question.
I think from the work
that Bob presented
and the meta analysis with
also the Bangladesh trial
data added on, I think it
seems like now we have--
the pooled estimate seems to be
pretty convincing, particularly
with regard to the impact on
fetal growth and reduction
in low birth weight such
that we can actually
change from iron and folic
acid to multiple micronutrient.
I think these longer-term
outcomes are interesting.
And we continue to
develop the evidence base
for seeing what other studies
can add to the knowledge base.
KEITH WEST: There's time
for maybe one or two more.
AUDIENCE: Do you have--
I'm over here.
Do you have-- you gave
15 micro-nutrients.
Do you have samples on
any of your subjects
for the measurements
of the nutrients
before you gave them to
see who was really low?
PARUL CHRISTIAN: Yeah.
So I didn't have time to show
all the two years of work that
went into just doing about
10 different biochemical
indicators of
micro-nutrient status.
And there's a lot of
deficiency in this population
across the board.
There was nothing that
they were not deficient in.
Maybe copper-- they
didn't have low copper.
But other than that,
there's a high burden
of multiple micronutrient
deficiency, which
is a good segue to, I
think, Keith's talk,
which is about the assessment
of micronutrient deficiencies
in these populations.
KEITH WEST: OK.
We should probably move on.
Thank you very much.
[APPLAUSE]
So we have two short,
pithy presentations
to broaden our thinking
about how to assess
and where we might be going
in the future with respect
to assessment and prevention
of micronutrient deficiencies.
And there's really
no better person
to pith our minds than
Dr. Alain Labrique, who
is one of our newest
associate professors,
full-time associate professors.
Just was promoted
this past month.
So Associate Professor
Alain Labrique,
would you please come up here
and share your magic with us
about your vision
of the future--
ALAIN LABRIQUE: Can
I borrow your phone?
KEITH WEST: --through
micro-nutrients?
Borrow-- what are you
going to do to it?
You're going to download it
on your earphone or something.
ALAIN LABRIQUE: Let me try.
Let me see something here.
Siri, what's my
micro-nutrient status?
SIRI: I don't know
what that means.
[LAUGHTER]
ALAIN LABRIQUE:
Clearly, Keith hasn't
upgraded to the new
version of the technology.
So you'll have to forgive
him if some of his remarks
are in the past century, but--
and as someone who started
his biology research
career pithing frogs, I really
appreciate that last comment.
Thanks, Keith.
So I was asked in
a very succinct way
to present something
that I do talk
quite a bit about these days.
And it's another hat that
I wear here at the school
as the director of a new
center, the Global mHealth
Initiative here at Hopkins.
So we're barely 130-few years
from when Alexander Graham
Bell made that first
seminal phone call
to his colleague in
the room next door.
And we find ourselves
in a state of affairs
where there are nearly as
many mobile phone connections
as there are human
beings on this planet.
It's generated this new field of
research and innovation, which
we like to call mHealth,
a state of research
and, really, innovation
where we try to find out
ways in which we can leverage
the ubiquitous ownership
of mobile technologies,
even in the most
remote rural populations,
where many of us
have described our work
over the course of today.
I think the seminal quality
here of this opportunity for us
as public health
practitioners is
that we're looking
at a space that's
untethered from those fixed-site
facilities where we tended
to do research in the past
but yet still remaining
connected to the broader health
systems which we work within.
Here at Hopkins, we have a
robust ecosystem of innovation
that spans the entire
university, where to date, we
have about 105 mHealth
projects being done, exploring
ways and really
quantifying the impact
that mobile technologies
can have on outcomes,
ranging from nutrition
to clinical care
in the spectrum of what we do.
But really fundamentally, we're
talking about three things
that mobile technologies
enable us to do here.
Connecting people--
everything we've
heard about today in terms
of micronutrient alleviation
programs or health
system interventions
is about linking
individuals within a health
system, those actors that
are critical to connect
to each other and to the
information systems which
support their work.
But public health is
also fundamentally
about compressing time, the time
it takes from diagnosis to care
or the identification
of a condition
to the rectification
of that status.
And I think, finally,
the most exciting way
that we see mobile
telephony changing
our paradigm of global
health is in creating
new windows of opportunity
where, as public health
interventionists,
we find ourselves
able to act on these
windows of time,
which we did not have
access to in the past.
And I'll give you a
few examples of these.
