Vitamin A supplementation and health outcomes for children in Nepal

PURPOSE

To compare vitamin A supplementation status of children age 6-60 months to the prevalence of vitamin A deficiency disease, malnutrition, diarrhea, and acute respiratory infection.

METHODS

The nutritional status of children was estimated using mid-upper-arm circumference measurements. A trained ophthalmology assistant assessed for clinical signs of vitamin A deficiency disease. A trained female community health worker interviewed mothers about child health status using a standardized questionnaire.

RESULTS

Compared to children who did not receive supplements, children who received vitamin A supplements regularly had less malnutrition, diarrhea, and acute respiratory infection, regardless of the number of children per household, age, sex, or father's occupation.

CONCLUSIONS

Supplementation with vitamin A is necessary twice a year. Children who received a vitamin A capsule only one time were not as protected as were those children who received vitamin A as a regular twice yearly scheduled dose.

Drumstick leaves as source of vitamin A in ICDS-SFP

OBJECTIVE

This pilot study is about to assess the feasibility and acceptability of introducing dehydrated drumstick leaves, (DDL) (Moringa oleifera), as a source of vitamin A, into the salty recipes provided by the supplementary food (SF) component of the Integrated Child Development Scheme (ICDS) along with nutrition communication (NC).

METHODS

An integrated approach was adapted in this study which included comprehensive training sessions for the staff of the ICDS and Non-government organization (NGO) involved in the SF preparations. Prior to the acceptability trials, data were elicited on the socio-economic profile and knowledge about vitamin A, from 60 children of 1-5 year of age attending two anganwadi centres of the ICDS.

RESULT

From these, 40 children attending one anganwadi were supplemented with pre-tested DDL incorporated recipes (5-7 g DDI/100 g product) along with NC for one month. Spot observations and organoleptic evaluation results indicated high compliance of the DDL-recipes by the children. The results also indicated that the recipes were highly acceptable to the ICDS authorities as well as the NGO staff.

CONCLUSION

The pilot study indicated that integration of NC along with the introduction of unconventional DDL, into the ICDS-SF, was feasible and can be endeavoured for a longer duration in the existing national programmes.

Vitamin A deficiency presenting as night blindness during pregnancy

We describe a patient with a 6-year history of pancreatic malabsorption following surgical subtotal pancreatectomy. She presented at 33 weeks of pregnancy with night blindness as a result of vitamin A deficiency. She had had two successful pregnancies 9 and 8 years previously, giving birth to a healthy baby boy on each occasion. We suggest that patients with long-term malabsorption due to intestinal or pancreatic disease should have vitamin A status checked prior to and during pregnancy so that prompt supplementation can be commenced if necessary. The possibility that vitamin A deficiency may be contributing to anaemia present in pregnancy should also be considered.

Vitamin A capsule distribution to control vitamin A deficiency in Indonesia: effect of supplementation in pre-school children and compliance with the programme

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a widespread vitamin A supplementation programme and to describe indicators of compliance with the programme in Indonesia.

DESIGN

Prospective cohort study. Children's anthropometric data were gathered at baseline (June 2000) and 4 months later (2 months after supplementation in August 2000). Serum retinol, haemoglobin, ferritin, alpha1-acid glycoprotein and C-reactive protein were measured at baseline and at follow-up. Caregivers of the children were interviewed using a questionnaire.

SETTING

Semi-urban and rural areas of Semarang district, Central Java, Indonesia.

SUBJECTS

Children aged 1-5 years.

RESULTS

After the supplementation, the proportion of children with a low concentration of retinol decreased in recipients from 18.8 to 14.5%. However, in non-recipients, the prevalence of vitamin A deficiency increased from 31.9 to 37.5%, this prevalence being significantly higher than in recipients. A significant decrease occurred in the proportion of recipients with low ferritin (26.5 to 16.2%) and haemoglobin (25.7 to 15.3%), whereas the proportions did not show a significant change after supplementation for non-recipients. Modest linear growth was detected in recipients after supplementation but there was no effect on ponderal growth. The coverage rate of the supplementation in the study areas was 60%. There was an association between compliance of the caregivers and their knowledge about the potential benefit of vitamin A supplementation, the place where sick children were taken and age of the children.

