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Lindsay H Allen

Publications and source records attributed to Lindsay H Allen.

At least 19 recordsLinked to original sources
PubMed2006

New approaches for designing and evaluating food fortification programs.

Historically, food fortification programs were often undertaken with little attention to issues such as micronutrient bioavailability, optimal levels of addition, or efficacy or to monitoring impact on nutritional status, health, and human function. Several developments in recent years have enabled substantial progress to be made in the design and evaluation of fortification programs. The methodology for estimating the prevalence of inadequate nutrient intakes in a population and tolerable upper intake levels has been established and can be used as the basis for estimating desirable amounts of nutrient addition. More attention is being paid to assessing the bioavailability of nutrients (especially minerals) using stable and radioactive isotopes, and bioavailability of iron compounds can be estimated from changes in total body iron calculated from the ratio of transferrin receptors to serum ferritin. Procedures for quality control of the fortification process have been established. New approaches to monitoring the impact of fortification over time include assessment of liver retinol stores using retinol isotope dilution. In summary, the design and evaluation of food fortification programs now requires a series of formative research procedures on the part of nutritionists, which were not often expected or conducted in the past.

Biological Availability↗
PubMed2006

Combined iron and folic acid supplementation with or without zinc reduces time to walking unassisted among Zanzibari infants 5- to 11-mo old.

Iron and zinc deficiencies have been associated with delayed motor development in nutritionally at-risk children, albeit inconsistently. In this community-based, randomized double-blind trial, iron+folic acid (FeFA) (12.5 mg Fe + 50 mug folic acid), zinc (Zn) (10 mg), and iron+folic acid+zinc (FeFA+Zn) supplements or a placebo were given daily for 1 y to nutritionally at-risk children in Pemba, Zanzibar. The effects of these treatments on attaining unassisted walking were evaluated using survival analysis for 354 children aged 5-11 mo at the start of supplementation. Treatment effects on changes in hemoglobin (Hb) and zinc protoporphyrin (ZPP) and height-for-age (HAZ) and weight-for-age (WAZ) Z scores were evaluated using linear regression. Attained motor milestone was recorded every 2 wk for 1 y. Hb, ZPP, HAZ, and WAZ were measured at baseline and after 6 mo of treatment. FeFA with or without Zn reduced the time it took for children to walk assisted. Children who received any iron walked unassisted sooner than those who received no iron [median difference approximately 15 d, P = 0.035, risk ratio (RR) = 1.28, 95% CI = 1.02, 1.61] and this effect was stronger in those who had iron deficiency anemia (IDA) at baseline (median difference was approximately 30 d; P = 0.002; RR = 1.68; 95% CI = 1.21, 2.32). FeFA alone and Zn alone improved Hb and ZPP compared with placebo. There were no significant treatment effects on changes in HAZ or WAZ. The effects of treatment on time to walking may have been mediated by improvements in iron status or hemoglobin, but were not mediated through improvements in growth.

Dietary Supplements↗
PubMed2006

Causes of nutrition-related public health problems of preschool children: available diet.

The primary goal of this review is to examine the timing and nature of dietary inadequacy during the first 5 years of life. An important issue is that many children in developing countries are already nutritionally depleted by the end of the first year of life, because maternal undernutrition can cause low fetal accumulation of nutrient stores and secretion of inadequate amounts of some micronutrients in breast milk. Improvement of maternal diet and micronutrient status is required to remedy this situation. During the period of complementary feeding, most households may be able to provide their young children with sufficient energy and protein from home-produced complementary foods, but many do not feed foods with an adequate energy density or a sufficient number of meals per day. Inadequate micronutrient intakes and resulting deficiencies are common in preschoolers because of a lack of sufficient animal source foods, and have been associated with delayed child development. Dietary diversity is an especially important determinant of micronutrient intakes when animal source food intake is low. Interventions with animal source foods have produced improvements in growth, micronutrient status, cognitive performance and activity of children. Although much is now known about the role of inadequate diets in preschooler malnutrition, on a global scale the ability of households to apply this knowledge to improve the diets of their children is still limited.

Breast Feeding↗
PubMed2005

Measurement of total vitamin B12 and holotranscobalamin, singly and in combination, in screening for metabolic vitamin B12 deficiency.

