Vitamin A Supplementation Programs and Country-Level Evidence of Vitamin A Deficiency

Increasing the availability and utilization of reliable data on population micronutrient (MN) status globally: the MN Data Generation Initiative

Micronutrient (MN) deficiencies can produce a broad array of adverse health and functional outcomes. Young, preschool children and women of reproductive age in low- and middle-income countries are most affected by these deficiencies, but the true magnitude of the problems and their related disease burdens remain uncertain because of the dearth of reliable biomarker information on population MN status. The reasons for this lack of information include a limited understanding by policy makers of the importance of MNs for human health and the usefulness of information on MN status for program planning and management; insufficient professional capacity to advocate for this information and design and implement related MN status surveys; high costs and logistical constraints involved in specimen collection, transport, storage, and laboratory analyses; poor access to adequately equipped and staffed laboratories to complete the analyses reliably; and inadequate capacity to interpret and apply this information for public health program design and evaluation. This report describes the current situation with regard to data availability, the reasons for the lack of relevant information, and the steps needed to correct this situation, including implementation of a multi-component MN Data Generation Initiative to advocate for critical data collection and provide related technical assistance, laboratory services, professional training, and financial support.

Rural-urban determinants of vitamin a deficiency among under 5 children in Bangladesh: Evidence from National Survey 2017-18

Background

Vitamin A supplementation reduces child morbidity, mortality, and blindness of people, especially in developing countries like Bangladesh. This study explores significant determinants of vitamin A deficiency among preschool children in rural and urban areas of Bangladesh.

Methods

The data set was extracted from a nationally representative survey based on a cross-sectional study, the BDHS-2017-18. The base survey was conducted using a two-stage stratified sample of households. A sample of 8364 (urban 2911, rural 5453) children under-5 years old was analyzed using bivariate and multivariate statistical techniques.

Results

Results have demonstrated that 73.9 and 73.2% of children have had a vitamin A supplementation from urban and rural areas, respectively. Logistic regression analysis showed that parents’ education plays a vital role in consuming vitamin A supplements in urban and rural areas. Children whose mothers have secondary (OR: 1.17, CI: 0.76–1.81) and higher (OR: 1.21, CI: 0.72–2.04) education were more likely to consume vitamin A supplementation than children whose mothers were illiterate in urban areas. However, in rural areas, children whose mothers have secondary education were about 24% and higher education with 60% more likely to consume vitamin A supplementation than children whose mothers were illiterate. Child’s age, regional variation and wealth index also contributing factors for vitamin A deficiency in Bangladesh.

Conclusions

These findings indicated that the consumption of vitamin A does not cover the target of sustainable development goals. Thus special national and community level efforts are required to ensure the coverage of the national vitamin A program is increased adequately to the most vulnerable groups of children in Bangladesh.

Analysis for policy to overcome barriers to reducing the prevalence of vitamin a deficiency among children (15-23 months) in Iran

BACKGROUND

About 30% of children < 5 years old are estimated to experience vitamin A deficiency worldwide. Globally, vitamin A deficiency can be reduced by five major interventions: supplementation, dietary modification, fortification, promotion of both public health, and breastfeeding. This prospective policy analysis (Prospective policy analysis focuses on the future outcomes of a proposed policy. Adapted from Patton, CV, and Sawicki DS. Basic Methods of Policy Analysis and Planning, Prentice-Hall, Inc. New Jersey,1993). (Patton A, Carl V, and David S. Basic methods of policy analysis and planning, prentice-hall, 3th ed. 2012) aimed to identify evidence-based policy options to minimize prevalence (VAD) among 15-23 months-children in Iran.

METHODS

Thirty-eight semi-structured face-to-face interviews were held with experts at high, middle, and low managerial levels in Iran's health system, as well as at Schools of Nutrition Sciences and dietetics, using purposive and snowball sampling. All interviews were recorded by a digital voice recorder and then transcribed, codified, and eventually analyzed using a mixed approach (inductive-deductive) by MAXQDA software version 10.

RESULTS

Most policies related to VAD reduction in this age group are supplementation, expansion of education, and awareness. Three main factors affecting VAD reduction policies emerged from the analysis: basic factors (governance, infrastructure, and organization), underlying factors (social factors, economy), and immediate factors (services). Due to its cross-sectoral nature, evaluating the results of the implementation of this policy requires strong and coherent inter-sectoral cooperation. The existing primary healthcare network (PHC) is a crucial means for successful implementation of policies to address VAD in Iran.

CONCLUSIONS

In addition to supplementation and assistance in this age group, other policies should be also planned to reduce VAD in various regions. In addition to the Ministry of Health & Medical Education (MoHME), other actors need to be involved, we advocate, throughout the entire policymaking process of policy-making to reduce VAD in Iran.

Refocusing vitamin A supplementation programmes to reach the most vulnerable

WHO recommends vitamin A supplementation (VAS) programmes for children 6–59 months where vitamin A deficiency is a public health problem. However, resources for VAS are falling short of current needs and programme coverage is suffering. The authors present the case for considering the options for shifting efforts and resources from a generalised approach, to prioritising resources to reach populations with continued high child mortality rates and high vitamin A deficiency prevalence to maximise child survival benefits. This includes evaluating where child mortality and/or vitamin A deficiency has dropped, as well as using under 5 mortality rates as a proxy for vitamin A deficiency, in the absence of recent data. The analysis supports that fewer countries may now need to prioritise VAS than in the year 2000, but that there are still a large number of countries that do. The authors also outline next steps for analysing options for improved targeting and cost-effectiveness of programmes. Focusing VAS resources to reach the most vulnerable is an efficient use of resources and will continue to promote young child survival.

Effects of vitamin and mineral supplementation during pregnancy on maternal, birth, child health and development outcomes in low- and middle-income countries: A systematic review

Background

Almost two billion people who are deficient in vitamins and minerals are women and children in low- and middle-income countries (LMIC). These deficiencies are worsened during pregnancy due to increased energy and nutritional demands, causing adverse outcomes in mother and child. To reduce micronutrient deficiencies, several strategies have been implemented, including diet diversification, large-scale and targeted fortification, staple crop bio-fortification and micronutrient supplementation.

Objectives

To evaluate and summarize the available evidence on the effects of micronutrient supplementation during pregnancy in LMIC on maternal, fetal, child health and child development outcomes. This review will assess the impact of single micronutrient supplementation (calcium, vitamin A, iron, vitamin D, iodine, zinc, vitamin B12), iron-folic acid (IFA) supplementation, multiple micronutrient (MMN) supplementation, and lipid-based nutrient supplementation (LNS) during pregnancy.

Search Methods

We searched papers published from 1995 to 31 October 2019 (related programmes and good quality studies pre-1995 were limited) in CAB Abstracts, CINAHL, Cochrane Central Register of Controlled Trials, Embase, International Initiative for Impact Evaluations, LILACS, Medline, POPLINE, Web of Science, WHOLIS, ProQuest Dissertations & Theses Global, R4D, WHO International Clinical Trials Registry Platform. Non-indexed grey literature searches were conducted using Google, Google Scholar, and web pages of key international nutrition agencies.