There are three main ways in
which mHealth technologies
are enabling the work that we
do in the global health space.
These range from
patient, provider,
to health system interventions.
At the patient
level, we're really
looking at improving access
to information, information
about diet, information
about food systems,
modifying behavior
through supporting
behavior-change strategies,
such as improving diet
and nutritional interventions.
Activity monitoring--
many of us have done work
in nutrition monitoring
exercise and caloric expenditure
over the course of the day.
And these technologies
are now embedded
in every single mobile
phone that each one of you
is carrying in the room today.
But as I think about the last
two speakers and this challenge
of getting better data
about nutritional intake
as an example, individuals
now across the world
are recording their
daily dietary intake
at levels of granularity
that we could not
imagine in a research context.
For providers, we're talking
about workflow management,
decision support tools
to enable clinicians
to adhere to clinical
decision algorithms
but also enhancing our ability
to improve surveillance
and tracking, being able
not just to detect outbreaks
but to identify and follow
kids through time as they
go through those essential
first years of life.
At the health
system level, we're
looking at innovations which
have changed the way we monitor
our workforce.
Today, Parul, Keith, myself,
we can log into a portal
and see where our 850
staff in rural Bangladesh
have been collecting mid
upper-arm circumferences
over the course of
the past two days.
And then finally, being able to
access that data in a much more
rapid turnaround time
has really transformed
the rate at which
we can do research
and the cost of this research
in large populations.
So the question is,
in these contexts,
where despite the
population density,
women are delivering in fairly
isolated locations, where
micronutrient access to
information and food supplies
are strained and in limited
shortage, in places where
providers are often
isolated from the health
systems with which
they serve, how
can we enhance their ability to
do the functions that they're
tasked with but
also make them feel
like they're part of the health
system which they're serving?
And finally, as Dr.
Black brought up,
how do we take these
interventions of known efficacy
and help them to achieve the
effective coverage that we
know will have the greatest
impact on lives saved?
So over the past 10 years,
we've seen not just hundreds,
but tens of thousands of
mHealth pilot studies.
In fact, someone
joked the other day
that there are more pilots
in the domain of mHealth
than there are in
the US Air Force.
So I'll give you a
few examples of this.
One recent study that we did
in Bangladesh, 170,000 women we
surveyed at the
beginning of last year.
71% of these rural
households that
represent a vast swath of the
greater Gangetic floodplain,
owned phones, despite
only 23% of those homes
having access to electricity.
Now, you talk about a
game-changing paradigm,
this is it right here.
We asked ourselves, could we
access that critical window
of time shortly after birth
when the risk of mortality
is the greatest?
So we had to know when
women were going into labor.
We empowered women with a way to
send a text message to us when
they were going into labor.
And 500 pregnancies
later, 90% of the time, we
had a skilled nurse midwife
attending that birth
in a context where 85% of
births occur in the home.
We have now deployed very
sophisticated systems
that are under evaluation
in rural Bangladesh,
which start with the
basic functions of census
enumeration, pregnancy
surveillance.
These systems that have been
part of our research enterprise
for decades are now being
delivered by frontline health
workers of the
government of Bangladesh
to do these functions as part
of their service delivery
activities, but
more importantly,
enabling us to mobilize
emergency referrals
and support when those
obstetric events take place
but then providing women with
that supporting information
about adequate nutrition
and health care
during those early
months of life.
With WHO in India, we're testing
these tablet-based systems,
which take those
antiquated tomes of paper
that they used to carry around
into digital interfaces that
allow them to target limited
resources to pregnant women who
need it the most, tracking
both post-natal antenatal care,
but also nutritional
adequacy and access
to essential things like iron,
folic acid supplementation.
We can also transform the way
we do counseling, enhancing
those paper-based flip charts
about diet and nutrition
with interactive
video footage that's
now available at
the point of care
in these rural communities.
The MAMA Project,
sponsored by USAID,
allows pregnant women to receive
gestationally age-appropriate
messages about their
pregnancy, from diet
all the way to newborn care.
UNICEF is using
RapidSMS and Child Count
to track the mid
upper-arm circumference
of under-five children to
be able to map and target
resources in these
nutritional monitoring
programs of the Millennium
Villages Project
in sub-Saharan Africa.
