Fortification of staple foods with vitamin A for vitamin A deficiency

BACKGROUND

Vitamin A deficiency is a significant public health problem in many low- and middle-income countries, especially affecting young children, women of reproductive age, and pregnant women. Fortification of staple foods with vitamin A has been used to increase vitamin A consumption among these groups.

OBJECTIVES

To assess the effects of fortifying staple foods with vitamin A for reducing vitamin A deficiency and improving health-related outcomes in the general population older than two years of age.

SEARCH METHODS

We searched the following international databases with no language or date restrictions: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 6) in the Cochrane Library; MEDLINE and MEDLINE In Process OVID; Embase OVID; CINAHL Ebsco; Web of Science (ISI) SCI, SSCI, CPCI-exp and CPCI-SSH; BIOSIS (ISI); POPLINE; Bibliomap; TRoPHI; ASSIA (Proquest); IBECS; SCIELO; Global Index Medicus - AFRO and EMRO; LILACS; PAHO; WHOLIS; WPRO; IMSEAR; IndMED; and Native Health Research Database. We also searched clinicaltrials.gov and the International Clinical Trials Registry Platform to identify ongoing and unpublished studies. The date of the last search was 19 July 2018.

SELECTION CRITERIA

We included individually or cluster-randomised controlled trials (RCTs) in this review. The intervention included fortification of staple foods (sugar, edible oils, edible fats, maize flour or corn meal, wheat flour, milk and dairy products, and condiments and seasonings) with vitamin A alone or in combination with other vitamins and minerals. We included the general population older than two years of age (including pregnant and lactating women) from any country.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and assessed eligibility of studies for inclusion, extracted data from included studies and assessed their risk of bias. We used standard Cochrane methodology to carry out the review.

MAIN RESULTS

We included 10 randomised controlled trials involving 4455 participants. All the studies were conducted in low- and upper-middle income countries where vitamin A deficiency was a public health issue. One of the included trials did not contribute data to the outcomes of interest.Three trials compared provision of staple foods fortified with vitamin A versus unfortified staple food, five trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus unfortified staple foods, and two trials compared provision of staple foods fortified with vitamin A plus other micronutrients versus no intervention. No studies compared staple foods fortified with vitamin A alone versus no intervention.The duration of interventions ranged from three to nine months. We assessed six studies at high risk of bias overall. Government organisations, non-governmental organisations, the private sector, and academic institutions funded the included studies; funding source does not appear to have distorted the results.Staple food fortified with vitamin A versus unfortified staple food We are uncertain whether fortifying staple foods with vitamin A alone makes little or no difference for serum retinol concentration (mean difference (MD) 0.03 μmol/L, 95% CI -0.06 to 0.12; 3 studies, 1829 participants; I² = 90%, very low-certainty evidence). It is uncertain whether vitamin A alone reduces the risk of subclinical vitamin A deficiency (risk ratio (RR) 0.45, 95% CI 0.19 to 1.05; 2 studies; 993 participants; I² = 33%, very low-certainty evidence). The certainty of the evidence was mainly affected by risk of bias, imprecision and inconsistency.It is uncertain whether vitamin A fortification reduces clinical vitamin A deficiency, defined as night blindness (RR 0.11, 95% CI 0.01 to 1.98; 1 study, 581 participants, very low-certainty evidence). The certainty of the evidence was mainly affected by imprecision, inconsistency, and risk of bias.Staple foods fortified with vitamin A versus no intervention No studies provided data for this comparison.Staple foods fortified with vitamin A plus other micronutrients versus same unfortified staple foods Fortifying staple foods with vitamin A plus other micronutrients may not increase the serum retinol concentration (MD 0.08 μmol/L, 95% CI -0.06 to 0.22; 4 studies; 1009 participants; I² = 95%, low-certainty evidence). The certainty of the evidence was mainly affected by serious inconsistency and risk of bias.In comparison to unfortified staple foods, fortification with vitamin A plus other micronutrients probably reduces the risk of subclinical vitamin A deficiency (RR 0.27, 95% CI 0.16 to 0.49; 3 studies; 923 participants; I² = 0%; moderate-certainty evidence). The certainty of the evidence was mainly affected by serious risk of bias.Staple foods fortified with vitamin A plus other micronutrients versus no interventionFortification of staple foods with vitamin A plus other micronutrients may increase serum retinol concentration (MD 0.22 μmol/L, 95% CI 0.15 to 0.30; 2 studies; 318 participants; I² = 0%; low-certainty evidence). When compared to no intervention, it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency (RR 0.71, 95% CI 0.52 to 0.98; 2 studies; 318 participants; I² = 0%; very low-certainty evidence) . The certainty of the evidence was affected mainly by serious imprecision and risk of bias.No trials reported on the outcomes of all-cause morbidity, all-cause mortality, adverse effects, food intake, congenital anomalies (for pregnant women), or breast milk concentration (for lactating women).