Selection Criteria

We included randomized controlled trials (individual and cluster-randomized) and quasi-experimental studies that evaluated micronutrient supplementation in healthy, pregnant women of any age and parity living in a LMIC. LMIC were defined by the World Bank Group at the time of the search for this review. While the aim was to include healthy pregnant women, it is likely that these populations had one or more micronutrient deficiencies at baseline; women were not excluded on this basis.

Data Collection and Analysis

Two authors independently assessed studies for inclusion and risk of bias, and conducted data extraction. Data were matched to check for accuracy. Quality of evidence was assessed using the GRADE approach.

Main Results

A total of 314 papers across 72 studies (451,723 women) were eligible for inclusion, of which 64 studies (439,649 women) contributed to meta-analyses. Seven studies assessed iron-folic acid (IFA) supplementation versus folic acid; 34 studies assessed MMN vs. IFA; 4 studies assessed LNS vs. MMN; 13 evaluated iron; 13 assessed zinc; 9 evaluated vitamin A; 11 assessed vitamin D; and 6 assessed calcium. Several studies were eligible for inclusion in multiple types of supplementation. IFA compared to folic acid showed a large and significant (48%) reduction in the risk of maternal anaemia (average risk ratio (RR) 0.52, 95% CI 0.41 to 0.66; studies = 5; participants = 15,540; moderate-quality evidence). As well, IFA supplementation demonstrated a smaller but significant, 12% reduction in risk of low birthweight (LBW) babies (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). MMN supplementation was defined as any supplement that contained at least 3 micronutrients. Post-hoc analyses were conducted, where possible, comparing the differences in effect of MMN with 4+ components and MMN with 3 or 4 components. When compared to iron with or without FA, MMN supplementation reduced the risk of LBW by 15% (average RR 0.85, 95% CI 0.77 to 0.93; studies = 28; participants = 79,972); this effect was greater in MMN with >4 micronutrients (average RR 0.79, 95% CI 0.71 to 0.88; studies = 19; participants = 68,138 versus average RR 1.01, 95% CI 0.92 to 1.11; studies = 9; participants = 11,834). There was a small and significant reduction in the risk of stillbirths (average RR 0.91; 95% CI 0.86 to 0.98; studies = 22; participants = 96,772) and a small and significant effect on the risk of small-for-gestational age (SGA) (average RR 0.93; 95% CI 0.88 to 0.98; studies = 19; participants = 52,965). For stillbirths and SGA, the effects were greater among those provided MMN with 4+ micronutrients. Children whose mothers had been supplemented with MMN, compared to IFA, demonstrated a 16% reduced risk of diarrhea (average RR 0.84; 95% CI 0.76 to 0.92; studies = 4; participants = 3,142). LNS supplementation, compared to MMN, made no difference to any outcome; however, the evidence is limited. Iron supplementation, when compared to no iron or placebo, showed a large and significant effect on maternal anaemia, a reduction of 47% (average RR 0.53, 95% CI 0.43 to 0.65; studies = 6; participants = 15,737; moderate-quality evidence) and a small and significant effect on LBW (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). Zinc and vitamin A supplementation, each both compared to placebo, had no impact on any outcome examined with the exception of potentially improving serum/plasma zinc (mean difference (MD) 0.43 umol/L; 95% CI -0.04 to 0.89; studies = 5; participants = 1,202) and serum/plasma retinol (MD 0.13 umol/L; 95% CI -0.03 to 0.30; studies = 6; participants = 1,654), respectively. When compared to placebo, vitamin D supplementation may have reduced the risk of preterm births (average RR 0.64; 95% CI 0.40 to 1.04; studies = 7; participants = 1,262), though the upper CI just crosses the line of no effect. Similarly, calcium supplementation versus placebo may have improved rates of pre-eclampsia/eclampsia (average RR 0.45; 95% CI 0.19 to 1.06; studies = 4; participants = 9,616), though the upper CI just crosses 1.

Authors' Conclusions

The findings suggest that MMN and vitamin supplementation improve maternal and child health outcomes, including maternal anaemia, LBW, preterm birth, SGA, stillbirths, micronutrient deficiencies, and morbidities, including pre-eclampsia/eclampsia and diarrhea among children. MMN supplementation demonstrated a beneficial impact on the most number of outcomes. In addition, MMN with >4 micronutrients appeared to be more impactful than MMN with only 3 or 4 micronutrients included in the tablet. Very few studies conducted longitudinal analysis on longer-term health outcomes for the child, such as anthropometric measures and developmental outcomes; this may be an important area for future research. This review may provide some basis to guide continual discourse around replacing IFA supplementation with MMN along with the use of single micronutrient supplementation programs for specific outcomes.

Mechanistic aspects of carotenoid health benefits - where are we now?

Dietary intake and tissue levels of carotenoids have been associated with a reduced risk of several chronic diseases, including cardiovascular diseases, type 2 diabetes, obesity, brain-related diseases and some types of cancer. However, intervention trials with isolated carotenoid supplements have mostly failed to confirm the postulated health benefits. It has thereby been speculated that dosing, matrix and synergistic effects, as well as underlying health and the individual nutritional status plus genetic background do play a role. It appears that our knowledge on carotenoid-mediated health benefits may still be incomplete, as the underlying mechanisms of action are poorly understood in relation to human relevance. Antioxidant mechanisms - direct or via transcription factors such as NRF2 and NF-κB - and activation of nuclear hormone receptor pathways such as of RAR, RXR or also PPARs, via carotenoid metabolites, are the basic principles which we try to connect with carotenoid-transmitted health benefits as exemplified with described common diseases including obesity/diabetes and cancer. Depending on the targeted diseases, single or multiple mechanisms of actions may play a role. In this review and position paper, we try to highlight our present knowledge on carotenoid metabolism and mechanisms translatable into health benefits related to several chronic diseases.

Disproportionate Vitamin A Deficiency in Women of Specific Ethnicities Linked to Differences in Allele Frequencies of Vitamin A-Related Polymorphisms

Background: While the current national prevalence rate of vitamin A deficiency (VAD) is estimated to be less than 1%, it is suggested that it varies between different ethnic groups and races within the U.S. We assessed the prevalence of VAD in pregnant women of different ethnic groups and tested these prevalence rates for associations with the vitamin A-related single nucleotide polymorphism (SNP) allele frequencies in each ethnic group. Methods: We analyzed two independent datasets of serum retinol levels with self-reported ethnicities and the differences of allele frequencies of the SNPs associated with vitamin A metabolism between groups in publicly available datasets. Results: Non-Hispanic Black and Hispanic pregnant women showed high VAD prevalence in both datasets. Interestingly, the VAD prevalence for Hispanic pregnant women significantly differed between datasets (p = 1.973 × 10⁻¹⁰, 95%CI 0.04–0.22). Alleles known to confer the risk of low serum retinol (rs10882272 C and rs738409 G) showed higher frequencies in the race/ethnicity groups with more VAD. Moreover, minor allele frequencies of a set of 39 previously reported SNPs associated with vitamin A metabolism were significantly different between the populations of different ancestries than those of randomly selected SNPs (p = 0.030). Conclusions: Our analysis confirmed that VAD prevalence varies between different ethnic groups/races and may be causally associated with genetic variants conferring risk for low retinol levels. Assessing genetic variant information prior to performing an effective nutrient supplementation program will help us plan more effective food-based interventions.

