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营养特异性干预措施预防和控制整个生命周期的贫血:系统评价概述。

Nutrition-specific interventions for preventing and controlling anaemia throughout the life cycle: an overview of systematic reviews.

机构信息

Graduate School of Public Health, St. Luke's International University, Tokyo, Japan.

Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan.

出版信息

Cochrane Database Syst Rev. 2021 Sep 26;9(9):CD013092. doi: 10.1002/14651858.CD013092.pub2.


DOI:10.1002/14651858.CD013092.pub2
PMID:34564844
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC8464655/
Abstract

BACKGROUND: Anaemia is a prevalent health problem worldwide. Some types are preventable or controllable with iron supplementation (pills or drops), fortification (sprinkles or powders containing iron added to food) or improvements to dietary diversity and quality (e.g. education or counselling). OBJECTIVES: To summarise the evidence from systematic reviews regarding the benefits or harms of nutrition-specific interventions for preventing and controlling anaemia in anaemic or non-anaemic, apparently healthy populations throughout the life cycle. METHODS: In August 2020, we searched MEDLINE, Embase and 10 other databases for systematic reviews of randomised controlled trials (RCTs) in anaemic or non-anaemic, apparently healthy populations. We followed standard Cochrane methodology, extracting GRADE ratings where provided. The primary outcomes were haemoglobin (Hb) concentration, anaemia, and iron deficiency anaemia (IDA); secondary outcomes were iron deficiency (ID), severe anaemia and adverse effects (e.g. diarrhoea, vomiting). MAIN RESULTS: We included 75 systematic reviews, 33 of which provided GRADE assessments; these varied between high and very low. Infants (6 to 23 months; 13 reviews) Iron supplementation increased Hb levels and reduced the risk of anaemia and IDA in two reviews. Iron fortification of milk or cereals, multiple-micronutrient powder (MMNP), home fortification of complementary foods, and supplementary feeding increased Hb levels and reduced the risk of anaemia in six reviews. In one review, lipid-based nutrient supplementation (LNS) reduced the risk of anaemia. In another, caterpillar cereal increased Hb levels and IDA prevalence. Food-based strategies (red meat and fortified cow's milk, beef) showed no evidence of a difference (1 review). Preschool and school-aged children (2 to 10 years; 8 reviews) Daily or intermittent iron supplementation increased Hb levels and reduced the risk of anaemia and ID in two reviews. One review found no evidence of difference in Hb levels, but an increased risk of anaemia and ID for the intermittent regime. All suggested that zinc plus iron supplementation versus zinc alone, multiple-micronutrient (MMN)-fortified beverage versus control, and point-of-use fortification of food with iron-containing micronutrient powder (MNP) versus placebo or no intervention may increase Hb levels and reduce the risk of anaemia and ID. Fortified dairy products and cereal food showed no evidence of a difference on the incidence of anaemia (1 review). Adolescent children (11 to 18 years; 4 reviews) Compared with no supplementation or placebo, five types of iron supplementation may increase Hb levels and reduce the risk of anaemia (3 reviews). One review on prevention found no evidence of a difference in anaemia incidence on iron supplementation with or without folic acid, but Hb levels increased. Another suggested that nutritional supplementation and counselling reduced IDA. One review comparing MMN fortification with no fortification observed no evidence of a difference in Hb levels. Non-pregnant