Novartis has launched
a phenomenal project
called SMS for Life
that enables them
to manage those essential
commodity supply chains
through simple text messaging
strategies that notify them
when a particular commodity
is in short supply.
So imagine using these and
leveraging these systems
for nutritional
commodity ascertainment.
But the future is here,
gentlemen and ladies,
that we have the technology
to do on-phone microscopy.
We were able to do ultrasound.
The FDA has approved
this Mobisante device
to do field-based ultrasound
using a mobile system.
We have pill bottles--
whether these are
micro-nutrients
or antibiotics--
that beep at you when you
have forgotten to take a dose.
Not only that, they will call
your wife or your mother-in-law
to say that you haven't
taken your drugs.
Please contact your
loved one and let
them know they need to
take their medication.
But there are also
new paradigms.
We think about
over-the-counter devices
that are now available
to do everything from ECG
to weight and
urinalysis at the home,
that individuals can do
these assessments and upload
data on a daily
basis in real time,
supplementing those
data points that we
need in our randomized trials.
And what's interesting
is all of this data
is wirelessly transmitted
to the data servers.
So again, it's important to
consider quality of data,
but the volume of data which
is now accessible to us
as researchers has
transformed dramatically.
We look at the advent
of a simple chip that's
less than the size of a quarter,
called the 3-axis accelerometer
that is now embedded in a number
of these commercial devices
that you can buy in any
store for less than $100.
And it will tell you
everything from your sleep
to the amount of steps that
you've taken and calories
that you've burned over
the course of the day.
Our colleagues
here at the school,
part of the 105 projects I
mentioned earlier-- this is
Larry Cheskin in the
School of Medicine,
has just completed a
randomized control trial
looking at tailored
text messaging
as a way of enhancing
weight management
support in populations
here in East Baltimore.
And they've shown
substantial improvements
associated with these
kinds of text messages.
I think if I got this message,
I might be a little bit irked.
But my wife jokes that when
I bought that accelerometer,
my weight actually
went up by 10 pounds.
So I may not be
the model citizen.
So there are companies that are
enhancing our ability to not
just track food consumption
and caloric intake
but also enhance
this with the ability
to scan our environment, to
scan the bottle of Rice Krispies
and know how many calories
that that particular ingredient
contains, but also
supplementing that
with real-time
monitoring of activity
and then engaging
the social network,
which we are now all a part of.
Your friends and family can
keep track of how you're doing
and encourage you through that
process of weight management.
Some of you may have seen
this device I've been carrying
around yesterday, which allows
you on your iPhone to conduct
a two-lead EKG that
is now FDA-approved,
a really transformative
technology that potentially
will see us in the future even
doing things like this where--
this is a technology
being developed
at Tufts, where
researchers are working
on image analysis,
where you'll be
able to take a
picture of a plate
and recognize the
composition and dietary
content of that
plate in hopefully
not too distant future.
There's a company called
AIRO that's apparently
developed a wrist band that has
a built in spectrometer that
hopefully will be
able to measure
caloric intake as you
are actually eating.
So I have to see
this to believe it,
but this is the company's claim.
But this is also
a reality, where
we're able to do flow
cytometry on a phone.
We're able to do nuclear
magnetic resonance on a phone.
And I tell you, we're
within three to five years
of seeing these products
being available to researchers
in the room.
So mNutrition-- we're looking at
faster access to digital data.
We're looking at improvements
in adherence monitoring
and promotion.
We're looking at ways
of engaging participants
in the research that we do and
enhancing the ability for us
as intervention scientists to
counsel and remind patients
who are enrolled in nutritional
intervention programs.
But I think this scope of
real-time activity and bio
monitoring is another frontier
that we should consider,
where we can also leverage
social groups as part
of the way we manage
diet and health
care in these communities.
And maybe we're
looking at a future
where we have point
of care, mProteomics,
on our mobile phones.
So sometimes I feel like this
gentleman at the Colbert Rally
for Change.
He's saying, what do we want?
Evidence-based change.
When do we want it?
After peer review.
And it's a rapidly
changing environment.
But I think it's important that
we have groups like the Hopkins
mHealth Initiative
that are really
pushing that frontier of doing
the rigorous research that's
published and subject to the
methodologies that really
determine the efficacy of these
strategies and technologies.
We published a paper
last year that really
posed this question,
that is there more hype
or hope on the horizon?
And we found that there were
215 mHealth clinical trials
in the gristmill.