Vitamin A Supplementation Coverage and Ocular Signs among Children Aged 6-59 Months in Aleta Chuko Woreda, Sidama Zone, Southern Ethiopia

Background

Periodic vitamin A supplementation to children is a cost-effective strategy to avert vitamin A deficiency. However, few pieces of evidence are available about the coverage of vitamin A supplementation at the community level in the study area. Therefore, the aim of this study was to assess vitamin A supplementation coverage and prevalence of ocular signs of vitamin A deficiency among children aged 6-59 months.

Methods

Community-based cross-sectional study design was conducted using a two-stage stratified random sampling method. Data were collected from mothers with children aged 6-59 months using a structured pretested questionnaire. A total of 665 children aged 6 to 59 months were examined for clinical signs and symptoms of vitamin A deficiency by trained clinical health professionals. Descriptive statistics and logistic regression were done.

Result

Vitamin A supplementation coverage in the study area was 36.2% (95% CI: 32.6-39.9). Overall, the prevalence of xerophthalmia was 2.7%. Age group 6-23 months (AOR: 2.1, 95% CI: 1.4-2.9), good maternal knowledge (AOR: 1.5, 95% CI: 1.2-2.1), children with high wealth status (AOR: 2.3, 95% CI: 1.4-3.8), precampaign health education on vitamin A (AOR: 3.4,95% CI: 2.1-5.6), member of Health Development Army (AOR: 2.7, 95% CI: 1.7-4.2), and access to health facility within <30 minutes (AOR: 2.5, 95% CI: 1.6-3.8) were significantly associated with the receipt of vitamin A capsule.

Conclusion

Vitamin A supplementation coverage of the study area was low as compared to the UNICEF threshold of 70%. Vitamin A deficiency is a public health problem in the study area. Increasing maternal level of knowledge, precampaign health education on vitamin A supplementation, and strengthening Health Development Army are recommended to increase the vitamin A supplementation coverage.

Review of the Micronutrient Situation in Rwanda

BACKGROUND

Rwanda's commitment to reducing malnutrition is evident in their multisectoral nutrition policy and wide array of nutrition partners. However, the prevalence of micronutrient deficiencies and the suitability of current strategies to address existing deficiencies is unclear.

OBJECTIVE

To review the available evidence related to the prevalence of micronutrient deficiencies across the life cycle and strategies in place to address them.

METHODS

We reviewed scientific and grey literature on nutritional problems in Rwanda, emphasizing micronutrient deficiencies and anemia, and current strategies to address micronutrient malnutrition.

RESULTS

Overall, there is scant evidence related to the types and prevalence of micronutrient deficiencies among populations across the life cycle in Rwanda. Existing evidence is primarily limited to outdated or small regional surveys focusing on iron or vitamin A among women and young children. Surveys have assessed the prevalence of anemia and indicate that anemia is very high among young children and moderately high among other age-groups. However, there are limited data on the context-specific causes of anemia in Rwanda across population groups. Current nutrition strategies mainly target women and young children and are primarily designed to reduce vitamin A deficiency and/or anemia caused by micronutrient deficiencies.

CONCLUSIONS

Rwanda has many nutrition programs in place that address micronutrient deficiencies in young children and a few for women of reproductive age. However, gaps exist in knowledge of the extent of different types of micronutrient deficiencies among all populations across the life cycle and whether the delivery of nutrients through current programs is meeting actual needs.

Vitamin A deficiency has declined in Malawi, but with evidence of elevated vitamin A in children

BACKGROUND

Reduction of vitamin A deficiency (VAD) in Malawi coincided with introduction of vitamin A-fortified staple foods, alongside continued biannual high-dose vitamin A supplementation (VAS).

OBJECTIVE

We describe coverage of vitamin A interventions and vitamin A status in the 2015-2016 Malawi Micronutrient Survey.

METHODS

Food samples and biospecimens were collected within a representative household survey across 105 clusters. Retinol was measured using ultraviolet excitation fluorescence (sugar) and photometric determination (oil). Preschool children (PSC, aged 6-59 mo, n = 1102), school-age children (SAC, aged 5-14 y, n = 758), nonpregnant women (n = 752), and men (n = 219) were initially assessed for vitamin A status using retinol binding protein (RBP) and modified relative dose response (MRDR). Randomly selected fasted MRDR participants (n = 247) and nonfasted women and children (n = 293) were later assessed for serum retinol, retinyl esters, and carotenoids. Analyses accounted for complex survey design.

RESULTS

We tested sugar and oil samples from 71.8% and 70.5% of the households (n = 2,112), respectively. All of the oil samples and all but one of the sugar samples had detectable vitamin A. National mean retinol sugar and oil contents were 6.1 ± 0.7 mg/kg and 6.6 ± 1.4 mg/kg, respectively. Receipt of VAS in the previous 6 mo was reported by 68.0% of PSC. VAD prevalence (RBP equivalent to <0.7µmol retinol/L) was 3.6% in PSC, and <1% in other groups. One woman and no children had MRDR ≥0.060 indicating VAD. Among fasted PSC and SAC, 18.0% (95% CI: 6.4, 29.6) and 18.8% (7.2, 30.5) had >5% of total serum vitamin A as retinyl esters, and 1.7% (0.0, 4.1) and 4.9% (0.0, 10.2) had >10% of total serum vitamin A as retinyl esters. Serum carotenoids indicated recent intake of vitamin A-rich fruits and vegetables.

CONCLUSIONS

Near elimination of VAD in Malawi is a public health success story, but elevated levels of vitamin A among children suggests that vitamin A interventions may need modification.

Factors associated with coverage of vitamin a supplementation among Bangladeshi children: mixed modelling approach

Background

Vitamin A deficiency (VAD) is a prominent and widespread public health problem in developing countries, including Bangladesh. About 2% of all deaths among under-five children are attributable to VAD. Evidence-based information is required to understand the influential factors to increase vitamin A supplementation (VAS) coverage and reduce VAD. We investigated the potential factors affecting VAS coverage and its significant predictors among Bangladeshi children aged 6 to 59 months using the VAS clustered data extracted from the latest Bangladesh Demographic and Health Survey 2014.

Methods

Data were analysed using mixed logistic regression (MLR) modelling approach in the generalised linear mixed model framework. The MLR model performs better than logistic regression for analysing the clustered data because of its minimum Akaike information criterion value. The likelihood ratio test showed that the variance component was significant. Therefore, the clustering effect among children was inevitable to use.

Results

VAS coverage among under-five children was 63.6%, which is not optimal and below the WHO’s recommendation and the country’s target of 90%. Children aged 25 to 36 months (AOR = 2.07, 95% CI: 1.711 to 2.513), who had higher educated mothers (AOR = 1.37, p = 0.033, 95% CI: 1.026–1.820) and fathers (AOR = 1.32, p = 0.027, 95% CI: 1.032–1.683), whose mothers had media exposure (AOR = 1.22, p = 0.006, 95% CI: 1.059–1.408) and NGO membership (AOR = 1.24, p = 0.002, 95% CI: 1.089–1.422) were more likely to consume VAS.