CONCLUSIONS

The vitamin A supplementation programme marginally decreased the proportion of vitamin A deficiency and had a marginal effect on the nutritional status of recipients. More than one micronutrient intervention is needed to increase the effectiveness of the supplementation programme. To increase compliance and coverage in the supplementation programme, nutrition communication and private healthcare practices need to be included in the programme.

Randomized efficacy trial of a micronutrient-fortified beverage in primary school children in Tanzania

BACKGROUND

Dietary supplements providing physiologic amounts of several micronutrients simultaneously have not been thoroughly tested for combating micronutrient deficiencies.

OBJECTIVE

We determined whether a beverage fortified with 10 micronutrients at physiologic doses influenced the iron and vitamin A status and growth of rural children (aged 6-11 y) attending primary schools.

DESIGN

In this randomized, double-blind, placebo-controlled efficacy trial, children were assigned to receive the fortified beverage or an unfortified beverage at school for 6 mo.

RESULTS

There were nonsignificant differences at baseline between children in the fortified and nonfortified groups in iron status, serum retinol, and anthropometry. At the 6-mo follow-up, among children with anemia (hemoglobin < 110 g/L), there was a significantly larger increase in hemoglobin concentration in the fortified group than in the nonfortified group (9.2 and 0.2 g/L, respectively). Of those who were anemic at baseline, 69.4% in the nonfortified group and 55.1% in the fortified group remained anemic at follow-up (RR: 0.79), a cure rate of 21%. The prevalence of children with low serum retinol concentrations (< 200 microg/L) dropped significantly from 21.4% to 11.3% in the fortified group compared with a nonsignificant change (20.6% to 19.7%) in the nonfortified group. At follow-up, mean incremental changes in weight (1.79 compared with 1.24 kg), height (3.2 compared with 2.6 cm), and BMI (0.88 compared with 0.53) were significantly higher in the fortified group than in the nonfortified group.

CONCLUSION

The fortified beverage significantly improved hematologic and anthropometric measurements and significantly lowered the overall prevalence of anemia and vitamin A deficiency.

[Iron and vitamin A deficiencies and prevalence of anemia in boys and girls between 6 to 24 months of age in Chaco, Argentina]

To determine the prevalence of anemia, and iron (ID) and vitamin A deficiencies aiming at their prevention, 414 children between 6 and 24 months of age, were randomly selected from the whole province of Chaco. A sociodemographic survey was implemented, and hemoglobin (Hb), plasma ferritin and retinol were measured. Anemia prevalence (Hb < 110 g/L) was 66.4%, without differences between age groups, and included 18% with Hb < 90 g/L. These cases were significantly less in children 6-8 month of age (5.1%) than in the others (approximately equal to 20%) (P: 0.007). Mean Hb was also higher in 6-8 months old children and was associated with lower prevalence of ID (ferritin < 12 micrograms/L) (p < 0.000) but not with age (p = 0.8865). ID already present, however, in 36.6% of children in this age group, reached a prevalence of 72.9% in children older than 18 months. Anemia prevalence was significantly higher in males, in children whose birth weight was < 3000 g, in those who had never taken iron supplements and among the poor, both structural and by income. Retinol values < 20 micrograms/dl occurred only in 5.1% of children. Iron nutrition prior to, during pregnancy and in children during the first 2 years of life must be improved by joining strategies based on community empowerment aimed at improving dietary iron, assuring effective preventive supplementation and promoting the opportune umbilical cord ligation.

Vitamin A and the nursing mother-infant dyad: evidence for intervention

From the evidence at hand, interventions to reduce vitamin A deficiency in the breastfeeding mother and baby are likely to confer several health benefits. These include reduced puerperal morbidity, night blindness, and mortality in the mother, and reduced morbidity and mortality in the baby beginning around 6 months of age. Additional evidence is still needed to increase our confidence in these inferences, and to clarify the best interventions for achieving these outcomes. Current evidence about the effects of improved vitamin A status on early infant morbidity or mortality is mixed. There is accumulating evidence against the hypothesis that maternal vitamin A supplementation during pregnancy will reduce mother-to-child HIV transmission. There is so far no evidence about whether improved infant vitamin A status can prevent mother-to-child HIV transmission. In sum, the probable benefits of improving the vitamin A status of the breastfeeding mother and her baby are substantial, but to achieve these benefits, more aggressive interventions will be needed.