BACKGROUND: The standard screening test for vitamin B12 deficiency, measurement of total plasma vitamin B12, has limitations of sensitivity and specificity. Plasma vitamin B12 bound to transcobalamin (holoTC) is the fraction of total vitamin B12 available for tissue uptake and therefore has been proposed as a potentially useful alternative indicator of vitamin B12 status. METHODS: We compared the diagnostic accuracy of total vitamin B12, holoTC, and a combination of both measures to screen for metabolic vitamin B12 deficiency in an elderly cohort (age > or = 60 years). Plasma methylmalonic acid and homocysteine were used as indicators of vitamin B12 deficiency. RESULTS: Low total vitamin B12 (< 148 pmol/L) and low holoTC (< 35 pmol/L) were observed in 6.5% and 8.0%, and increased methylmalonic acid (> 350 nmol/L) and homocysteine (> 13 micromol/L) were observed in 12.1% and 17.0% of the study participants. In multiple regression models, holoTC explained 5%-6% more of the observed variance in methylmalonic acid and homocysteine than did total vitamin B12 (P < or = 0.004). ROC curve analysis indicated that total vitamin B12 and holoTC were essentially equivalent in their ability to discriminate persons with and without vitamin B12 deficiency. Individuals with low concentrations of both total vitamin B12 and holoTC had significantly higher concentrations of methylmalonic acid and homocysteine than did individuals with total vitamin B12 and/or holoTC within the reference intervals (P < 0.001). CONCLUSIONS: HoloTC and total vitamin B12 have equal diagnostic accuracy in screening for metabolic vitamin B12 deficiency. Measurement of both holoTC and total vitamin B12 provides a better screen for vitamin B12 deficiency than either assay alone.

Aged↗
PubMed2005

Multiple micronutrients in pregnancy and lactation: an overview.

This overview of multiple micronutrients during pregnancy and lactation emphasizes 2 relatively neglected issues. The first is that maternal micronutrient status in the periconceptional period, and throughout pregnancy and lactation, should be viewed as a continuum; too often these 3 stages are treated and discussed separately from both a scientific and a public health perspective. Iron and vitamin B-12 are included as examples to stress how status at conception affects maternal, fetal, and infant status and health until the child is weaned. The second issue is that while most attention has been focused on a few micronutrients, for example iron and folate as discussed elsewhere in this Supplement, multiple micronutrient deficiencies occur simultaneously when diets are poor. Some of these deserve more attention as causes of poor pregnancy outcome, including other B vitamin deficiencies that result in homocysteinemia, antioxidants, vitamin D, and iodine. In lactation, maternal status or intake of the B vitamins (except folate), vitamin A, selenium and iodine strongly affect the amount of these nutrients secreted in breast milk. This can result in the infant consuming substantially less than the recommended amounts and further depleting stores that were low at birth. While the optimal mode of meeting recommended micronutrient intakes is an adequate diet, in some situations supplementation is also important. Unfortunately, information is lacking on the optimal formulation of micronutrient supplements for pregnant women, and the need to continue these supplements during lactation is not recognized in many situations where maternal and infant health could benefit.

Anemia, Iron-Deficiency↗
PubMed2005

Low folate status is associated with impaired cognitive function and dementia in the Sacramento Area Latino Study on Aging.

BACKGROUND: Low folate status is associated with poor cognitive function and dementia in the elderly. Since 1998, grain products in the United States have been fortified with folic acid, which has reduced the prevalence of folate deficiency and hyperhomocysteinemia. OBJECTIVE: We investigated whether folate status is associated with cognitive function and dementia in a cohort of elderly Latinos (aged >or= 60 y; n = 1789) exposed to folic acid fortification. DESIGN: Global cognitive function was assessed by the Modified Mini-Mental State Examination (3MSE) and specific cognitive functions by cross-culturally validated neuropsychological tests. Dementia was diagnosed according to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 3rd edition revised, and California Alzheimer Disease Diagnostic and Treatment criteria. Red blood cell (RBC) folate was measured by automated chemiluminescence and total plasma homocysteine by HPLC. RESULTS: The prevalence of folate deficiency (RBC folate <or= 160 ng/mL) was <1%. After control for confounding by homocysteine, vitamin B-12, creatinine, demographic variables, and depressive symptom score, RBC folate was directly associated with 3MSE (P = 0.005) and delayed recall (P = 0.007) scores. In addition, adjusted odds ratios for low 3MSE score (<or=78) and dementia diagnosis per unit increase in RBC folate were significantly below unity (P <or= 0.008), which indicated that the relative risks of cognitive impairment and dementia decreased with increasing RBC folate concentration. In contrast, adjusted odds ratios for low 3MSE score and dementia diagnosis per unit increase in homocysteine were not significant. CONCLUSION: RBC folate is directly associated with cognitive function scores and is inversely associated with dementia in elderly Latinos despite folic acid fortification.