Conclusion

The relevant authorities should create proactive awareness programs for highly vulnerable local communities, specifically targeted to educate the children’s mothers about the necessity and benefits of childhood nutrition.

Global patterns in vision loss burden due to vitamin A deficiency from 1990 to 2017

OBJECTIVE

To investigate the vision loss burden due to vitamin A deficiency (VAD) at the global, regional and national levels by year, age, sex and socio-economic status using prevalence and years lived with disability (YLD).

DESIGN

International, retrospective, comparative burden-of-disease study.

SETTING

Prevalence and YLD data were extracted from the Global Burden of Disease (GBD) Study 2017. The association of age-standardised YLD rates and human development index (HDI) was tested by Pearson correlation and linear regression analyses. The Gini coefficient and concentration index (CI) were calculated to demonstrate the trends in between-country inequality in vision loss burden due to VAD.

PARTICIPANTS

All participants met the GBD inclusion criteria.

RESULTS

The age-standardised prevalence rate increased by 9·2 %, while the age-standardised YLD rates rose by 10·8 % from 1990 to 2017. Notably, the vision loss burden caused by VAD showed a declining trend since 2014. The vision loss burden was more concentrated in the post-neonatal age group and decreased with increasing age. The age-standardised YLD rates were inversely correlated with HDI (r = -0·2417, P = 0·0084). The CI and Gini coefficients indicated that socio-economic-related and between-country inequality declined from 2000 to 2017. VAD was the eighth leading cause of the age-standardised prevalence rate and ninth leading cause of age-standardised YLD rate among fifteen causes of vision loss in 2017.

CONCLUSION

VAD has become one of the significant leading causes of vision loss globally. Efforts to control vision impairment related to VAD are needed, especially for children in countries with lower socio-economic status.

Potential of pumpkin to combat vitamin A deficiency during complementary feeding in low and middle income countries: variety, provitamin A carotenoid content and retention, and dietary reference intakes

The risk of child vitamin A deficiency (VAD) in low and middle income countries (LMICs) begins during the age range of complementary feeding (6-24 months), when children are fed complementary foods (CFs) deficient in vitamin A. However, pumpkin, a source of provitamin A carotenoids (PVACs) is widely cultivated in LMICs, but underutilized as a complementary food. Moreover, when consumed by humans, PVACs are bioconverted to retinol, the active form of vitamin A used by the body. This study evaluated the potential of pumpkin toward combating VAD by reviewing varieties of pumpkin cultivated in LMICs and their provitamin A carotenoid (PVAC) content; retention of PVACs in pumpkin during processing it as a CF; and the extent to which a CF prepared from pumpkin may meet the dietary reference intakes (DRIs) for vitamin A for children aged 6-24 months old. Pumpkin may combat VAD because the varieties cultivated have high β-carotene content, it is a provitamin A biofortifiable food crop, and 100% retention of PVACs was observed when processed using home cooking methods. Feeding less than 50 g of cooked pumpkin per day meets 100% of the recommended dietary allowance (RDA) and adequate intake (AI) of vitamin A for children 6 to 24 months old. Consumption of pumpkin may be used to complement vitamin A supplementation, fortification, and diversification of CFs with animal source foods. For better yield of pumpkin in LMICs, nutrition sensitive agricultural programmes such as biofortification and agronomic management of pumpkin need to be promoted and supported.

Adequate vitamin A liver stores estimated by the modified relative dose response test are positively associated with breastfeeding but not vitamin A supplementation in Senegalese urban children 9-23 months old: A comparative cross-sectional study

Vitamin A supplementation (VAS) in 6-59-month-old children is recommended but its sustainability is currently questioned. In Senegal, available data suggest that VAS should be maintained, but geographic and age-related specificities need to be addressed to better implement and target VAS programming. The objective of this comparative cross-sectional study, conducted in urban settings of Dakar, was to compare the vitamin A liver stores (VALS) assessed using the modified-relative dose response (MRDR) test between supplemented and non-supplemented 9-23 month-old children and to study their relationship with VAS. The supplemented group (n = 119) received VAS (either 100 000 UI or 200 000 UI) 2 to 6 months before evaluation while the non-supplemented group (n = 110) had not received VAS during the past 6 months. In addition to MRDR, serum retinol concentrations (SR), and biomarkers of subclinical inflammation were measured. Children's health-related data and feeding patterns were collected. Mean MRDR values (VAS: 0.030 ± 0.017, non-VAS: 0.028 ± 0.016, P = 0.389) and inflammation-adjusted SR (VAS: 1.34 ± 0.37, non-VAS: 1.3 ± 0.35, P = 0.515) of children were adequate. Low prevalence of VALS (VAS: 5.2%, non-VAS: 5.4%) and inflammation-adjusted VAD (VAS: 2.6%, non-VAS: 0.9%) were detected despite high presence of infections and inflammation. Children were mostly still being breastfed (VAS: 85.7%, non-VAS: 77.3%) and complementary feeding indicators were similar in both groups. Only breastfeeding was associated with VALS and was found to reduce by 76% at least, the odds of VAD (adjusted OR = 0.24, 95% CI: 0.07-0.8, P = 0.020). Based on MRDR values, VAS was not related to improved VALS and SR as well as VAD reduction among these children with adequate VALS. Reinforcing breastfeeding advocacy and morbidity prevention/control are essential in this setting. Scaling-back VAS in this subpopulation should be examined regarding the risk of hypervitaminosis A after an evaluation of dietary vitamin A intake sufficiency and a more quantitative assessment of VALS.

Dietary vitamin a intake, coverage of vitamin a megadose supplementation, and prevalence of vitamin a deficiency among marginalized children 6–59 months in anganwadis of Chandigarh: A multistage cluster sampling survey

Background:

Lack of recent local data regarding Vitamin A deficiency, dietary intake, and coverage of biannual high-dose Vitamin A prophylaxis among marginalized children poses challenges for policy change.

Objective:

Our study aimed to evaluate the burden of serum Vitamin A deficiency, dietary Vitamin A intake, and current Vitamin A supplementation coverage.

Methodology:

We enrolled 216 children aged 6–60 months from 30 Anganwadis of Chandigarh using two-stage cluster sampling.

Results:

Dietary intake of Vitamin A-rich foods and vegetables in the last 24 h was observed only in 20% of enrolled children. Although 79.21% (160/202) of children aged ≥9 months reported receiving Vitamin A supplementation, only 38.52% had documented record of age-appropriate complete supplementation. None of the children showed ocular manifestations of Vitamin A deficiency. For the subjects in which C-reactive protein levels were ≤5 mg/l (n = 148), 35.14% (52/148) had serum retinol ≤0.7 μmol/L and 2.03% (3/148) had serum retinol ≤0.3 μmol/L. The multivariate odds ratios (ORs) of Vitamin A deficiency (serum retinol <0.7) were 2.23 times higher in subjects with inappropriate complementary feeding (OR: 2.23; 95% confidence interval [CI]: 1.07–4.80; P = 0.035) whereas odds were significantly lower for middle (OR: 0.27; 95% CI: 0.09–0.76; P = 0.015) and higher income (OR: 0.14; 95% CI: 0.03–0.53; P = 0.005) families in reference to low-income group.