AUTHORS' CONCLUSIONS

Fortifying staple foods with vitamin A alone may make little or no difference to serum retinol concentrations or the risk of subclinical vitamin A deficiency. In comparison with provision of unfortified foods, provision of staple foods fortified with vitamin A plus other micronutrients may not increase serum retinol concentration but probably reduces the risk of subclinical vitamin A deficiency.Compared to no intervention, staple foods fortified with vitamin A plus other micronutrients may increase serum retinol concentration, although it is uncertain whether the intervention reduces the risk of subclinical vitamin A deficiency as the certainty of the evidence has been assessed as very low.It was not possible to estimate the effect of staple food fortification on outcomes such as mortality, morbidity, adverse effects, congenital anomalies, or breast milk vitamin A, as no trials included these outcomes.The type of funding source for the studies did not appear to distort the results from the analysis.

Common garden experiment reveals altered nutritional values and DNA methylation profiles in micropropagated three elite Ghanaian sweet potato genotypes

Micronutrient deficiency is the cause of multiple diseases in developing countries. Staple crop biofortification is an efficient means to combat such deficiencies in the diets of local consumers. Biofortified lines of sweet potato (Ipomoea batata L. Lam) with enhanced beta-carotene content have been developed in Ghana to alleviate Vitamin A Deficiency. These genotypes are propagated using meristem micropropagation to ensure the generation of virus-free propagules. In vitro culture exposes micropropagated plants to conditions that can lead to the accumulation of somaclonal variation with the potential to generate unwanted aberrant phenotypes. However, the effect of micropropagation induced somaclonal variation on the production of key nutrients by field-grown plants has not been previously studied. Here we assessed the extent of in vitro culture induced somaclonal variation, at a phenotypic, compositional and genetic/epigenetic level, by comparing field-maintained and micropropagated lines of three elite Ghanaian sweet potato genotypes grown in a common garden. Although micropropagated plants presented no observable morphological abnormalities compared to field maintained lines, they presented significantly lower levels of iron, total protein, zinc, and glucose. Methylation Sensitive Amplification Polymorphism analysis showed a high level of in vitro culture induced molecular variation in micropropagated plants. Epigenetic, rather than genetic variation, accounts for most of the observed molecular variability. Taken collectively, our results highlight the importance of ensuring the clonal fidelity of the micropropagated biofortified lines in order to reduce potential losses in the nutritional value prior to their commercial release.

Household coverage of vitamin A fortification of edible oil in Bangladesh

Mandatory fortification of edible oil (soybean and palm) with vitamin A was decreed in Bangladesh in 2013. Yet, there is a dearth of data on the availability and consumption of vitamin A fortifiable oil at household level across population sub-groups. To fill this gap, our study used a nationally representative survey in Bangladesh to assess the purchase of fortifiable edible oil among households and project potential vitamin A intake across population sub-groups. Data is presented by strata, age range and poverty-the factors that potentially influence oil coverage. Across 1,512 households, purchase of commercially produced fortifiable edible oil was high (87.5%). Urban households were more likely to purchase fortifiable oil (94.0%) than households in rural low performing (79.7%) and rural other strata (88.1%) (p value: 0.01). Households in poverty were less likely to purchase fortifiable oil (82.1%) than households not in poverty (91.4%) (p <0.001). Projected estimates suggested that vitamin A fortified edible oil would at least partially meet daily vitamin A estimated average requirement (EAR) for the majority of the population. However, certain population sub-groups may still have vitamin A intake below the EAR and alternative strategies may be applied to address the vitamin A needs of these vulnerable sub-groups. This study concludes that a high percentage of Bangladeshi population across different sub-groups have access to fortifiable edible oil and further provides evidence to support mandatory edible oil fortification with vitamin A in Bangladesh.

Vitamin A and Pregnancy: A Narrative Review

Vitamin A is a crucial micronutrient for pregnant women and their fetuses. In addition to being essential for morphological and functional development and for ocular integrity, vitamin A exerts systemic effects on several fetal organs and on the fetal skeleton. Vitamin A requirements during pregnancy are therefore greater. Vitamin A deficiency (VAD) remains the leading cause of preventable blindness in the world. VAD in pregnant women is a public health issue in most developing countries. In contrast, in some developed countries, excessive vitamin A intake during pregnancy can be a concern since, when in excess, this micronutrient may exert teratogenic effects in the first 60 days following conception. Routine prenatal vitamin A supplementation for the prevention of maternal and infant morbidity and mortality is not recommended; however, in regions where VAD is a public health issue, vitamin A supplementation is recommended to prevent night blindness. Given the importance of this topic and the lack of a complete, up-to-date review on vitamin A and pregnancy, an extensive review of the literature was conducted to identify conflicting or incomplete data on the topic as well as any gaps in existing data.

Sensory and cultural acceptability tradeoffs with nutritional content of biofortified orange-fleshed sweetpotato varieties among households with children in Malawi

BACKGROUND

Biofortified orange-fleshed sweetpotato (OFSP) varieties are being promoted to reduce vitamin A deficiencies due to their higher beta-carotene content. For OFSP varieties to have impact they need to be accepted and consumed at scale amongst populations suffering from vitamin A deficiencies.

OBJECTIVE

We investigated the sensory and cultural acceptability of OFSP varieties amongst households with children aged between 2-5 years old in two areas in Central and Southern Malawi using an integrated model of the Theory of Planned Behavior (TPB) and the Health Belief Model (HBM).