Aged↗
PubMed2005

Nutrition knowledge and practices, and consumption of vitamin A--rich plants by rural Nepali participants and nonparticipants in a kitchen-garden program.

Food-based nutrition interventions, including kitchen gardens and nutrition education, offer a potentially sustainable approach to reducing multiple nutritional deficiencies, but they have been poorly evaluated in developing countries. In a poor region of the terai (the flat, subtropical agricultural region that borders on India) in rural Nepal, we developed and evaluated the impact of a nutrition program added to the Market Access for Rural Development (MARD) Project. The primary objective of the MARD Project was to augment household income by increasing the production of high-economic-value crops. The objective of the nutrition program was to increase vitamin A and iron intakes by promoting kitchen gardens (training, technical assistance, and seed distribution) and nutrition education. One-third of the kitchen-garden program participants also attended nutrition education or agricultural training sessions that were part of the MARD Project. The program was evaluated after 36 months by a cross-sectional nutrition survey in 430 MARD households with kitchen gardens and 389 non-MARD control households. The lack of knowledge about nutrition, including the causes, prevention, and treatment of night-blindness and anemia, was remarkable. However, compared with control households, the kitchen-gardens group had significantly more nutrition knowledge (38% vs. 13% knew one of the causes of night-blindness, and 17% vs. 3% knew one of the causes of anemia), were more likely to feed special complementary foods to infants and to preserve food, and consumed more of 16 types of home-produced micronutrient-rich vegetables and fruits. Although the cross-sectional nature of the study limits our ability to attribute these differences to the program, we observed a striking lack of nutrition knowledge in these communities, and a clear opportunity to increase the intake of vitamin A through home production of vitamin A-rich plants.

Adult↗
PubMed2004

Plasma folate concentrations are associated with depressive symptoms in elderly Latina women despite folic acid fortification.

BACKGROUND: A relation between low folate status and depression has been recognized since the 1960s. Since 1998, flour in the United States has been fortified with folic acid, and the prevalence of folate deficiency has decreased dramatically. OBJECTIVE: We investigated whether, in this era of folic acid fortification, low folate status is a determinant of depressive symptoms in a cohort of elderly Latinos (aged >/=60 y) participating in the Sacramento Area Latino Study on Aging (SALSA). DESIGN: In a cross-sectional logistic regression analysis of data from SALSA (n = 627 M, 883 F), odds ratios (ORs) were ascertained for elevated depressive symptoms [Center for Epidemiologic Studies Depression Scale (CES-D) score >/=16] among tertiles of plasma folate. Depressive symptoms were assessed by using the CES-D. Plasma folate concentrations were determined by radioassay. RESULTS: The prevalence of folate deficiency (plasma folate </= 6.8 nmol/L) in the SALSA population was <1%. For men, no significant association between folate tertile and high CES-D score was observed. The adjusted OR for high CES-D score in women in the lowest tertile of folate was 2.04 (95% CI: 1.38, 3.02), which was significantly different from that in women in the highest tertile of folate (P < 0.001). CONCLUSION: These data indicate that, despite folic acid fortification, low folate status is associated with depressive symptoms in elderly Latina women (but not elderly Latino men).

Acculturation↗
PubMed2004

Folate and vitamin B12 status in the Americas.

There is growing interest in the potential for folic acid fortification in the Americas and recognition of the high prevalence of low plasma vitamin B12 concentrations reported in various studies. This review summarized available data on plasma vitamin B12 and folate concentrations in the Americas. At least 40% of individuals had deficient or marginal plasma vitamin B12 concentrations in almost all locations and across age groups. Low plasma folate concentrations were less common. It is hypothesized that vitamin B12 deficiency may result from a low intake of animal source foods, while a higher intake of refined flour may result in low plasma folate.