Conclusions:

Subclinical Vitamin A deficiency is still a public health crisis with suboptimal dietary intake of Vitamin A-rich foods and compromised food diversity necessitating targeted approach for marginalized children.

The Potential Influence of Vitamin A, C, and D and Zinc Supplements on the Severity of COVID-19 Symptoms and Clinical Outcomes: An Updated Review of Literature

Coronavirus disease-19 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 is an ongoing viral epidemic that originated in China in December 2019. To date, no specific treatment is available for COVID-19. However, several studies have reported the benefits of vitamins A, C, and D and zinc in critically ill patients and in those with various infections, including respiratory infections and sepsis. The objective of this review is to discuss the potential role of vitamin A, C, and D and zinc supplementation in enhancing immune response, and reducing the severity of symptoms, and mortality rate in patients with COVID-19. Several clinical studies have shown that different doses of vitamins A, C, and D and/or zinc supplements reduce the ventilator, length of intensive care unit stay, and mortality rate. Future randomized clinical trials are warranted to conclusively establish protocols for the optimal doses of vitamin A, C, and D, as well as zinc supplements for improved clinical outcomes in patients with COVID-19.

Vitamin A supplementation and estimated number of averted child deaths in Ethiopia: 15 years in practice (2005-2019)

Vitamin A supplementation (VAS), started as a short‐term strategy pending dietary improvements, has been implemented in Ethiopia for the last 15 years. We aimed to describe the trends in VAS coverage and estimated the associated reductions in child mortality. VAS coverage data obtained from the District Health Information System and the Demographic and Health Surveys were linked to child mortality data from the United Nations Interagency Group for Child Mortality Estimation (UN IGME). The number of child deaths averted was modelled assuming 12% and 24% reductions in all‐cause mortality. From 2006 to 2011, VAS was delivered through campaigns, and coverage was above 85%. However, from 2011 onwards, VAS delivery was integrated to the routine health system, and the coverage declined to <60% with significant disparities by wealth quintile and rural–urban residence. VAS has saved between 167,563 to 376,030 child lives (2005–2019), but additional lives (>42,000) could have been saved with a universal coverage (95%). Inconsistent supply of vitamin A capsules, but more importantly, low access to health care, and the limited contact opportunities for children after 24 months may have contributed to the declining VAS coverage. Any changes in target or scale‐up should thus consider these spatial and socioeconomic variations. Increasing the coverage of VAS and closing the equity gap in access to nutrition services is critical. However, with alternative programmes like vitamin A fortification being set‐up, the benefits and safety of VAS need to be closely monitored, particularly in areas where there will be overlap.

Child Night Blindness and Bitot's Spots Are Public Health Problems in Lay Armachiho District, Central Gondar Zone, Northwest Ethiopia, 2019: A Community-Based Cross-Sectional Study

Background

Night blindness (XN) is a condition in which a person cannot see in dim light and is the earliest clinical manifestation of vitamin A deficiency. Globally, vitamin A deficiency is a public health problem in 122 countries, of which 45 countries have moderate to severe child night blindness. Therefore, this study is aimed at assessing the prevalence and associated factors of night blindness and Bitot's spot among children aged 24-59 months.

Methods

A community-based cross-sectional study was employed from February to March 2019 among children aged 24-59 months in the Lay Armachiho District, Amhara region. A structured and pretested questionnaire was used for data collection. Descriptive summary statistics were used to describe the study population. Bivariate and multivariable logistic regression models were used to identify associated factors.

Results

Out of 1007 children, 1.9% and 2.2% had night blindness and Bitot's spot, respectively. Illiterate mothers (AOR = 2.94; 95%CI = (1.12, 6.72)), age of 48 to 59 months (AOR = 9.81; 95%CI = (1.24, 77.36)), ≥4 family sizes (AOR = 4.52; 95%CI = (1.02, 19.90)), had diarrhea (AOR = 5.00; 95%CI = (1.73, 14.54)), and had a respiratory tract infection (AOR = 3.14; 95%CI = (1.02, 9.70)) were significantly associated with night blindness. Age of 48-59 months (AOR = 4.23; 95%CI = (1.13, 14.86)) and mothers who did not wash their hands after using the toilet (AOR = 3.02; 95%CI = (1.01, 9.13)) were predictor variables for Bitot's spots.

Conclusion

The prevalence of night blindness and Bitot's spots was high. Child's age, mother's educational status, family size, diarrhea in the last 2 weeks, and respiratory tract infection in the last 2 weeks were predictive variables for night blindness. Besides, handwashing practice after using the toilet and child's age were significantly associated with Bitot's spot among children. Therefore, both night blindness and Bitot's spots are a public health problem and call for the attention of health professionals in primary health care facilities.

Impact of home food production on nutritional blindness, stunting, wasting, underweight and mortality in children: a systematic review and meta-analysis of controlled trials

Vitamin A deficiency is highly prevalent and remains the major cause of nutritional blindness in children in low-and middle-income countries, despite supplementation programmes. Xeropthalmia (severe drying and thickening of the conjunctiva) is caused by vitamin A deficiency and leads to irreversible blindness. Vitamin A supplementation programmes effectively reduce vitamin A deficiency but many rural children are not reached. Home food production may help prevent rural children's vitamin A deficiency. We aimed to systematically review trials assessing effects of home food production (also called homestead food production and agricultural interventions) on xeropthalmia, nightblindness, stunting, wasting, underweight and mortality (primary outcomes). We searched Medline, Embase, Scopus, Cochrane CENTRAL and trials registers to February 2019. Inclusion of studies, data extraction and risk of bias were assessed independently in duplicate. Random-effects meta-analysis, sensitivity analyses, subgrouping and GRADE were used. We included 16 trials randomizing 2498 children, none reported xerophthalmia, night-blindness or mortality. Home food production may slightly reduce stunting (mean difference (MD) 0.13 (z-score), 95% CI 0.01 to 0.24), wasting (MD 0.05 (z-score), 95% CI -0.04 to 0.14) and underweight (MD 0.07 (z-score), 95% CI -0.01 to 0.15) in young children (all GRADE low-consistency evidence), and increase dietary diversity (standardized mean difference (SMD) 0.24, 95% CI 0.15 to 0.34). Home food production may usefully complement vitamin A supplementation for rural children. Large, long-duration trials with good randomization, allocation concealment and correct adjustment for clustering are needed to assess effectiveness of home food production on nutritional blindness in young children.

Retention of vitamin A after goat milk processing into cheese: a nutritional strategy

The deficiency in micronutrients is a public health problem, principally in lower-middle-income countries. Vitamin A (VA) is considered a micronutrient fundamental to the maintenance and development of different tissues in the organism. Therefore, it is an essential micronutrient in the human diet. In these terms, goat milk is the leading food consumed to provide nutritional support in innumerous lower-middle-income countries. Here our work aimed to produce goat cheese studying strategies to promote the retention of VA. Our experiment design also explores the use of the salting process to evaluate the levels of VA retention. The level of VA in goat cheese was determined using LC-MS/MS analysis. Additionally, the redox status of the goat cheese in terms of lipid peroxidation and protein oxidation was determined. The texture analysis was also evaluated to verify if the redox status and salting process influence the texture profile. The results showed that the salting process during goat cheese production improves the retention of VA in goat cheese. Moreover, the salting process also is related to alterations in the status redox of the goat cheese and texture parameters. Therefore, our results show that goat cheese production can be an alternative to produced dairy derivates with recognized concentrations of VA for human nutrition.