So I posted that there
is hope on the horizon.
And we will see more
robust, rigorous research
coming forward.
And here's sort of a digest
of some of the evidence
that we have right now.
We know that mHealth for smoking
cessation is very effective.
We know it improves patient
adherence to drug regimens
and vaccine schedule adherence.
And for stock-outs for
anti-malarials in Africa,
it's been exceptionally
efficacious.
So the world is changing.
It's becoming more
and more connected.
And with this reality,
I hope that I've
been able to pith
your brains and make
it a pithy comment for mobile
technologies in the research
that we're doing.
Thanks so much.
[APPLAUSE]
KEITH WEST: Well,
thank you, Alain.
That, I'm sure,
imploded everyone.
And you ran away so fast
that I couldn't even
say are there any questions.
So we won't take any right now.
And we'll go through this last
10-minute kind of Whitman's
sampler on nutrition.
And then we'll open
up for our dialogue.
Let's see.
Where's my-- am I
supposed to do this?
AUDIENCE: There's a phone here.
KEITH WEST: There's
a phone here, yeah.
Siri, where are my slides?
[LAUGHTER]
SPEAKER: [INAUDIBLE]
KEITH WEST: Thank you.
AUDIENCE: Maybe you
should ask the rat.
KEITH WEST: I couldn't stand
having the rat in front of Bob
during his talk.
AUDIENCE: [INAUDIBLE]
KEITH WEST: Now I could
put the rat back up.
He's not jumping
so well these days.
He's 100 years old.
So we're going to
switch a little bit here
toward some work--
just very quickly
share with you work
that we're doing on the
plasma proteome, mining
it, exploring it,
as a way to assess
micronutrient deficiencies
at a population level
and to reveal hidden hunger.
It's very much in
the formative stages.
This is a very complex
area of our science.
Our biology is
extremely complex.
But we're trying to bring that
complexity to some simplicity
in terms of potential use.
When we look for
micronutrient deficiencies--
some of the talks that
we've heard today--
there can be expected
to be many micronutrient
deficiencies in under-nourished
populations coexisting.
This is an example from one
of our populations in Nepal.
And there's two messages here.
These are pregnant women
in Sarlahi, the population
that Dr. Christian described.
One message is, the more
you look, the more you find.
So the more you measure, the
more you'll find deficiencies.
And the second message
is that they're not
all at the same level.
They're different.
And so we need to be thinking
about how to better assess
populations in real time to
make evidence-based decisions
for public health programs
that can address their needs.
Right now, existing
micronutrient analyses
require high-tech, expensive,
and slow and very sensitive
instrumentation.
I see Dr. Bob Cole in our
proteomics mass spec laboratory
across the street here.
And you know, he has to pet
his mass specs every day,
polish them and
take care of them.
Or if he looks at them crooked,
they will shut down on him.
So we have HPLCs.
We have immunoassays.
We have atomic absorption
spectrophotometry.
We have many different assays
for many different nutrients.
And those are our
gold standards.
But they are slow.
And they are expensive.
And they are not performed in
Rangpur, Bangladesh or Lusaka,
Zambia.
They're performed
in Baltimore or
a similar well-equipped area.
We need to find a cheap way
to get this problem defined
more quickly.
They remain hidden.
These deficiencies
remain as hidden today
as when that term hidden
hunger was recoined in 1991.
So what we need are methods to
assess deficiencies precisely,
that is, with a sufficient
sample size that
can deliver reliable estimates.
Efficiently-- multiple
nutrients at the same time.
Cheaply-- to assess large
samples repeatedly over time
so we can monitor accurately
against whatever existing gold
standards we want
to put it up to.
Locally-- that is, in
the affected countries.
Easily-- requiring
minimal technical skills
and readily in weeks
rather than years.
And this way we can
detect and monitor change
and build programs.
Preferably, this will
be on a single platform.
None of this exists.
No matter what Dr. Labrique
says, we're not there yet.
But we may not be terribly far.
We approached the Gates
Foundation several years ago.
And they thought that
it was sufficiently
risky to provide us with a
grant to explore the plasma
proteome as a potential way of
assessing micronutrient status,
with an axiom being that
all nutrients, as soon
as they hit the mouth, are
associated with a proteome,
from digestion, absorption,
transport, storage,
utilization, excretion.