Integrating strategies for combating vitamin A deficiency: successes in Asia

Indonesia and Bangladesh were among the first countries to distribute vitamin A capsules (VAC) to underfives in the early 1970s. Since then, VAC coverage has increased very much. In Indonesia, VAC are now distributed to underfives in two special months. In Cambodia, VAC distribution started less than a decade ago and coverage is yet <50%. After being linked to National Immunization Days, it is now linked to Immunization Outreach, which seems a good strategy. Because VAC are only distributed to underfives and postpartum women, and because coverage is usually around 50-80%, other strategies are implemented simultaneously. Recent HKI-evaluations found that promotion of dark-green leafy vegetables and eggs in Indonesia increased their consumption and improved vitamin A status. In Bangladesh, underfives and women of households with a homestead garden and/or poultry had a lower risk of vitamin A deficiency. The HKI Homestead Food Production Program aims at improving homestead food production activities in order to increase production and consumption of vitamin A-rich foods. Food fortification in Indonesia reaches large parts of the population, while coverage is related to socio-economic status and urban/rural location. The successes in Asia emphasize the need for multiple strategies and integration with other health and agricultural programs.

A randomized, 4-month mango and fat supplementation trial improved vitamin A status among young Gambian children

Supplementation with carotene-rich fruits may be an effective and sustainable approach to prevent vitamin A deficiency. To test the effectiveness of mango supplementation, 176 Gambian children, aged 2 to 7 y, were randomly assigned to one of four treatments: 75 g of dried mango containing approximately 150 micro g retinol activity equivalents with (MF) or without (M) 5 g of fat, 5 d/wk for 4 mo or 60,000 micro g of vitamin A (A) or placebo (P) capsule at baseline. After 4 mo, plasma beta-carotene was greater in both the M (P < 0.05) and MF (P = 0.07) groups compared with the P group. After controlling for baseline plasma retinol, elevated acute phase proteins and age, plasma retinol concentrations in the A and MF, but not M, groups were higher than in the P group at the end of the study (P < 0.01). Increases in retinol concentrations, however, were small in both groups. These results support the use of dietary supplementation with dried mangoes and a source of fat as one of several concurrent strategies that can be used to help maintain vitamin A status of children in developing countries where there is a severe seasonal shortage of carotenoid-rich foods.

Chlormethiazole treatment prevents reduced hepatic vitamin A levels in ethanol-fed rats

BACKGROUND

Chronic ethanol intake results in decreased hepatic vitamin A levels through both enhanced degradation of vitamin A via a cytochrome P450 enzyme (CYP)-dependent process and increased mobilization of vitamin A from the liver into the circulation. This study investigated whether treatment with chlormethiazole, a CYP inhibitor, restores vitamin A in the livers of ethanol-fed rats.

METHODS

Ethanol-exposed and non-ethanol-exposed rats were treated with or without chlormethiazole (10 and 100 mg/kg body weight) for 1 month. Liver and plasma levels of retinol and retinyl palmitate were analyzed by high-performance liquid chromatography. Expressions of hepatic lecithin:retinol acyltransferase (LRAT) and cellular retinol-binding protein were analyzed with reverse transcription-polymerase chain reaction. Hepatic retinol esterification by LRAT was examined by using incubations of the microsomal fractions of livers with exogenous sources of retinol.

RESULTS

Ethanol-feeding in rats for a month resulted in lower hepatic levels of retinol and retinyl palmitate than those found in controls and the occurrence of several polar retinoid metabolites. In contrast, treatment with chlormethiazole at two different doses in ethanol-fed rats completely blocked the formation of hepatic retinoid polar metabolites and restored hepatic levels of retinol and hepatic retinyl palmitate in a dose-dependent manner. Furthermore, increased plasma concentrations of retinyl palmitate in rats fed with ethanol, which indicate increased mobilization of vitamin A, were partially inhibited by chlormethiazole treatment. However, neither ethanol nor chlormethiazole treatment altered the expression and activity of LRAT in the liver of rats. Hepatic expression of cellular retinol-binding protein increased significantly in ethanol-fed rats with or without chlormethiazole treatment compared with control rats.

CONCLUSIONS

These data suggest that chlormethiazole can restore both hepatic retinol and retinyl ester concentrations to normal levels in ethanol-fed rats through blocking enhanced both degradation of vitamin A and mobilization of vitamin A from the liver into the circulation.