Americas↗
PubMed2003

Titers of antibody to common pathogens: relation to food-based interventions in rural Kenyan schoolchildren.

BACKGROUND: Undernutrition is widely perceived to affect the development of an effective immune system. OBJECTIVE: We used a mini-analysis system to quantitate antibody titers and evaluate the sera of 200 Kenyan schoolchildren for antibodies to Helicobacter pylori [isotypes of immunoglobulins A (IgA), G (IgG), and M (IgM)], hepatitis A virus, rotavirus, tetanus toxoid (IgG), and a panel of recombinant malarial antigens (MSP1(19), MSP2, Ag512, MSP4, and MSP5). DESIGN: Children participated in a school-based feeding intervention with meat, milk, or nonanimal-source foods or in a nonintervention control group. Microvolumes (200 mL) of sera were analyzed at baseline and after 1 y. RESULTS: Nearly all children had elevated titers of antibody to H. pylori, hepatitis A virus, rotavirus, and malaria at the outset, despite a high prevalence of apparent biochemical micronutrient deficiencies and stunting, but many had titers of tetanus toxoid IgG antibodies below the protective concentration. Children with low hemoglobin had a greater proportion of elevated H. pylori IgM antibody titers at baseline, which suggests that current infection with H. pylori may be associated with anemia. Compared with the control subjects, only the group eating meat had a significant increase in H. pylori IgM antibodies during the intervention (P = 0.019). No other group comparisons with the control subjects were statistically significant. The additional finding that the sera of some children showed inadequate tetanus-protective antibodies, despite immunization, suggests that the vaccination program was suboptimal. CONCLUSIONS: A large battery of immune assays can be performed on microvolumes of sera. Furthermore, despite evidence of malnutrition, children do develop significant antibody-mediated responses to common pathogens.

Adolescent↗
PubMed2003

High prevalence of cobalamin deficiency in Guatemalan schoolchildren: associations with low plasma holotranscobalamin II and elevated serum methylmalonic acid and plasma homocysteine concentrations.

BACKGROUND: Studies conducted in Guatemala, Mexico, and Venezuela have found high prevalences of low plasma cobalamin (vitamin B-12) concentrations in infants and children. It is not known whether these low cobalamin concentrations are accompanied by altered metabolic functions. OBJECTIVE: We sought to assess the prevalence of cobalamin deficiency in Guatemalan children by using sensitive and specific markers of deficiency. DESIGN: Children (n = 553) were screened for low plasma cobalamin. Those with low plasma cobalamin (< 162 pmol/L) were matched by age, grade, and sex to those with marginal (162-221 pmol/L) and adequate (> 221 pmol/L) concentrations. In this matched subset (n = 180), additional biochemical indicators of cobalamin deficiency were measured. RESULTS: Of the 553 children screened, 11% had low plasma cobalamin and an additional 22% had marginal concentrations. The prevalences of elevated serum methylmalonic acid (MMA), plasma homocysteine, or both were significantly higher in children with low and marginal plasma cobalamin than in children with adequate plasma cobalamin. Mean serum MMA was high in all groups compared with values reported in other populations. Mean plasma holotranscobalamin II concentrations were significantly lower in children with low rather than marginal or adequate plasma cobalamin. However, holotranscobalamin II was a less sensitive indicator of cobalamin depletion than was MMA. CONCLUSION: Biochemical markers of cobalamin deficiency confirmed that the cobalamin status of children with low and marginal plasma cobalamin is inadequate to support normal metabolic function.

Analysis of Variance↗
PubMed2003

Ascorbic acid from lime juice does not improve the iron status of iron-deficient women in rural Mexico.