METHODS

Sensory acceptability was measured using a triangle, preference and acceptance test using three OFSP varieties and one control variety, among 270 adults and 60 children. Based on a food ethnographic study, a questionnaire on cultural acceptability was developed and administered to 302 caretakers. Data were analyzed by calculating Spearman's correlations between constructs and multiple linear regression modeling.

RESULTS

The sensory evaluation indicates that all three OFSP varieties are accepted (scores >3 on 5-point scale), but there is a preference for the control variety over the three OFSP varieties. Almost all caretakers are intending to frequently prepare OFSP for their child in future (97%). Based on regression analysis, the constructs 'subjective norms' (β = 0.25, p = 0.00) reflecting social pressure, and 'attitudes toward behavior' (β = 0.14 p = 0.01), reflecting the feelings towards serving their child OFSP, were the best predictors for caretakers' behavior to prepare OFSP for their child.

CONCLUSIONS

Our study shows that both sensory and cultural attributes can influence acceptability of varieties and consumption amongst households with children. Considering these attributes can improve the impact of biofortified crops in future programming, by reducing Vitamin A deficiencies through the intake of these nutrient-rich crops.

β-Cryptoxanthin and zeaxanthin are highly bioavailable from whole-grain and refined biofortified orange maize in humans with optimal vitamin A status: a randomized, crossover, placebo-controlled trial

Background

Biofortification of staple crops with β-carotene is a strategy to reduce vitamin A deficiency, and several varieties are available in some African countries. β-Cryptoxanthin (BCX)-enhanced maize is currently in field trials. To our knowledge, maize BCX bioavailability has not been assessed in humans. Serum retinol 13C content and xanthophyll concentrations are proposed effectiveness biomarkers for biofortified maize adoption.

Objective

We determined the relative difference in BCX and zeaxanthin bioavailability from whole-grain and refined BCX-biofortified maize during chronic feeding compared with white maize and evaluated short-term changes in 13C-abundance in serum retinol.

Design

After a 7-d washout, 9 adults (mean ± SD age: 23.4 ± 2.3 y; 5 men) were provided with muffins made from BCX-enhanced whole-grain orange maize (WGOM), refined orange maize (ROM), or refined white maize (RWM) for 12 d in a randomized, blinded, crossover study followed by a 7-d washout. Blood was drawn on days 0, 3, 6, 9, 12, 15, and 19. Carotenoid areas under the curve (AUCs) were compared by using a fixed-effects model. 13C-Abundance in serum retinol was determined by using gas chromatography/combustion/isotope-ratio mass spectrometry on days 0, 12, and 19. Vitamin A status was determined by 13C-retinol isotope dilution postintervention.

Results

The serum BCX AUC was significantly higher for WGOM (1.70 ± 0.63 μmol ⋅ L-1 ⋅ d) and ROM (1.66 ± 1.08 μmol ⋅ L-1 ⋅ d) than for RWM (-0.06 ± 0.13 μmol ⋅ L-1 ⋅ d; P < 0.003). A greater increase occurred in serum BCX from WGOM muffins (131%) than from ROM muffins (108%) (P ≤ 0.003). Zeaxanthin AUCs were higher for WGOM (0.94 ± 0.33) and ROM (0.96 ± 0.47) than for RWM (0.05 ± 0.12 μmol ⋅ L-1 ⋅ d; P < 0.003). The intervention did not affect predose serum retinol 13C-abundance. Vitamin A status was within an optimal range (defined as 0.1-0.7 μmol/g liver).

Conclusions

BCX and zeaxanthin were highly bioavailable from BCX-biofortified maize. The adoption of BCX maize could positively affect consumers' BCX and zeaxanthin intakes and associated health benefits. This trial is registered at www.clinicaltrials.gov as NCT02800408.

Vitamin A and beta (β)-carotene supplementation for cystic fibrosis

BACKGROUND

People with cystic fibrosis (CF) and pancreatic insufficiency are at risk of a deficiency in fat-soluble vitamins, including vitamin A. Vitamin A deficiency predominantly causes eye and skin problems, while excessive levels of vitamin A can harm the respiratory and skeletal systems in children and interfere with the metabolism of other fat-soluble vitamins. Most CF centres administer vitamin A as supplements to reduce the frequency of vitamin A deficiency in people with CF and to improve clinical outcomes such as growth, although the recommended dose varies between different guidelines. Thus, a systematic review on vitamin A and vitamin A-like supplementation (carotenes or other retinoids) in people with CF would help guide clinical practice. This is an update of an earlier Cochrane Review.

OBJECTIVES

To determine if supplementation with vitamin A, carotenes or other retinoid supplements in children and adults with CF reduces the frequency of vitamin A deficiency disorders, improves general and respiratory health and affects the frequency of vitamin A toxicity.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Cystic Fibrosis Trials Register compiled from electronic database searches and handsearching of journals and conference abstract books. Additionally we searched several ongoing trials registries, including ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform and the International Standard Randomised Controlled Trial Number Registry.Most recent database searches: 01 June 2018.