Vitamin A supplementation of women postpartum and of their infants at immunization alters breast milk retinol and infant vitamin A status

Vitamin A supplementation of lactating mothers and of infants at the time of diphtheria-pertussis-tetanus (DPT) and oral polio vaccine (OPV) immunizations have both been suggested as measures to prevent deficiency among infants. This multicenter randomized, double-blind, placebo-controlled trial was conducted in Ghana, India and Peru to determine the effect of maternal vitamin A supplementation on breast milk retinol and of maternal and infant supplementation on infant vitamin A status. Mothers in the intervention group received 60 mg vitamin A (as retinol palmitate) at 18-42 d postpartum; their infants were given 7.5 mg three times, i.e., at 6, 10 and 14 wk of age with DPT and OPV immunizations. Mothers and infants in the comparison group received a placebo. Maternal supplementation resulted in higher breast milk retinol at 2 mo postpartum [difference in means 7.1, 95% confidence interval (CI), 3.4, 10.8 nmol/g fat] and lower proportion of mothers with breast milk retinol < or = 28 nmol/g fat (15.2 vs. 26.6%, 95% CI of difference -16.6, -4.1%). At 6 and 9 mo, maternal supplementation did not affect breast milk retinol or the proportion of mothers with low breast milk retinol. Vitamin A supplementation of the mothers and their infants reduced the proportion of infants with serum retinol < or = 0.7 micro mol/L (30.4 vs. 37%, 95% CI of difference -13.7, 0.6%) and that with low vitamin A stores as indicated by the modified relative dose response (MRDR) > 0.06 (44.2 vs. 52.9%, 95% CI of difference -16.6, -0.9%) at 6 mo. Supplementation had no effect at 9 mo. The beneficial effect of supplementation on breast milk retinol and infants' vitamin A status varied by site. It was greatest in India followed by Ghana and Peru. At the doses used, maternal supplementation improved breast milk retinol status at 2 mo (P < 0.001) and maternal and infant supplementation modestly increased (P = 0.03) infant vitamin A status at 6 mo of age. Additional strategies to improve vitamin A status of 6- to 9-mo-old infants must be considered.

History of the International Vitamin A Consultative Group 1975-2000

The International Vitamin A Consultative Group (IVACG) was established in May 1975. Since then, IVACG has actively led the campaign against vitamin A deficiency disorders (VADD). It operates through a network of policy makers, program administrators, and scientists interested in resolving the problem of VADD. Through its international meetings, IVACG provides a forum to exchange new ideas, to discuss research findings and their policy implications, and share experiences with program interventions. It provides technical guidance through state-of-the-art publications on VADD. More than 30 technical references have been developed. IVACG collaborates with international organizations in developing and establishing policy guidelines for diagnosis, treatment, and prevention of VADD. During its 25 years, IVACG has given careful consideration to the role of vitamin A in infections, morbidity and mortality; assessment methods for use in the field and laboratory; other micronutrients and their interaction with vitamin A; bioavailability of vitamin A in foods; various interventions including supplementation, fortification and dietary diversification; the link between science and action; and sustainable control of VADD. IVACG is recognized as a credible source and galvanizing force in the field. It should continue to identify important research and policy issues and provide policy recommendations upon which others can act. Greater emphasis should be placed on integrated and multisectoral strategies, taking into account a community's overall needs for social, economic, and ecologic development.

Application of isotope dilution technique in vitamin A nutrition

The isotope dilution technique involving deuterated retinol has been developed to quantitatively estimate total body reserves of vitamin A in humans. The technique provided good estimates in comparison to hepatic vitamin A concentrations in Bangladeshi surgical patients. Kinetic studies in the United States, Bangladesh, and Guatemala indicated the mean equilibration time of 17 to 20 days irrespective of the size of hepatic reserves. Due to the controversy surrounding the efficacy of a carotene-rich diet on improvement of vitamin A status, the isotope dilution technique was proposed to pursue this research question further (IAEA's coordinated research program). In the Philippines, schoolchildren with low serum retinol concentrations showed significant improvement in total body vitamin A stores following intake of carotene-rich foods (orange fruits and vegetables), using a three-day deuterated-retinol-dilution procedure. When Chinese kindergarten children were fed green and yellow vegetables during the winter, their total body vitamin A stores were sustained as compared to a steady decline of vitamin A stores in the control children. Likewise, daily consumption of purified beta-carotene or diet rich in provitamin A carotenoids were shown to prevent a loss in total body vitamin A stores among Thai lactating women during the rice-planting season. These studies demonstrate potentials of the isotope dilution technique to evaluate the impact of provitamin A carotenoid intervention programs.