women of reproductive age (19 to 49 years; 5 reviews) Two reviews suggested that iron therapy (oral, intravenous (IV), intramuscular (IM)) increased Hb levels; one showed that iron folic acid supplementation reduced anaemia incidence; and another that daily iron supplementation with or without folic acid or vitamin C increased Hb levels and reduced the risk of anaemia and ID. No review reported interventions related to fortification or dietary diversity and quality. Pregnant women of reproductive age (15 to 49 years; 23 reviews) One review apiece suggested that: daily iron supplementation with or without folic acid increased Hb levels in the third trimester or at delivery and in the postpartum period, and reduced the risk of anaemia, IDA and ID in the third trimester or at delivery; intermittent iron supplementation had no effect on Hb levels and IDA, but increased the risk of anaemia at or near term and ID, and reduced the risk of side effects; vitamin A supplementation alone versus placebo, no intervention or other micronutrient might increase maternal Hb levels and reduce the risk of maternal anaemia; MMN with iron and folic acid versus placebo reduced the risk of anaemia; supplementation with oral bovine lactoferrin versus oral ferrous iron preparations increased Hb levels and reduced gastrointestinal side effects; MNP for point-of-use fortification of food versus iron and folic acid supplementation might decrease Hb levels at 32 weeks' gestation and increase the risk of anaemia; and LNS versus iron or folic acid and MMN increased the risk of anaemia. Mixed population (all ages; 22 reviews) Iron supplementation versus placebo or control increased Hb levels in healthy children, adults, and elderly people (4 reviews). Hb levels appeared to increase and risk of anaemia and ID decrease in two reviews investigating MMN fortification versus placebo or no treatment, iron fortified flour versus control, double fortified salt versus iodine only fortified salt, and rice fortification with iron alone or in combination with other micronutrients versus unfortified rice or no intervention. Each review suggested that fortified versus non-fortified condiments or noodles, fortified (sodium iron ethylenediaminetetraacetate; NaFeEDTA) versus non-fortified soy sauce, and double-fortified salt versus control salt may increase Hb concentration and reduce the risk of anaemia. One review indicated that Hb levels increased for children who were anaemic or had IDA and received iron supplementation, and decreased for those who received dietary interventions. Another assessed the effects of foods prepared in iron pots, and found higher Hb levels in children with low-risk malaria status in two trials, but no difference when comparing food prepared in non-cast iron pots in a high-risk malaria endemicity mixed population. There was no evidence of a difference for adverse effects. Anaemia and malaria prevalence were rarely reported. No review focused on women aged 50 to 65 years plus or men (19 to 65 years plus). AUTHORS' CONCLUSIONS: Compared to no treatment, daily iron supplementation may increase Hb levels and reduce the risk of anaemia and IDA in infants, preschool and school-aged children and pregnant and non-pregnant women. Iron fortification of foods in infants and use of iron pots with children may have prophylactic benefits for malaria endemicity low-risk populations. In any age group, only a limited number of reviews assessed interventions to improve dietary diversity and quality. Future trials should assess the effects of these types of interventions, and consider the requirements of different populations.