Until they reached
their metabolic fate,
there is a proteome.
We don't know what that is.
But there's a proteome that
accompanies that transition.
And the assumption
is that we can
measure some aspect of that
proteome in its relationship
to micro-nutrients in plasma.
And so we set out in 500
children in the NNIPS-3 cohort
to assess micronutrient
status and inflammation
status by conventional means,
measure the relative abundance
of the plasma proteome
by tandem mass
spec and bioinformatics and
high density statistics,
and identify a plasma
nutriproteome, that is,
the proteins that are measured
in relative abundance that
correlate with micronutrient
status measured
by the gold standard,
by our convention
and to push it further to see
if we could identify models
whereby proteins could
predict multiple micronutrient
status at a population level.
This is the one slide
on the proteomics.
We measure the micronutrient
status of the plasma
by our traditional indicators.
We have about 23
analytes where you
reduce the plasma of
highly abundant proteins--
albumin, haptoglobulin, IgG,
IgA, antitrypsin, transferrin--
proteins that are so large
they basically cover up
the hundreds to thousands
of low-abundance proteins
that you could
otherwise measure.
We then look for these
low-abundance proteins
by a very complex mass
spectrometry system
and look for differential
expression of the proteins
and relate those abundance
levels to the nutrient levels
that we measure by our
conventional assays.
We have a few papers that are
out on this technique right
now, one that just came
out in October describing
what we have found, looking
first at proof of concept.
So in this first paper, we've
looked at five micronutrient
protein diets, that is, proteins
that are inextricably connected
to nutrients-- vitamin E with
a key apolipoprotein that comes
out of the liver
into circulation,
vitamin A with
retinol-binding protein,
vitamin D with its
binding proteins,
selenium with its major
transport protein,
and copper with ceruloplasmin--
to see if we could identify
a clear relationship that
would be sufficient to
predict in the future.
And we were delighted to see
with retinol binding protein
how it is related--
when RBP is measured by
this mass spec process
of fractionation and
reassembling the data
to find the proteins based
on peptide sequences,
to see RBP come up with
a strong association,
strong correlation
with serum retinol--
here's the serum retinol
level distribution.
And this is an estimate
of relative abundance
of the RBP using a linear
mixed-effects model that
removes some annoying variation
that comes with the technique.
So you can just see-- this
is a continuous spectrum
of relative abundance.
But the thing to look at is that
we've got an r square of 0.77.
That is, that RBP
measured this way explains
77% of the variation
in plasma retinol
in this population
of 500 children.
This thrilled us and
propelled us forward.
It's not just RBP, though.
Give you a hint.
For those of you who love
to work on vitamin A,
what would your next
protein that you
would expect to be most strongly
related to plasma vitamin A be?
Right.
Transthyretin, because
it travels in the blood
in the same complex with RBP.
And that is what we found.
Here's transthyretin.
These are proteins that are
associated with plasma retinol
with a p-value--
this is just a short list
at this small level--
and a q, a q being
the probability
of it being a false
positive, being quite small,
less than 1%.
So these are almost
assuredly proteins
that are associated with
plasma retinol in circulation.
And they range from
the carrier proteins
to apolipoproteins to
negative relationships
with complement
factors that are known
to be involved in
fighting infection
to various coagulation factors.
It's sort of
reflecting our biology
as it relates to vitamin
A through the proteome.
And if one goes further, this
is the false discovery rate
of 0.01.
I'm not going to ask
you to read these.
But these are all proteins that
are positively associated with
vitamin A-- vitamin
A is up here--
and negatively associated
with vitamin A,
and therefore positively
associated with each other
or negatively associated
with those proteins.
So it's a correlation
matrix that
shows the variability
and the extensiveness
of the proteome that is
associated with plasma retinol.
And-- oh, I did that same
thing that Harry did, I think--
what are those?
Well, these are
the gene symbols.
But these are all
apolipoproteins
that are involved
in lipid transport.
Vitamin A is known to be
a fat-soluble vitamin.
It's involved in
lipid metabolism.
It's carried by lipocalins,
by lipid-carrying proteins.
So it makes a lot
of sense, not just
the RBP or the
transthyretin, but many
of these other molecules
we never think about
in association with vitamin A.
Or they may be
involved with growth
in some growth-factor
binding proteins
and related
molecules, positively
associated with plasma retinol.