BACKGROUND: Although ascorbic acid (AA) increases dietary iron bioavailability, there has been no food-based community trial of its efficacy in improving iron status. OBJECTIVE: The objective was to assess the efficacy of 25 mg AA as agua de limón (limeade), consumed with each of 2 daily meals, in improving the iron status of iron-deficient women. DESIGN: Two rural Mexican populations were randomly assigned to an AA or a placebo group, each with 18 iron-deficient women. The AA group was given 500 mL limeade containing 25 mg AA twice a day, 6 d/wk, for 8 mo. The placebo group was given a lime-flavored beverage free of AA or citric acid. Beverages were consumed within 30 min of 2 main daily meals. Data were collected on morbidity (3 times/wk), dietary intake (on 6 d), socioeconomic status, parasites (twice), medical history, and response to treatment. Blood samples at 0, 2, 4, 6, and 8 mo were analyzed for hemoglobin, plasma AA, plasma ferritin, transferrin receptors, and C-reactive protein. RESULTS: AA intake was significantly (P < 0.0001) higher in the AA group, but nonheme iron, heme iron, and phytic acid intakes did not differ significantly. Plasma AA was significantly (P < 0.01) higher in the AA group at 2, 4, 6, and 8 mo. There were no final differences between groups in hemoglobin, plasma ferritin, or transferrin receptor concentrations or in the ratio of transferrin receptors to plasma ferritin after control for initial concentrations. CONCLUSION: Increasing dietary AA by 25 mg at each of 2 meals/d did not improve iron status in iron-deficient women consuming diets high in phytate and nonheme iron.

Adult↗
PubMed2003

The efficacy of a local ascorbic acid-rich food in improving iron absorption from Mexican diets: a field study using stable isotopes.

BACKGROUND: One potentially sustainable approach to improving iron status at the community level is to encourage the consumption of local ascorbic acid-rich foods, in conjunction with meals high in nonheme iron. OBJECTIVE: The study, conducted in rural Mexico, measured stable isotopes of iron to evaluate the effect on iron absorption of the addition of 25 mg ascorbic acid as agua de limón (limeade) to 2 typical meals per day for 2 wk. DESIGN: Fifteen nonpregnant, nonlactating, iron-deficient (ferritin < 12 microg/L) women (x +/- SD age: 28.3 +/- 7.7 y) fasted overnight and were brought to a community clinic. After an initial blood sample, subjects consumed 0.25 mg (57)Fe with both breakfast and lunch for 14 d. On day 29, another blood sample was taken, and a reference dose of 2.7 mg (58)Fe with 25 mg ascorbic acid was given. For the following 15 d, participants consumed 0.25 mg (57)Fe added to both breakfast and lunch with 25 mg ascorbic acid added to each meal as limeade. A final blood sample was taken on day 59. RESULTS: Iron absorption was calculated from recovery of isotopes in blood obtained 14 d after administration of each isotope. When 25 mg ascorbic acid as limeade was added to test meals twice a day for 2 wk, iron absorption increased significantly (P < 0.001) in every subject: the mean absorption rose from 6.6 +/- 3.0% to 22.9 +/- 12.6%. CONCLUSIONS: The consumption of 25 mg ascorbic acid as limeade twice daily with meals substantially improved iron absorption and may improve the iron status of nonpregnant, nonlactating, iron-deficient women.

Adult↗
PubMed2003

Homocysteine and cognitive function in the Sacramento Area Latino Study on Aging.

BACKGROUND: Elevated plasma homocysteine (hyperhomocysteinemia), an independent risk factor for vascular disease, has been reported to be inversely correlated with objective measures of cognitive function in patients with Alzheimer disease and in community-dwelling older adults. OBJECTIVE: We evaluated the cross-sectional relation between total plasma homocysteine concentration and cognitive function in elderly Latinos (aged > or = 60 y; n = 1789) participating in the Sacramento Area Latino Study on Aging. DESIGN: Global cognitive function was assessed by using the Modified Mini-Mental State Examination, and specific cognitive functions were assessed by using 6 instruments developed for cross-cultural and multilingual neuropsychological evaluation of older persons. Associations between the cognitive function scores and total plasma homocysteine concentrations were then measured by multiple regression analysis with control for potential confounding by nutrient status (red blood cell folate, plasma vitamin B-12), kidney function (serum creatinine), demographic variables (age, sex, education, acculturation), and depressive symptoms. RESULTS: Modest inverse associations were found between homocysteine concentrations and several indexes of cognitive function, including the global Modified Mini-Mental State Examination assessment and the picture-association, verbal attention-span, and pattern-recognition tests (P < or = 0.05). Demographic variables, particularly age and education, were more strongly associated with cognitive function scores than was homocysteine. CONCLUSIONS: Homocysteine is a modest independent predictor of cognitive function in community-dwelling elderly Latinos. Reducing plasma homocysteine concentrations by administering B-vitamin supplements may provide some protection against cognitive decline in this and other elderly populations, but the effect may be limited.