SELECTION CRITERIA

All randomised or quasi-randomised controlled studies comparing all preparations of oral vitamin A, carotenes or retinoids (or in combination), used as a supplement compared to placebo at any dose, for at least three months, in people with CF (diagnosed by sweat tests or genetic testing) with and without pancreatic insufficiency.

DATA COLLECTION AND ANALYSIS

Two authors individually assessed study quality and extracted data on outcome measures. The authors assessed the quality of the evidence using the GRADE system. Investigators were contacted to retrieve missing quantitative data.

MAIN RESULTS

No studies of vitamin A or other retinoid supplementation were eligible for inclusion. However, one randomised study of beta (β)-carotene supplementation involving 24 people with CF who were receiving pancreatic enzyme substitution was included. The study compared successive β-carotene supplementation periods (high dose followed by low dose) compared to placebo. The results for the low-dose supplementation period should be interpreted with caution, due to the lack of a wash-out period after the high-dose supplementation.The included study did not report on two of the review's primary outcomes (vitamin A deficiency disorders and mortality); results for our third primary outcome of growth and nutritional status (reported as z score for height) showed no difference between supplementation and placebo, mean difference (MD) -0.23 (95% confidence interval (CI) -0.89 to 0.43) (low-quality evidence). With regards to secondary outcomes, supplementation with high-dose β-carotene for three months led to significantly fewer days of systemic antibiotics required to treat pulmonary exacerbations, compared to controls, MD -15 days (95% CI -27.60 to -2.40); however, this was not maintained in the second three-month section of the study when the level of β-carotene supplementation was reduced, MD -8 days (95% CI -18.80 to 2.80) (low-quality evidence). There were no statistically significant effects between groups in lung function (low-quality evidence) and no adverse events were observed (low-quality evidence). Supplementation affected levels of β-carotene in plasma, but not vitamin A levels. The study did not report on quality of life or toxicity.

AUTHORS' CONCLUSIONS

Since no randomised or quasi-randomised controlled studies on retinoid supplementation were identified, no conclusion on the supplementation of vitamin A in people with CF can be drawn. Additionally, due to methodological limitations in the included study, also reflected in the low-quality evidence judged following the specific evidence grading system (GRADE), no clear conclusions on β-carotene supplementation can be drawn. Until further data are available, country- or region-specific guidelines regarding these practices should be followed.

The Potential of Integrating Provitamin A-Biofortified Maize in Smallholder Farming Systems to Reduce Malnourishment in South Africa

Biofortification interventions have the potential to combat malnutrition. This review explored the use of provitamin A-biofortified maize (PVABM) as a vitamin A deficiency (VAD) reduction agricultural-based strategy. Maize has been identified as one of the key staple crops for biofortification to reduce hidden hunger in Africa. Most nutrition interventions have not been successful in reducing hunger because rural communities, who mainly rely on agriculture, have been indirectly excluded. The biofortification intervention proposed here aims to be an inclusive strategy, based on smallholder farming systems. Vitamin A is a micronutrient essential for growth, immune function, reproduction and vision, and its deficiency results in VAD. VAD is estimated to affect more than 250 million children in developing countries. In Africa, especially sub-Saharan Africa, maize is a staple food for rural communities, consumed by most household members. Due to carotenoids, PVABM presents an orange color. This color has been reported to lead to negative perceptions about PVABM varieties. The perceived agronomic traits of this maize by smallholder farmers have not been explored. Adoption and utilization of PVABM varieties relies on both acceptable consumer attributes and agronomic traits, including nutritional value. It is therefore important to assess farmers' perceptions of and willingness to adopt the varieties, and the potential markets for PVABM maize. It is essential to establish on-farm trials and experiments to evaluate the response of PVABM under different climatic conditions, fertilizer levels and soils, and its overall agronomic potential. For the better integration of PVABM with smallholder farming systems, farmer training and workshops about PVABM should be part of any intervention. A holistic approach would enhance farmers' knowledge about PVABM varieties and that their benefits out-compete other existing maize varieties.

Vitamin A nutrition among East Timor refugee children

BACKGROUND AND OBJECTIVES

Children age 6 to 72 months, living in refugee camps are at increased risk of developing vitamin A deficiency (VAD), resulting in increased morbidity and mortality. Due to poverty, often this population group has limited access to foods containing vitamin A from animal-based food sources and do not commonly consume available foods containing beta-carotene. To date, there is a paucity of data on vitamin A intake in young refugee children. To determine vitamin A intake in children ages 6 to 72 months at refugee camps in East Timor.

METHODS AND STUDY DESIGN

A cross sectional study was carried out among children ages 6 to 72 months at refugee camps near Dili, East Timor. A detailed vitamin A intake questionnaire was ascertained from the primary caretaker, and the criteria and indicator cut off values suggested by World Health Organization (WHO) were used to classify the populations' vitamin A risk.

RESULTS

Although animal sources of vitamin A were limited due to costs, all 89 children commonly consumed fruit containing vitamin A sources more than 3 times a week. Most children (69.7%) had been breast fed regularly, while 30.3% combined with bottle milk. 80.9% of children received vitamin A supplementation.