The Nutritional Impact of Milk Beverages in Reducing Nutrient Inadequacy among Children Aged One to Five Years in the Philippines: A Dietary Modelling Study

Around half of Filipino children are not consuming any dairy products on a given day, which has shown to be associated with increased risk of inadequate nutrient intakes. The current study applies dietary modelling to assess the nutritional impact of meeting dairy recommendations in reducing nutrient inadequacy in children aged one to five years in the Philippines. Dietary intake data of Filipino children aged one to five years (n = 3864) were analyzed from the 8th National Nutrition Survey 2013. Children who did not meet national dairy recommendations were identified. Two scenarios were applied, based on two types of commonly consumed milk products by the survey participants. In scenario one, one serving of powdered milk was added to the diet of these children. In scenario two, one serving of a young children milk (YCM) or preschool children milk (PCM) was added to the diet of children aged one to two years and three to five years, respectively. Mean nutrient intakes and percentages of children with inadequate intakes were estimated before and after applying modelling scenarios. Scenario one demonstrated improvement in calcium, phosphorus, sodium, vitamin A and riboflavin intakes, while in scenario two, further improvement of intakes of a wider range of nutrients including iron, selenium, zinc, magnesium, potassium, vitamins C, D, E, thiamin, niacin, vitamins B6, and B12 was observed. In both scenarios, if all children would meet their dairy recommendations, theoretical reductions in population nutrient inadequacy would be observed for all micronutrients, for example, only 20% of children aged one to two years would be inadequate in vitamin A instead of the current 60%, iron inadequacy would see a 5% reduction, and approximately 10% reduction for calcium and 20% reduction for folate. The present study is the first to apply dietary modelling to assess the theoretical impact of meeting dairy recommendations on nutrient inadequacy in children in the Philippines. Dairy consumption should be encouraged as part of the strategy to reduce nutrient inadequacies. Calcium, iron, vitamins D, E, and folate are of concern in the Philippines as the level of inadequacies are extremely high in early years, YCM and PCM can help increase the intake of these nutrients.

An Accidental Nutritionist

My career as an accidental nutritionist began with my immersion in cholera control, a cyclone disaster, a smallpox epidemic, and formal training in ophthalmology and epidemiology. Interest in blindness prevention inexplicably led me to (re)pioneer the effects, treatment, and prevention of vitamin A deficiency, while faced with intense criticism by many leading scientists in the nutrition community. The resulting efforts by the World Health Organization and UNICEF in support of programs for the global control of vitamin A deficiency still face vocal opposition by some senior scientists, despite having been estimated to have saved tens of millions of children from unnecessary death and blindness. This entire journey was largely an accident!

Vitamin A as a Transcriptional Regulator of Cardiovascular Disease

Vitamin A is a micronutrient and signaling molecule that regulates transcription, cellular differentiation, and organ homeostasis. Additionally, metabolites of Vitamin A are utilized as differentiation agents in the treatment of hematological cancers and skin disorders, necessitating further study into the effects of both nutrient deficiency and the exogenous delivery of Vitamin A and its metabolites on cardiovascular phenotypes. Though vitamin A/retinoids are well-known regulators of cardiac formation, recent evidence has emerged that supports their role as regulators of cardiac regeneration, postnatal cardiac function, and cardiovascular disease progression. We here review findings from genetic and pharmacological studies describing the regulation of both myocyte- and vascular-driven cardiac phenotypes by vitamin A signaling. We identify the relationship between retinoids and maladaptive processes during the pathological hypertrophy of the heart, with a focus on the activation of neurohormonal signaling and fetal transcription factors (Gata4, Tbx5). Finally, we assess how this information might be leveraged to develop novel therapeutic avenues.

Understanding multifactorial drivers of child stunting reduction in Exemplar countries: a mixed-methods approach

BACKGROUND

Several countries have notably reduced childhood stunting relative to economic growth over the past 15-20 y. The Exemplars in Stunting Reduction project, or "Exemplars," studies success factors among these countries with a lens toward replicability.

OBJECTIVES

This paper details the standardized mixed-methods framework for studying determinants of childhood stunting reduction applied in Exemplars studies.

METHODS

An expert technical advisory group (TAG), criteria for identifying Exemplar countries, evidence-based frameworks, mixed methodologies (quantitative, qualitative, policy, literature review), effective research partnerships, case study process and timeline, and data triangulation and corroboration are presented.

RESULTS

Experts in health, nutrition, and evaluation methods were selected at the study outset to provide technical support to all phases of research (TAG). Exemplar countries were selected by the TAG, who considered quantitative data (e.g., annual rates of stunting change compared with economic growth, country population size) and qualitative insights (e.g., logistics of country work, political stability). Experienced country research partners were selected and an inception meeting with stakeholder consultations was held to launch research and garner support. Evidence-based conceptual frameworks underpinned all Exemplars research activities. A systematic review of published peer-reviewed and grey literature was undertaken, along with in-depth policy and program analysis of nutrition-specific and -sensitive investments. Both descriptive and advanced quantitative analysis was undertaken (e.g., equity analyses, difference-in-difference regression, Oaxaca-Blinder decomposition). Qualitative data collection using in-depth interviews and focus groups was conducted with national and community stakeholders (i.e., child care workers and mothers) to understand country experiences. The case study process was iterative, and all research outputs were triangulated to develop the stunting reduction narrative for each country. Findings were shared with country experts for weigh-in and corroboration through dissemination events.

CONCLUSIONS

Exemplars research uses a mixed-methods framework for studying positive outliers that can be applied across diverse health and development outcomes.

Drivers of stunting reduction in the Kyrgyz Republic: A country case study

BACKGROUND

Chronic malnutrition among infants and children continues to represent a global public health concern. The Kyrgyz Republic has achieved rapid declines in stunting over the last 20 y, despite modest increases in gross domestic product per capita.

OBJECTIVE

This study aimed to conduct a systematic, in-depth assessment of national, community, household, and individual drivers of nutrition change and stunting reduction, as well as nutrition-specific and -sensitive policies and programs, in the Kyrgyz Republic.

METHODS

This mixed methods study employed 4 inquiry methods, including: 1) a systematic scoping literature review; 2) retrospective quantitative data analyses, including linear regression multivariable hierarchical modeling, difference-in-difference analysis, and Oaxaca-Blinder decomposition; 3) qualitative data collection and analysis; and 4) analysis of key nutrition-specific and -sensitive policies and programs.