Negative associations
with wound healing,
with the Von Willebrand factor.
Host defense molecules--
all negatively related
to serum retinol.
We know that serum retinol
goes down in inflammation.
And so this is a confirmation
of that kind of a relationship
that we're seeing
in the proteome
that we can see through
this mass spec process.
Another example is vitamin
E, plasma alpha-tocopherol.
It doesn't have a single protein
that it's carried in the blood
with.
So we chose Apo C, because it's
an important early lipoprotein
that vitamin E is released
with into circulation
from the liver.
And we have Dr. Maret Traber
here from Oregon State
University, who we're
delighted to see,
who is the world's
expert in vitamin E.
So I talked about vitamin E
with a lot of humility here.
And happy to have you here.
Here's the correlate, the
r squared with plasma,
between plasma vitamin
E and relative abundance
of this particular
apolipoprotein.
Again, the distribution
of alpha-tocoferol here,
and a fairly good r square.
Maybe not good enough
to predict, but strong.
But here's the
alpha-tocopherome in the plasma.
And if you looked
at these carefully,
you would find more
lipid transport proteins
that vitamin D is
intimately associated with.
You would see a
negative relationship
with cell adhesion molecules,
all of which have--
most-- a story to
tell with respect
to vitamin E or a
negative relationship
with host defense molecules,
alpha 1 acid glycoprotein
or other related molecules.
So just a few more
examples-- this
is selenium with the main
plasma-carrying protein,
selenoprotein P1, a
good, strong correlation
between the mass spec-based
relative abundance
in the plasma selenium level.
Here is vitamin D with
vitamin D binding protein.
It's carrier, less strong but
still a very good r square.
That's a correlation
coefficient above 0.5 telling us
that it's probably not
good enough for prediction,
but it's a step
forward toward that.
So we've been looking
at all the nutrients.
And this is just a summary of
the fat-soluble nutrient plasma
proteome right now,
A, D, Es, and K
that we have found so far.
These are the
numbers of proteins
that we have found that
have a probability of being
false of less than 10%.
And we've just begun to
identify potential predictors
and have an initial model where,
for example, four proteins will
explain, right now our estimate
is around 83% of plasma vitamin
A or eight proteins,
73% of plasma vitamin E.
But we're not hitting the
mark on these other vitamins
right now.
There's a lot to talk about
in terms of why that may be.
There are people here
interested in carotenoids.
They are generally turning
out not to be strongly related
with plasma proteins, except
for beta-cryptoxanthin, where
we've identified 52 proteins.
And we're working with
an r-square of 0.51.
Water-soluble vitamins
and trace elements--
we've been able to
look at some of these.
We are not exhaustive in
the conventional assays
that we've been
able to do so far.
Folate, surprisingly,
has no proteome
in the plasma associated
with this level of strength,
with that level of
confidence, whereas B6
has 88 proteins and
an r square of 0.58.
B-12 is striking out so far
at this level of resolution,
whereas copper is going
through the roof in terms
of the number of proteins
that are strongly
associated with it.
Selenium only has
three, but those
who are working with
selenium could probably
predict what they are.
That's the SEPT1 protein,
the glutathione peroxidase 3,
and there's one other one.
And then there are-- it goes
beyond the micro-nutrients.
This is the lipid and acute
phase response plasma proteome.
So we've got high-density
lipoproteins and low-density
lipoproteins measured
in this plasma.
Now, we're identifying 62
and 15 proteins respectively.
And for the HDL, we've
got an r square of 0.68.
For the acute phase
reactants of AGP and CRP,
hundreds of proteins
and very strong
associated r squares with six
proteins and three proteins
only in the model.
So what you see is it depends
on the eyes of the beholder.
And one sees a 2D
gel on the left side.
But you can also see
artwork in all of this.
And so we're calling it
the plasma awe-some--
[LAUGHTER]
--as a way of taking chances,
of exploring our biology,
of seeing how we can
relate nutrient status
at a measurable,
eventually simple level,
that could be put onto one
of Dr. Labrique's iPhones,
obviously, not mine.
But in a platform
in the future where
we will be able to, at
least on a population level,
be able to say
deficient, not deficient,
if deficient do something,
do something now.
Because we've done it cheaply.
We can do it repeatedly.
And we can lift this
veil of hidden off
of this form of hunger.
Thank you.
[APPLAUSE]