CONCLUSION

Children in East Timor refugee camps have adequate vitamin A intake.

Promotion of Orange-Fleshed Sweet Potato Increased Vitamin A Intakes and Reduced the Odds of Low Retinol-Binding Protein among Postpartum Kenyan Women

Background: Orange-fleshed sweet potato (OFSP) improves vitamin A (VA) status of young children; research with pregnant and lactating women is limited.Objective: We examined the effectiveness of the Mama SASHA (Sweetpotato Action for Security and Health in Africa) program to improve nutrition knowledge, diets, and nutritional status of pregnant and lactating women (PLW) in Western Kenya.Methods: Eight health facilities were allocated to the Mama SASHA intervention or comparison arms. PLW in intervention facilities received enhanced nutrition counseling at health clinics, were linked with community-based maternal support groups, and received vouchers for OFSP vine cuttings. Control PLW received clinic-based nutrition counseling only. A total of 505 women in early and midpregnancy, attending their first antenatal care visit, and with no previous engagement in project activities were enrolled from the 8 facilities. Nutrition and health-seeking knowledge, food security, dietary patterns, and anthropometric measurements were collected at 4 time points at ≤9 mo postpartum. VA intakes were assessed with multipass 24-h recalls in a subsample of 206 mothers at 8-10 mo postpartum. VA status was assessed by using serum retinol-binding protein (RBP). Impacts were estimated with multilevel mixed models adjusted for clustering and differences at enrollment.Results: At enrollment, 22.9% of women had RBP <1.17 μmol/L. By 9 mo postpartum, intervention women had significantly higher intakes of VA [adjusted difference = 297.0 retinol activity equivalent (RAE) units; 95% CI: 82, 513 RAE units; P = 0.01; n = 206], greater consumption of VA-rich fruit and vegetables in the previous 7 d (difference-in-difference estimate: 0.40 d; 95% CI: 0.23, 0.56 d; P < 0.01), and a 45% reduction in the odds of RBP <1.17 μmol/L (OR: 0.55; 95% CI: 0.33, 0.92; P = 0.01).Conclusion: Promotion of OFSP to PLW through health services is a feasible strategy to improve women's nutrition knowledge, VA intakes, and maternal RBP.

We Need Studies of the Mortality Effect of Vitamin A Supplementation, Not Surveys of Vitamin A Deficiency

It is usually acknowledged that high-dose vitamin A supplementation (VAS) provides no sustained improvement in vitamin A status, and that the effect of VAS on mortality is more likely linked to its immunomodulating effects. Nonetheless, it is widely assumed that we can deduce something about the need for continuing or stopping VAS programs based on studies of the biochemical prevalence of vitamin A deficiency (VAD). This is no longer a tenable assumption. The justification for using VAS is to reduce child mortality, but there is now doubt that VAS has any effect on overall child mortality. What we need now are not surveys of VAD, but proper randomized trials to evaluate whether VAS has beneficial effects on overall child survival.

Genetic Variations Associated with Vitamin A Status and Vitamin A Bioavailability

Blood concentration of vitamin A (VA), which is present as different molecules, i.e., mainly retinol and provitamin A carotenoids, plus retinyl esters in the postprandial period after a VA-containing meal, is affected by numerous factors: dietary VA intake, VA absorption efficiency, efficiency of provitamin A carotenoid conversion to VA, VA tissue uptake, etc. Most of these factors are in turn modulated by genetic variations in genes encoding proteins involved in VA metabolism. Genome-wide association studies (GWAS) and candidate gene association studies have identified single nucleotide polymorphisms (SNPs) associated with blood concentrations of retinol and β-carotene, as well as with β-carotene bioavailability. These genetic variations likely explain, at least in part, interindividual variability in VA status and in VA bioavailability. However, much work remains to be done to identify all of the SNPs involved in VA status and bioavailability and to assess the possible involvement of other kinds of genetic variations, e.g., copy number variants and insertions/deletions, in these phenotypes. Yet, the potential usefulness of this area of research is exciting regarding the proposition of more personalized dietary recommendations in VA, particularly in populations at risk of VA deficiency.

Dietary deficiency of vitamin A among rural children: A community-based survey using a food-frequency questionnaire

BACKGROUND

Overt vitamin A deficiency has been controlled in most parts of India, but prevalence of subclinical deficiency may still be high, which may enhance susceptibility to infections, reduce growth potential and also lead to higher mortality. We aimed to: (i) assess the consumption pattern of vitamin A-rich foods in children 1-5 years of age in rural Jammu; and (ii) estimate the dietary deficiency of vitamin A leading to risk of subclinical vitamin A deficiency in cluster- villages of the study area.

METHODS

In 2011, we conducted a survey of 750 children by selecting 50 from each of the 1 5 clusters. The Helen Keller International's Food-Frequency Questionnaire (HKI-FFQ) modified to the local context was used to assess past week's intake for 28 food-items, including vitamin A-rich foods.