RESULTS

Stunting prevalence has decreased in the Kyrgyz Republic, however, subnational variations and inequities persist. Child growth Victora curves show improvements in height-for-age z-scores (HAZ) for children in the Kyrgyz Republic between 1997 and 2014, indicating increased intrauterine growth and population health improvements. The decomposition analysis explained 88.9% (0.637 SD increase) of the predicted change in HAZ for children under 3 y (1997-2012). Key factors included poverty (61%), maternal nutrition (14%), paternal education (6%), fertility (6%), maternal age (3%), and wealth accumulation (2%). Qualitative analysis revealed poverty reduction, increased migration and remittances, food security, and maternal nutrition as key drivers of stunting decline. Systematic scoping literature review findings supported quantitative and qualitative results, and indicated that land reforms and improved food security represented important factors. Key nutrition-specific and -sensitive policies and programs implemented involved breastfeeding promotion, social protection schemes, and land and health sector reforms.

CONCLUSIONS

Improvements in stunting were achieved amidst political and economic changes. Multilevel enablers, including poverty reduction, improved food security, and introduction of land and health reforms have contributed to improvements in health, nutrition, and stunting among children in the Kyrgyz Republic.

Vitamin A deficiency in Brazilian Children younger than 5 years old: a systematic review

Abstract Objectives: to examine the nutritional status of vitamin A in Brazilian children under 5 years old, delimiting their deficiency and associated factors. Methods: this is a systematic review of articles published between 2008 and 2018, using the SciELO, Bireme, and PubMed electronic databases. A validated instrument critically evaluated the studies. The summary measures were obtained by the random effect model, and their results are presented using the Forest Plot graph. The qualitative synthesis was based on the description of the main factors associated with Vitamin A Deficiency. Results: we included 14 cross-sectional studies with observations in basic health units, daycare centers, and households. The summary measure indicated Vitamin A Deficiency of 20% (CI95%= 17% - 23%), with high homogeneity according to the source of the sample. Lower age of the child, low birth weight, poor iron nutritional status, diarrhea, subclinical infection, inadequate basic sanitation conditions, younger mothers and less maternal educa-tion represented the main exposures associated with the outcome. Conclusion: the results show Vitamin A Deficiency as a public health problem in Brazilian children under 5 years old, especially when related to the development of infectious processes and maternal and child characteristics that show greater susceptibility.

Child acceptability of a novel provitamin A carotenoid, iron and zinc-rich complementary food blend prepared from pumpkin and common bean in Uganda: a randomised control trial

BACKGROUND

Ugandan children are fed homemade complementary foods (CFs) which are usually deficient in vitamin A, iron and zinc. Novel homemade CFs rich in vitamin A, iron and zinc need to be developed, and assessed for their acceptability among target children.

OBJECTIVE

Homemade provitamin A carotenoids (PVACs), iron and zinc-rich complementary food (CF), common bean pumpkin blend (BPB) formulated from pumpkin (Sweet cream) and common bean (Obwelu) and PVAC-rich pumpkin blend (PB) from Sweet cream were prepared by expert peer mothers. This study compared child acceptability of BPB and PB (control).

METHODS

The crossover acceptability study randomly assigned Ugandan children 6 to 24 months old to either receive 100 g of BPB (n = 35) or 100 g of PB (n = 35) on day one. After a washout period of one day, children crossed over to receive either BPB (n = 35) or PB (n = 35). The amount of CF consumed, duration of consumption, and micronutrient intake were assessed. The CF was acceptable if children consumed ≥50 g (50%) of served food (100 g). A paired t-test was used to determine the mean differences within participants between BPB and PB. The level of statistical significant difference was set at a probability value of 5% (p = 0.05).

RESULTS

The mean consumption of BPB and PB was 53.9 g and 54.4 g, respectively. The mean duration for consumption of BPB and PB was 20.6 and 20.3 min, respectively. There was no significant difference in the amounts consumed, and duration of consumption in BPB and PB (p > 0.05). The mean intake of vitamin A was significantly higher (p < 0.00001) in PB (152.5 μgRAE) compared to BPB (100.9 μgRAE). The mean iron intake was significantly higher in BPB (1.1 mg) (p < 0.00001) compared to PB (0.3 mg). Furthermore, zinc intake was significantly higher (p < 0.00001) in BPB (0.58 mg) compared to PB (0.13 mg).

CONCLUSION

A homemade complementary food, BPB, made from locally available common bean and pumpkin is rich in PVACs, iron and zinc and is acceptable to children in the age range of complementary feeding in Uganda.

TRIAL REGISTRATION

Pan African Clinical Trials Registry www.pactr.org as PACTR202002576768667 . Retrospectively registered. Date of registration: 29/January/2020.

Prediction of Vitamin A Stores in Young Children Provides Insights into the Adequacy of Current Dietary Reference Intakes

BACKGROUND

Limited data were available in infants and children when vitamin A (VA) DRIs were established; recommendations were developed based on average breast milk VA intake and extrapolation of data from adults.

OBJECTIVES

Our objective was to evaluate whether DRIs and reported intakes, with and without VA from intervention programs, would be sufficient to develop adequate VA stores from birth to age 5 y in Bangladeshi, Filipino, Guatemalan, and Mexican children.

METHODS

A mathematical relationship was established, defined by a series of equations, to predict VA total body stores (TBS) as a function of age based on VA intake and utilization. TBS calculated using reported VA intakes, with and without additional VA from intervention programs, were compared to those predicted using DRIs (specifically, Adequate Intake and RDA). Liver VA concentrations were also estimated.

RESULTS

Our predictions showed that for these 4 groups, DRIs were sufficient to attain liver VA concentrations >0.07 μmol/g by 1 wk of age and sustain positive VA balance for 5 y. Using reported intakes, which were lowest in Bangladeshis from 1 y on and highest in Guatemalans, predicted VA stores in Bangladeshi and Filipino children increased until ∼2-3 y, then TBS stabilized and liver VA concentrations decreased with age. When VA interventions were included, stores exceeded those predicted using DRIs by 12-18 mo. In contrast, reported intakes alone in Guatemalan and Mexican children resulted in VA stores that surpassed those calculated using DRIs. For all populations, reported intakes were sufficient to build liver concentrations >0.07 μmol/g by 3 mo.

CONCLUSIONS

Although more information is needed to better define dietary VA requirements in children, our results suggest that for an average, generally healthy child in a low- or middle-income country, current DRIs are sufficient to maintain positive VA balance during the first 5 y of life.

Liver is widely eaten by preschool children in the Northern Cape province of South Africa: Implications for routine vitamin A supplementation

Previous research has demonstrated a virtual absence of vitamin A deficiency and adequacy of vitamin A intake through consumption of liver in preschool children of a community in the Northern Cape province of South Africa where sheep farming is common, and liver, an exceptionally rich source of vitamin A, is frequently eaten. Only 60-75 g of liver per month is needed to meet the vitamin A requirement of preschool children. Because this may have implications for routine vitamin A supplementation, and because liver consumption for the rest of the province is unknown, the study aim was to establish the prevalence and frequency of liver intake in a provincial-wide survey. An unquantified liver-specific food frequency questionnaire, covering a period of 1 month, complemented by a 1-year recall, was administered to mothers of 2- to 5-year-old children (n = 2,864) attending primary health care facilities in all five districts and 26 subdistricts. A total of 86% of children were reported to eat liver, which was eaten in all districts by at least 80% of children. The overall median frequency of liver intake was 1.0 [25th, 75th percentiles: 0.5, 3.0] times per month and ranged from 1.0 [0.3, 2.0] to 2.0 [1.0, 4.0] for the various districts. Based on a previously reported portion size of 66 g, these results suggest vitamin A dietary adequacy in all districts and possibly also vitamin A intake exceeding the Tolerable Upper Intake Level in some children. Routine vitamin A supplementation in this province may not be necessary and should be reconsidered.