摘要

背景:贫血是全世界普遍存在的健康问题。一些类型的贫血可以通过铁补充剂(药丸或滴剂)、强化(撒在食物上的含铁粉末或颗粒)或改善饮食多样性和质量(例如教育或咨询)来预防或控制。

目的:总结系统评价中关于营养特定干预措施在预防和控制整个生命周期中贫血或非贫血、看似健康人群的贫血和缺铁性贫血的益处或危害的证据。

方法:2020 年 8 月,我们在 MEDLINE、Embase 和其他 10 个数据库中搜索了关于贫血或非贫血、看似健康人群的随机对照试验(RCT)的系统评价。我们遵循了标准的 Cochrane 方法,对提供了 GRADE 评级的研究进行了提取。主要结局指标是血红蛋白(Hb)浓度、贫血和缺铁性贫血(IDA);次要结局指标是缺铁(ID)、严重贫血和不良反应(如腹泻、呕吐)。

主要结果:我们纳入了 75 项系统评价,其中 33 项提供了 GRADE 评估;这些评估在高低之间存在差异。婴儿(6 至 23 个月;13 项研究)铁补充剂增加了两项研究中的 Hb 水平并降低了贫血和 IDA 的风险。牛奶或谷物中的铁强化、多种微量营养素粉末(MMNP)、补充食品的家庭强化以及补充喂养增加了 Hb 水平并降低了六项研究中的贫血风险。一项研究表明,基于脂质的营养素补充剂(LNS)降低了贫血的风险。另一项研究表明,毛毛虫麦片增加了 Hb 水平和 IDA 的流行率。基于食物的策略(红肉和强化牛奶、牛肉)没有显示出差异(一项研究)。学前和学龄儿童(2 至 10 岁;8 项研究)每日或间歇性铁补充剂增加了 Hb 水平并降低了两项研究中的贫血和 ID 风险。一项研究发现,间歇性方案在 Hb 水平方面没有差异,但增加了贫血和 ID 的风险。所有研究都表明,与锌加铁补充剂相比,单独使用锌、含有 MMN 的饮料与对照相比、使用含有铁的微量营养素粉末(MNP)进行食物局部强化与安慰剂或无干预相比,可能会增加 Hb 水平并降低贫血和 ID 的风险。强化乳制品和谷物食品在贫血的发生率方面没有显示出差异(一项研究)。青少年儿童(11 至 18 岁;4 项研究)与无补充剂或安慰剂相比,五种类型的铁补充剂可能会增加 Hb 水平并降低贫血的风险(三项研究)。一项关于预防的研究发现,铁补充剂加或不加叶酸对贫血发生率没有差异,但 Hb 水平升高。另一项研究表明,营养补充和咨询减少了 IDA。一项比较 MMN 强化与无强化的研究观察到 Hb 水平没有差异。育龄妇女(19 至 49 岁;5 项研究)两项研究表明,铁治疗(口服、静脉(IV)、肌内(IM))增加了 Hb 水平;一项研究表明,铁叶酸补充剂降低了贫血的发生率;另一项研究表明,每日补充铁加或不加叶酸或维生素 C 增加了 Hb 水平并降低了贫血和 ID 的风险。没有研究报告与强化或饮食多样性和质量相关的干预措施。育龄妇女(15 至 49 岁;23 项研究)每项研究都表明:在第三孕期或分娩时以及产后期间,每日补充铁加或不加叶酸增加了 Hb 水平,并降低了第三孕期或分娩时以及 ID 的风险,而间歇性铁补充剂对 Hb 水平和 IDA 没有影响,但增加了接近分娩时和 ID 的贫血风险,减少了不良反应的风险;单独补充维生素 A 可能会增加孕产妇的 Hb 水平并降低孕产妇贫血的风险;MMN 加铁和叶酸与安慰剂相比降低了贫血的风险;口服牛乳铁蛋白与口服铁制剂相比增加了 Hb 水平并减少了胃肠道不良反应;用于食物局部强化的 MNP 与铁和叶酸补充剂相比可能会降低 32 周妊娠时的 Hb 水平并增加贫血的风险;LNS 与铁或叶酸和 MMN 增加了贫血的风险。混合人群(所有年龄;22 项研究)铁补充剂与安慰剂或对照相比,增加了健康儿童、成年人和老年人的 Hb 水平(四项研究)。两项研究调查了 MMN 强化与安慰剂或无治疗、强化面粉与对照、双强化盐与仅碘强化盐、单独铁强化大米或与其他微量营养素联合强化大米与未强化大米或无干预相比,Hb 水平似乎增加,贫血和 ID 的风险降低。每项研究都表明,与未强化的调味料或面条相比,强化(乙二胺四乙酸铁钠;NaFeEDTA)与未强化的酱油,以及双强化盐与对照盐相比,可能会增加 Hb 浓度并降低贫血的风险。一项研究表明,接受铁补充剂的贫血或 IDA 儿童的 Hb 水平升高,接受饮食干预的儿童的 Hb 水平降低。另一项评估了在铁锅中烹饪食物的效果,发现两项试验中低疟疾风险儿童的 Hb 水平较高,但在高疟疾流行混合人群中比较非铸造铁锅烹饪的食物时没有差异。不良反应没有差异。贫血和疟疾的流行率很少报道。没有研究关注 50 至 65 岁以上的妇女或 19 至 65 岁以上的男子。

作者结论:与不治疗相比,每日铁补充剂可能会增加婴儿、学前和学龄儿童以及孕妇和非孕妇的 Hb 水平并降低贫血和 IDA 的风险。在低疟疾风险人群中,婴儿铁强化食品和儿童铁锅的使用可能具有预防疟疾的益处。在任何年龄组中,只有少数研究评估了改善饮食多样性和质量的干预措施。未来的试验应评估这些类型的干预措施的效果,并考虑不同人群的需求。

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