RESULTS

The study revealed that plant sources such as amaranth, carrots, etc. and animal sources such as eggs and butter were the major sources of vitamin A in the study population. Consumption of amaranth (2.7 days/week) and carrots (1.7 days/week) was moderate but that of animal foods rich in vitamin A was low to negligible (1.1 day/week for eggs and 0.2 day/week for liver and fish combined). The majority (80%) of the cluster-villages manifested inadequate intake of vitamin A-rich foods, thereby making subclinical vitamin A deficiency a public health problem for the whole area. Faulty diets, improper breastfeeding practices, low coverage of vitamin A supplementation and high prevalence of undernutrition could be related to the observed subclinical deficiency.

CONCLUSION

Dietary diversification by including both plant and animal sources of vitamin A in adequate amounts along with improved breastfeeding, better implementation of mega-dose vitamin A supplementation and minimizing undernutrition may help in lowering subclinical vitamin A deficiency. The HKI-FFQ may be used as a proxy indicator of vitamin A intake/status for identifying pockets at risk of subclinical vitamin A deficiency in resource-constrained settings.

Neonatal vitamin A supplementation for the prevention of mortality and morbidity in term neonates in low and middle income countries

BACKGROUND

Vitamin A deficiency is a major public health problem in low and middle income countries. Vitamin A supplementation in children six months of age and older has been found to be beneficial, but no effect of supplementation has been noted for children between one and five months of age. Supplementation during the neonatal period has been suggested to have an impact by increasing body stores in early infancy.

OBJECTIVES

To evaluate the role of vitamin A supplementation for term neonates in low and middle income countries with respect to prevention of mortality and morbidity.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE via PubMed (1966 to 13 March 2016), Embase (1980 to 13 March 2016) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 13 March 2016). We also searched clinical trials databases, conference proceedings and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials. Also trials with a factorial design.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted study data. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence.

MAIN RESULTS

We included 12 trials (168,460 neonates) in this review, with only a few trials reporting disaggregated data for term infants. Therefore, we analysed data and presented estimates for term infants (when specified) and for all infants.Data for term neonates from three studies did not show a statistically significant effect on the risk of infant mortality at six months in the vitamin A group compared with the control group (typical risk ratio (RR) 0.80; 95% confidence interval (CI) 0.54 to 1.18; I2 = 63%). Analysis of data for all infants from 11 studies revealed no evidence of a significant reduction in the risk of infant mortality at six months among neonates supplemented with vitamin A compared with control neonates (typical RR 0.98, 95% CI 0.89 to 1.07; I2 = 47%). We observed similar results for infant mortality at 12 months of age with no significant effect of vitamin A compared with control (typical RR 1.04, 95% CI 0.94 to 1.15; I2 = 47%). Limited data were available for the outcomes of cause-specific mortality and morbidity, vitamin A deficiency, anaemia and adverse events.

AUTHORS' CONCLUSIONS

Given the high burden of death among children younger than five years of age in low and middle income countries, and the fact that mortality in infancy is a major contributory cause, it is critical to obtain sound scientific evidence of the effect of vitamin A supplementation during the neonatal period on infant mortality and morbidity. Evidence provided in this review does not indicate a potential beneficial effect of vitamin A supplementation among neonates at birth in reducing mortality during the first six months or 12 months of life. Given this finding and the absence of a clear indication of the biological mechanism through which vitamin A could affect mortality, along with substantial conflicting findings from individual studies conducted in settings with potentially varying levels of maternal vitamin A deficiency and infant mortality, absence of follow-up studies assessing any long-term impact of a bulging fontanelle after supplementation and the finding of a potentially harmful effect among female infants, additional research is warranted before a decision can be reached regarding policy recommendations for this intervention.

Ensuring the Supply of and Creating Demand for a Biofortified Crop with a Visible Trait: Lessons Learned from the Introduction of Orange-Fleshed Sweet Potato in Drought-Prone Areas of Mozambique

Background

Orange-fleshed sweet potato (OFSP) is a promising biofortified crop for sub-Saharan Africa because it has high levels of provitamin A carotenoids, the formed vitamin A is bioavailable, and white-fleshed sweet potato is already widely grown.

Objectives

To examine whether farmers will adopt varieties with a distinct visible trait, young children will eat OFSP in sufficient quantities to improve vitamin A intake, OFSP can serve as an entry point for promoting a more diversified diet, and lessons can be drawn to assure sustained adoption.

Methods

The 2-year quasi-experimental intervention study followed households and children ( n = 741; mean age, 13 months at baseline) through two agricultural cycles in drought prone-areas of Mozambique.

Results

OFSP is acceptable to farmers when introduced by using an integrated approach. In the second year, intervention children ( n = 498) were more likely than control children ( n = 243) to have consumed OFSP (54% vs. 4%), dark-green leaves (60% vs. 46%), or ripe papaya (65% vs. 42%) on 3 or more days in the previous week ( p < .001 for all comparisons). Their vitamin A intakes were nearly eight times higher than those of control children (median, 426 vs. 56 μg RAE [retinol activity equivalents], p < .001). Diet diversification was limited by difficult agroecological conditions and low purchasing power. However, dietary diversity was higher among intervention than control children (32% vs. 9% consuming food from more than four groups; p < .001).

Conclusions

An integrated OFSP-based approach had a positive impact on the vitamin A intake of young children. A market development component and improved vine multiplication systems are recommended to assure sustained adoption.