Food fortification to reduce vitamin A deficiency: International Vitamin A Consultative Group recommendations

In developed countries, food fortification has proven an effective and low-cost way to increase the micronutrient supply and reduce the consequences of micronutrient deficiencies. It has been rarely used in the developing world, but general conclusions can be drawn. The biological efficacy, but not the effectiveness, of fortifying oil and hydrogenated oil products as well as cereal flours and meals with vitamin A has been shown. Sugar has been fortified with vitamin A in Central American countries for years, and biological efficacy and program effectiveness are well established. Efficacy of fortifying monosodium glutamate with vitamin A was demonstrated but a program has not been established. Fortification with vitamin A in the developing world should satisfy certain elements for success. a) A potential food matrix (a food regularly consumed, produced by a few centralized factories, without sensorial changes compared with the nonfortified equivalent, and nutrient remains bioavailable and in a sufficient amount) is required. b) Fortified foods should provide at least 15% of the recommended daily intakes for the target group (e.g., individuals consuming the lowest amount of the fortified food). c) Voluntary fortification of processed foods should be regulated to prevent excessive consumption of vitamin A. d) Neighboring countries should harmonize technical standards, facilitate compliance and minimize conflicts over global trade laws. e) A practical monitoring system should be instituted. f) Social marketing activities should be permanent and aimed at industry, government and consumers. g) Food fortification should be combined with other strategies (e.g., supplementation) to reach those not adequately covered by fortification alone. Infants and small children, whose dietary habits differ from those of adults, require special attention. Fortification of food commodities is a very attractive and economic way to prevent and control vitamin A deficiency. Effective food fortification might make supplementation of postpartum women and older children unnecessary.

Assessment and control of vitamin A deficiency: the Annecy Accords

Comprehensive recommendations for the assessment and control of vitamin A deficiency (VAD) were rigorously reviewed and revised by a working group and presented for discussion at the XX International Vitamin A Consultative Group meeting in Hanoi, Vietnam. These recommendations include standardized definitions of VAD and VAD disorders. VAD is defined as liver stores below 20 micro g (0.07 micro mol) of retinol per gram. VAD disorders are defined as any health and physiologic consequences attributable to VAD, whether clinically evident (xerophthalmia, anemia, growth retardation, increased infectious morbidity and mortality) or not (impaired iron mobilization, disturbed cellular differentiation and depressed immune response). An estimated 140 million preschool-aged children and at least 7.2 million pregnant women are vitamin A deficient, of whom >10 million suffer clinical complications, principally xerophthalmia but also increased mortality, each year. A maternal history of night blindness during a recent pregnancy was added to the clinical criteria for assessing vitamin A status of a population, and the serum retinol criterion for a "public health problem" was revised to 15% or more of children sampled having levels of <20 micro g/dL (0.7 micro mol/L). Clinical trials and kinetic models indicate that young children in developing countries cannot achieve normal vitamin A status from plant diets alone. Fortification, supplementation, or other means of increasing vitamin A intake are needed to correct widespread deficiency. To improve the status of young infants, the vitamin A supplements provided to mothers during their first 6 wk postpartum and to young infants during their first 6 mo of life should be doubled.

Process indicators for monitoring and evaluating vitamin A programs

Vitamin A deficiency disorders (VADD) are a major public health problem in many parts of the world and one of the leading underlying causes of childhood mortality. Therefore, VADD control programs can contribute to reaching the international development goal of reducing childhood mortality by two thirds by the year 2015. Although economic development leads to greater food consumption of animal products (the most bioavailable source of vitamin A), other strategies, such as high dose vitamin A capsule supplementation, fortification and food production programs have been developed to tackle the VADD problem independent of economic development efforts. In this article, we discuss the essential role of process indicators in monitoring and fine-tuning VADD control and prevention programs toward ensuring that such programs will be more effective and cost-effective.