Age Factors↗
PubMed2003

Interventions for micronutrient deficiency control in developing countries: past, present and future.

There has been an evolution in our understanding of the causes of undernutrition and of the nutrition intervention programs that should be prioritized. This article discusses why nutrition programs have shifted their primary emphasis from control of protein deficiency, to energy deficiency, and now to micronutrient deficiencies. It has become recognized by the nutrition community that micronutrient malnutrition is very widespread, and is probably the main nutritional problem in the world. The most commonly used strategies for micronutrient deficiency control are supplementation and fortification, because they are cost-effective and to some extent, relatively easy to deliver. They have important limitations, however. Relatively little emphasis has been placed on food-based approaches to control micronutrient malnutrition. Evidence from several past studies, including the Nutrition Collaborative Research Support Program (N-CRSP), indicated a strong positive association between animal source food (ASF) intake, micronutrient status, and many human functions. This association motivated the intervention studies supported by the Global Livestock CRSP and described in this supplement, which found benefits of increasing ASF intake. In contrast to the common assumption that increasing consumption of ASF in poor communities is infeasible, and will only cause environmental problems, the articles in this supplement show the potential economic benefits of animal ownership in poor communities, and provide examples of innovative programs that have increased local production and consumption. Much more communication is needed among the nutrition, agriculture and development communities to achieve improved dietary quality for poor populations.

Animals↗
PubMed2003

Nutritional importance of animal source foods.

Animal source foods can provide a variety of micronutrients that are difficult to obtain in adequate quantities from plant source foods alone. In the 1980s, the Nutrition Collaborative Research Support Program identified six micronutrients that were particularly low in the primarily vegetarian diets of schoolchildren in rural Egypt, Kenya and Mexico: vitamin A, vitamin B-12, riboflavin, calcium, iron and zinc. Negative health outcomes associated with inadequate intake of these nutrients include anemia, poor growth, rickets, impaired cognitive performance, blindness, neuromuscular deficits and eventually, death. Animal source foods are particularly rich sources of all six of these nutrients, and relatively small amounts of these foods, added to a vegetarian diet, can substantially increase nutrient adequacy. Snacks designed for Kenyan schoolchildren provided more nutrients when animal and plant foods were combined. A snack that provided only 20% of a child's energy requirement could provide 38% of the calcium, 83% of the vitamin B-12 and 82% of the riboflavin requirements if milk was included. A similar snack that included ground beef rather than milk provided 86% of the zinc and 106% of the vitamin B-12 requirements, as well as 26% of the iron requirement. Food guides usually recommend several daily servings from animal source food groups (dairy products and meat or meat alternatives). An index that estimates nutrient adequacy based on adherence to such food guide recommendations may provide a useful method of quickly evaluating dietary quality in both developing and developed countries.

Animals↗
PubMed2003

Animal source foods improve dietary quality, micronutrient status, growth and cognitive function in Kenyan school children: background, study design and baseline findings.

A previous longitudinal three-country study in Egypt, Kenya and Mexico found significant positive associations between intake of animal source foods (ASF) and growth, cognitive development and physical activity. To test for a causal relationship, a controlled school feeding intervention study was designed to test the hypotheses that ASF would improve micronutrient status, growth and cognitive function in Kenyan primary school children. Twelve rural Kenyan schools with 554 children were randomized to four feeding interventions using a local vegetable stew as the vehicle. The groups were designated as Meat, Milk, Energy and Control, who received no feedings. Feeding was carried out on school days for seven terms during 21 mo. Preintervention baseline measures included nutritional status, home food intake, anthropometry, biochemical measures of micronutrient status, malaria, intestinal parasites, health status and cognitive and behavioral measures. The measurements of each child were repeated at intervals over 2 y. Baseline data revealed stunting and underweight in approximately 30% of children and widespread inadequate intakes and/or biochemical evidence of micronutrient deficiencies, particularly of iron, zinc, vitamins A and B-12, riboflavin and calcium. Little or no ASF were eaten and fat intake was low. Malaria was present in 31% of children, and hookworm, amebiasis and giardia were widely prevalent. The outcomes measured were rates of change or increase during the intervention in cognitive function, growth, physical activity and behavior and micronutrient status. Hierarchical linear random effects modeling was used for analysis of outcomes.

Animals↗