Safety and Impact of Vitamin A Supplementation Delivered with Oral Polio Vaccine as Part of the Immunization Campaign in Orissa, India

A study was carried out in Orissa, India, to evaluate the impact on vitamin A status of vitamin A supplementation integrated with an immunization campaign. Data were collected from a representative sample of 1,811 children, aged 12 to 48 months, at baseline and then at 4 and 16 weeks following implementation of vitamin A supplementation. The primary outcome indicator was serum retinol. The coverage of vitamin A supplementation was 97%. There was a significant decline in the prevalence of Bitot's spots from 2.9% to 1.9% at 4 weeks, but the prevalence increased to 3.6% by 16 weeks. Serum retinol concentrations increased between baseline and 4 weeks (from 0.62 ± 0.32 to 0.73 ± 0.23 μmol/L, p < .001) but then decreased to 0.50 ± 0.19 μmol/l at 16 weeks, which was significantly lower than at baseline (p < .001). The greatest increase in serum retinol from baseline to 4-week follow-up was among children with lowest baseline serum retinol and children with Bitot's spots at baseline. This study demonstrates the short-term benefits of vitamin A supplementation to be significant, especially for those whose status is most compromised. At the same time, the benefit of vitamin A supplementation in this population was transient. The impact of the vitamin A could not be sustained for the full 16 weeks in the study population. This finding calls for exploration of other means to improve vitamin A status, perhaps by adjusting the vitamin A supplementation schedule with more aggressive measures to improve intake of foods rich in bioavailable vitamin A, such as small amounts of animal foods or fortified foods. The study demonstrates the feasibility of integrating vitamin A supplementation with immunization campaigns.

Biofortified β-carotene rice improves vitamin A intake and reduces the prevalence of inadequacy among women and young children in a simulated analysis in Bangladesh, Indonesia, and the Philippines

BACKGROUND

Vitamin A deficiency continues to be a major public health problem affecting developing countries where people eat mostly rice as a staple food. In Asia, rice provides up to 80% of the total daily energy intake.

OBJECTIVE

We used existing data sets from Bangladesh, Indonesia, and the Philippines, where dietary intakes have been quantified at the individual level to 1) determine the rice and vitamin A intake in nonpregnant, nonlactating women of reproductive age and in nonbreastfed children 1-3 y old and 2) simulate the amount of change that could be achieved in the prevalence of inadequate intake of vitamin A if rice biofortified with β-carotene were consumed instead of the rice consumed at present.

DESIGN

We considered a range of 4-20 parts per million (ppm) of β-carotene content and 10-70% substitution levels for the biofortified rice. Software was used to estimate usual rice and vitamin A intake for the simulation analyses.

RESULTS

In an analysis by country, the substitution of biofortified rice for white rice in the optimistic scenario (20 ppm and 70% substitution) decreased the prevalence of vitamin A inadequacy from baseline 78% in women and 71% in children in Bangladesh. In Indonesia and the Philippines, the prevalence of inadequacy fell by 55-60% in women and dropped by nearly 30% in children from baseline.

CONCLUSIONS

The results of the simulation analysis were striking in that even low substitution levels and modest increases in the β-carotene of rice produced a meaningful decrease in the prevalence of inadequate intake of vitamin A. Increasing the substitution levels had a greater impact than increasing the β-carotene content by >12 ppm.

Effect of routine prenatal supplementation on vitamin concentrations in maternal serum and breast milk

OBJECTIVE

The aim of the present study was to assess the effect of multivitamin supplements and their different vitamin A sources on retinol concentrations in serum and colostrum milk of postpartum women.

METHODS

This was a retrospective cross-sectional study composed of healthy postpartum women attending two Brazilian private maternity wards (N = 100). According to the type of multivitamin taken during pregnancy, the women were assigned to one of four groups: control group (CG; n = 25), formulation 1 (F1; n = 25), formulation 2 (F2; n = 25), and formulation 3 (F3; n = 25). Blood and colostrum samples were collected under fasting conditions and retinol was analyzed by high-performance liquid chromatography. Dietary vitamin A was assessed using a food frequency questionnaire. Retinol concentrations <20 μg/dL (<0.70 μmol/L) in serum and <60 μg/dL (2.10 μmol/L) in colostrum were considered indicative of vitamin A deficiency.

RESULTS

Of women in the control group, 12% (n = 3) presented serum retinol levels below the cut-off value for adequacy; this was not observed in the supplemented groups. Evaluating the retinol content in breast milk, supplemented groups F1 and F3 presented 4% (n = 1) of inadequacy cases, whereas F2 presented 40% (n = 10). The concentrations found in the F2 and F3 groups were statistically different (P < 0.05).

CONCLUSIONS

The use of multivitamin supplements containing vitamin A during pregnancy prevents vitamin A deficiency regardless of the source administered. In breast milk, supplementation with β-carotene provided a lower concentration of vitamin A compared with retinol.