Assessment and control of vitamin A deficiency disorders

The XX International Vitamin A Consultative Group (IVACG) meeting in Hanoi, Vietnam, in February 2001 celebrated 25 y of progress in prevention and control of vitamin A deficiency disorders (VADD). Programmatic themes included the following: 1) intervention innovations, 2) integration of vitamin A interventions, 3) the increased risk to health of women who are deficient, 4) measurement of progress and impact and 5) programmatic sustainability. The history of IVACG was remembered and the growth of the group from a meeting of 30 to 40 persons in 1975 to nearly 600 delegates from 63 countries was described. Successful adaptation to new challenges and scientific advances, in moving science to practice, was noted. Guidelines for indicators and interventions were reviewed. A set of revised recommendations were made, including the following indicators for assessment (and, for some, outcome evaluation) of VADD: 1) under-five mortality rate >50 as a surrogate indicator to trigger action, 2) maternal night blindness >5%, 3) rapid dark adaptation worse than -1.11 log cd/m(2) and 4) serum retinol <0.7 micro mol/L (>15%) in young children (<6 y). Key recommendations for specific interventions were to double the existing dose of prophylactic vitamin A supplementation to 50,000 international units (IU) at the three Expanded Programme on Immunization contacts for young infants (<6 mo) and to two doses of 200,000 IU each for women within 6 wk after delivery; to support fortification as a valid and necessary strategy to combat VADD; and to recognize that food-based approaches should include promoting breast-feeding and consuming animal products, because promoting plant-based foods alone will not eliminate VADD in young children due to the low bioefficacy of dietary beta-carotene. This meeting clearly set the agenda for the twenty-first century and called for successful implementation of integrated approaches that will eliminate VADD.

High vitamin A content in some small indigenous fish species in Bangladesh: perspectives for food-based strategies to reduce vitamin A deficiency

Recognising the importance of fish in the Bangladeshi diet, the objective of the present study was to screen commonly consumed fish species for vitamin A content to evaluate the potential of fish as a vitamin A source in food-based strategies to combat vitamin A deficiency. Samples of 26 commonly consumed fish species and one crustacean were collected in Kishoreganj and Mymensingh, Bangladesh. To obtain edible parts, the fish were cleaned by Bangladeshi women according to traditional practices. Distribution of vitamin A in parts of the fish and the effect of the cleaning practices on the vitamin A content in#10; edible parts were assessed. The content of vitamin A compounds was analysed by high-performance liquid chromatography. The vitamin A content in small fish ranged from 2680 retinol equivalents (RE)/100 g raw edible parts in mola (Amblypharyngodon mola) to 20 RE/100 g raw edible parts in chata (Colisa lalia; an alternative scientific name is Colisa lalius). The vitamin A content in cultured species, silver carp (Hypophthalmichthys molitrix), rui (Labeo rohita), mrigal (Cirrhinus mrigala) and tilapia (Oreochromis niloticus) was low, <30 RE/100 g raw edible parts. In mola, 90% of the vitamin A was found in the eyes and viscera. The vitamin A content in the screened fish species was highly variable, by more than a factor of 100. The existence of commonly consumed fish in Bangladesh belonging to the categories of very high and high vitamin A content offers a great unexploited potential for food-based strategies to improve the vitamin A intake by promoting the production and consumption of these species.

[Survey on vitamin A deficiency in children under-6-years in China]

OBJECTIVE

To understand the prevalence and spatial distribution of vitamin A deficiency (VAD) in China among children at ages under six years.

METHODS

About 8,600 children under 6 years of age in 14 cities and 28 counties of 14 provinces were selected with stratified cluster sampling for survey, including interview with questionnaire for their family information and nutritional status. Blood specimens were collected for measuring serum level of VA with fluorescent spectrophotometry in laboratory.

RESULTS

Totally, 8,669 children under 6 (2,877 in urban area and 5,792 in rural area) were surveyed in 14 provinces, with 4,629 males and 4,040 females. Eight cases of night blindness and seven cases of xerophthalmia were found among the children at ages of two to five years. Sixty-one mothers of the children in this group were also found suffering from night blindness. All the cases of night blindness and xerophthalmia both in children and mothers were living in rural areas. Based on their serum levels of VA, 11.7% of the all 1 018 children were diagnosed as VAD, with serum VA concentrations below or equal to 0.70 micro mol/L. Prevalence of VAD was 15.0% and 5.8% in rural (23.3% in the poverty-stricken counties) and urban areas, respectively, and 5.8%, 11.5% and 16.8% in the coastal, inland and remote areas, respectively. The average serum level of VA was 1.20 micro mol/L and 0.99 micro mol/L for urban and rural areas, respectively, with a national average of 1.06 micro mol/L. And, babies under six months of age with an average serum levels of VA < or = 0.70 micro mol/L accounted for 33.4%, and those at ages of four to five years with the same level of VA accounted for 8%. There was significant difference in serum levels of VA between ages, but no significant difference between genders.