Provitamin A retention and sensory acceptability of amahewu, a non-alcoholic cereal-based beverage made with provitamin A-biofortified maize

BACKGROUND

Vitamin A deficiency is a major public health problem in sub-Saharan Africa. Amahewu is a popular southern African lactic acid fermented non-alcoholic maize-based beverage, which is deficient in vitamin A. In this study, provitamin A retention and sensory acceptability of amahewu processed using provitamin A-biofortified maize and three types of inoculums during fermentation (malted maize, wheat bran and Lactobacillus starter culture) were investigated.

RESULTS

The total provitamin A content of amahewu samples, estimated as β-carotene, β-cryptoxanthin and α-carotene content, ranged from 3.3 to 3.8 g kg(-1) (dry weight). Provitamin A was substantially retained (79- 90% β-carotene equivalent) in amahewu after fermentation. Amahewu samples prepared with added starter cultures had the lowest retention of provitamin A. Consumers (approx. 69%) liked provitamin A-biofortified amahewu either moderately or very much. Principal component analysis of amahewu sensory data showed that 71% of variation was due to maize types and 18% of variation could be due to the inoculum used during fermentation. Amahewu samples prepared using provitamin A-biofortified maize were slightly more liked (mean score: 7.0 ± 1.2) compared to those of white maize reference samples. The use of starter culture combined with either malted maize or wheat bran as inoculum during fermentation improved the taste and aroma of amahewu and hence its acceptability.

CONCLUSION

Provitamin A is substantially retained in amahewu after fermentation. The slightly high acceptability of amahewu prepared using provitamin A-biofortified maize compared to that of white maize thus suggests that fermented product like amahewu can potentially be used to deliver provitamin A to vulnerable individuals.

Interpretation of Serum Retinol Data From Latin America and the Caribbean

BACKGROUND

In recent decades, the general socioeconomic situation in Latin America and the Caribbean countries has improved, and many vitamin A programs have been implemented in an attempt to reduce vitamin A deficiency in the region.

OBJECTIVE

To examine vitamin A status in Latin America and the Caribbean based on serum retinol concentrations and to contrast available data published before and after 1998.

METHODS

A systematic review was performed. National surveys or representative studies that reported vitamin A status were selected.

RESULTS

Ten national surveys and six representative studies were identified. Data for children under 6 years of age indicate that Guatemala and Nicaragua have practically eradicated vitamin A deficiency (less than 2% prevalence of serum retinol < 20 μg/dL). In Costa Rica, Cuba, El Salvador, and Panama, the prevalence of vitamin A deficiency ranged from 2.8% to 9.4%. In Peru, Honduras, Argentina, Ecuador, and Brazil, vitamin A deficiency is a moderate public health problem (prevalence from 14.0% to 17.4%), while in Colombia, Mexico, and Haiti it is a severe public health problem (prevalence from 24.3% to 32.0%). Disadvantaged groups (indigenous people and those of Afro-Colombian descent) have the highest rates of deficiency. The prevalence of vitamin A deficiency is under 20% in school-children and adult women. When data published before and after 1998 for children under 6 years of age were compared, most Central American countries had a reduction in the prevalence of vitamin A deficiency (p < .05), whereas in South American countries, the prevalence of vitamin A deficiency increased over time (p < .05).

CONCLUSIONS

The prevalence of vitamin A deficiency in children under 6 years of age has decreased in many Central American countries, but vitamin A deficiency still remains a public health problem in numerous Latin America and Caribbean countries, especially among disadvantaged and vulnerable groups. Because of issues with the accuracy of the serum retinol biomarker reflecting body stores, these results must be interpreted with caution.

An enigma: why vitamin A supplementation does not always reduce mortality even though vitamin A deficiency is associated with increased mortality

BACKGROUND

Vitamin A deficiency (VAD) is associated with increased mortality. To prevent VAD, WHO recommends high-dose vitamin A supplementation (VAS) every 4-6 months for children aged between 6 months and 5 years of age in countries at risk of VAD. The policy is based on randomized clinical trials (RCTs) conducted in the late 1980s and early 1990s. Recent RCTs indicate that the policy may have ceased to be beneficial. In addition, RCTs attempting to extend the benefits to younger children have yielded conflicting results. Stratified analyses suggest that whereas some subgroups benefit more than expected from VAS, other subgroups may experience negative effects.

METHODS AND RESULTS

We reviewed the potential modifiers of the effect of VAS. The variable effect of VAS was not explained by underlying differences in VAD. Rather, the effect may depend on the sex of the child, the vaccine status and previous supplementation with vitamin A. Vitamin A is known to affect the Th1/Th2 balance and, in addition, recent evidence suggests that vitamin A may also induce epigenetic changes leading to down-regulation of the innate immune response. Thus VAS protects against VAD but has also important and long-lasting immunological effects, and the effect of providing VAS may vary depending on the state of the immune system.

CONCLUSIONS

To design optimal VAS programmes which target those who benefit and avoid those harmed, more studies are needed. Work is ongoing to define whether neonatal VAS should be considered in subgroups. In the most recent RCT in older children, VAS doubled the mortality for males but halved mortality for females. Hence, we urgently need to re-assess the effect of VAS on older children in large-scale RCTs powered to study effect modification by sex and other potential effect modifiers, and with nested immunological studies.