CONCLUSION

VAD did exist in children of China, especially in the remote and poverty-stricken rural areas and VA supplementation is urgently needed for the children in these regions.

[Vitamin A deficiency in Brazil: an overview]

Prolonged vitamin A deficiency may cause a severe disorder, hypovitaminosis A, that in turn may result in xerophthalmia and blindness. Although preventable, hypovitaminosis A is still a public health problem in many developing countries. This article presents an overview of the information available about vitamin A deficiency in the world and especially in Brazil. The piece also discusses the social impact of hypovitaminosis A, which is an important determinant of morbidity and mortality among children, and the relevance of prevention in the fight against this disorder. Although some studies have been done in Brazil, the information concerning vitamin A deficiency is not sufficient to determine the magnitude and severity of hypovitaminosis A on a national level, especially due to the small size of the samples studied and to the dearth of clinical and biochemical studies, which often present contradictory results. Nevertheless, it is clear that the intake of vitamin A is below recommended levels among the poor and that most children do not consume the amount recommended by the World Health Organization. In part, this could be remedied by educating people on foods that are rich in vitamin A and by correcting their attitudes toward certain dietary taboos. As part of this effort, schools play a major role in the prevention of vitamin A deficiency, among both students and the broader community.

Recommendations for monitoring and evaluating vitamin A programs: outcome indicators

Monitoring and evaluation are essential components of vitamin A intervention programs. They enable program managers to track progress in achieving their goals. Recommendations for outcome indicators are based on suggestions from the International Vitamin A Consultative Group Meeting (IVACG) workshop in late October 2000 in Annecy, France, followed by a pre-XX IVACG meeting in Hanoi, Vietnam. In areas with detectable xerophthalmia or eye signs, a fall in the prevalence of Bitot's spots to <0.5% and a decrease in night blindness during pregnancy to <5% indicates that vitamin A deficiency (VAD) is no longer a public health problem, although it still may be responsible for excess morbidity and mortality. Pupillary dark adaptation has been proposed as an objective indicator of vitamin A status. A program is considered to have made progress when the mean pupillary threshold improves to better than -1.24 log cd/m(2). For biochemical indices, the shift of mean or median values or the frequency distribution of preschool children with serum retinol concentration below 0.70 micromol (20 microg/dL), lactating mothers with breast milk retinol values below 0.70 micromol (6 microg per g of milk fat) or below 1.05 micromol (8 microg per g of milk fat) are useful to monitor program progress.

[Pre-cooked corn flour intake and its contribution of iron and vitamin A in low income preschoolers]

The objective of this study was to determine whether the addition of iron and vitamin A (VA) to corn flour, supplied through a national enrichment program since 1993, allows preschoolers to achieve an adequate intake of these nutrients. Data from the assessment of 196 children (4-6 year old) from Valencia, Venezuela is presented, including socio-demographic, anthropometric, anemia, VA deficiency (by conjunctival impression cytology (CIC) and serum retinol), and food intake. 92% of the children lived in poverty. 12% were below the norm for weight-for-height. 13% had anemia, 9% had VA deficiency according to CIC, and 0.5% according to serum retinol (< 0.70 mumol/L), 30% were at risk of VA deficiency (0.70-1.05 mmol/L). 17%, 37%, and 5% of the sample had an insufficient intake (< 80% of RDA) of energy, iron, and VA, respectively. When excluding from the analysis the amount of iron and VA from corn flour enrichment, an additional 38% and 10% of the sample showed deficient intakes of each nutrient, respectively. According to the weight-for-height indicator, iron intake was significantly lower in undernourished children (p < 0.05) than in those normal or above the norm; this was not so for VA. It is concluded that iron enrichment contributes to the improvement of the intake of this nutrient but is not enough to provide an adequate amount of it; and that the addition of VA does not seem to have an important effect on the diet of this age group.