National Prevalence of Micronutrient Deficiencies, Anaemia, Genetic Blood Disorders and Over- and Undernutrition in Omani Women of Reproductive Age and Preschool Children

A national cross-sectional survey was conducted to estimate the prevalence of anaemia, micronutrient deficiencies, haemoglobin disorders and over- and undernutrition in children and women of reproductive age in Oman. Wasting and stunting were found in 9.3% and 11.4% of children aged 0-59 months, respectively, while 4.2% were overweight or obese. In addition, 23.8% were anaemic and 10.2%, 9.5% and 10.6% had iron, vitamin A and vitamin D deficiencies, respectively. Sickle cell and β-thalassaemia genetic traits were present in 5.3% and 4.2% of children and 4.7% and 2.8% of women, respectively. Overall, 9.1% of Omani women were underweight and 59.2% were overweight or obese. The prevalence of anaemia was 27.8%, while iron, folate, vitamin B12 and vitamin D deficiencies affected 24.8%, 11.6%, 8.9% and 16.2%, respectively. Anaemia among both children and women and the prevalence of overweight and obesity in women are the most concerning nutritional problems in Oman.

Outer retina changes on optical coherence tomography in vitamin A deficiency

Background

Vitamin A deficiency is rare in the United States and can be missed in patients with malabsorption syndromes without a high dose of suspicion. Ocular complications of hypovitaminosis A include xerosis and nyctalopia, and to a lesser extent reduction in visual acuity and color vision. Outer retinal changes, as seen on spectral domain optic coherence tomography (SD-OCT), in patients with vitamin A deficiency have previously not been documented.

Case presentation

We present two cases with symptoms of severe nyctalopia who were subsequently diagnosed with severe Vitamin A deficiency and their unique findings on SD-OCT of outer nuclear layer diffuse thinning with irregular appearance of the interdigitating zone and the ellipsoid zone as well as normalization after vitamin A supplementation.

Conclusions

Outer nuclear layer thinning and disruption of the outer retinal bands on SD-OCT are reversible with correction of vitamin A deficiency. Improvement in visual acuity, color vision, and nyctalopia are possible with early diagnosis and appropriate treatment.

Dietary β-Carotene Rescues Vitamin A Deficiency and Inhibits Atherogenesis in Apolipoprotein E-Deficient Mice

Vitamin A deficiency (VAD) is a major health problem, especially in developing countries. In this study, we investigated the effect of VAD from weaning to adulthood in apoE^−/− mice. Three-week-old male mice were allocated into four diet groups: I. VAD II. VAD+vitamin A (VA), 1500 IU retinyl-palmitate; III. VAD+β-carotene (BC), 6 g/kg feed, containing 50% all-trans and 50% 9-cis BC. IV. VAD with BC and VA (BC+VA). After 13 weeks, we assessed the size of atherosclerotic plaques and measured VA in tissues and BC in plasma and tissues. VAD resulted in diminished hepatic VA levels and undetectable brain VA levels compared to the other groups. BC completely replenished VA levels in the liver, and BC+VA led to a two-fold elevation of hepatic VA accumulation. In adipose tissue, mice fed BC+VA accumulated only 13% BC compared to mice fed BC alone. Atherosclerotic lesion area of BC group was 73% lower compared to VAD group (p < 0.05). These results suggest that BC can be a sole source for VA and inhibits atherogenesis.

The Co-Occurrence of Overweight and Micronutrient Deficiencies or Anemia among Women of Reproductive Age in Malawi

BACKGROUND

In low-resource settings, urbanization may contribute to the individual-level double burden of malnutrition (DBM), whereby under- and overnutrition co-occur within the same individuals.

OBJECTIVE

We described DBM prevalence among Malawian women by urban-rural residence, examined whether urban residence was associated with DBM, and assessed whether DBM prevalence was greater than the prevalence expected by chance given population levels of under- and overnutrition, which would suggest DBM is a distinct phenomenon associated with specific factors.

METHODS

We analyzed nationally representative data of 723 nonpregnant women aged 15-49 y from the 2015-2016 Malawi Micronutrient Survey. DBM was defined as co-occurring overweight or obesity (OWOB) and ≥1 micronutrient deficiency or anemia. We used Poisson regression models to examine the association between urban residence and DBM and its components. The Rao-Scott modified chi-square test compared the observed and expected DBM prevalence.

RESULTS

Nationally, 10.8% (95% CI: 7.0, 14.5) of women had co-occurring OWOB and any micronutrient deficiency and 3.4% (95% CI: 1.3, 5.5) had co-occurring OWOB and anemia. The prevalence of co-occurring OWOB and any micronutrient deficiency was 2 times higher among urban women than rural women [urban 32.6 (24.1, 41.2) compared with rural 8.6 (5.2, 11.9), adjusted prevalence ratio: 2.0 (1.1, 3.5)]. Co-occurring OWOB and anemia prevalence did not significantly differ by residence [urban 6.9 (0.6, 13.2) compared with rural 3.0 (0.8, 5.3)]. There were no statistically significant differences in observed and expected prevalence estimates of DBM.

CONCLUSIONS

This analysis shows that co-occurring OWOB and any micronutrient deficiency was higher among women in urban Malawi compared with rural areas. However, our finding that co-occurring OWOB and any micronutrient deficiency or anemia may be due to chance suggests that there may not be common causes driving DBM in Malawian women. Thus, there may not be a need to design and target interventions specifically for women with DBM.

Glycyrrhetinic acid attenuates disturbed vitamin a metabolism in non-alcoholic fatty liver disease through AKR1B10

Abnormal vitamin A (retinol) metabolism plays an important role in the occurrence of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). In this study, NAFLD and NASH models were established to investigate the effects of food additives glycyrrhizic acid (GL) on retinol metabolism in NAFLD/NASH mice. Potential targets of GL and its active metabolite glycyrrhetinic acid (GA) were analyzed by RNA sequence, bioinformatics, and molecular docking analyses. Gene transfection and enzymatic kinetics were used to identify the target of GL. The results showed that GL could resolve the fatty and inflammatory lesions in the mouse liver, thereby improving the disorder of retinol metabolism. RNA sequence analysis of model mice liver revealed significant changes in AKR1B10 (retinol metabolic enzymes). Bioinformatics and molecular docking analyses showed that AKR1B10 is a potential target of GA but not GL. GA could inhibit AKR1B10 activity, which then affects retinol metabolism, whereas GL only had the same effect after hydrolysis into GA. In AKR1B10-KO hepatocytes, GA, GL, and hydrolysates of GL had no regulatory effect on retinol metabolism. Therefore, GA, the active metabolite of GL, as a novel AKR1B10 inhibitor, could promote retinoic acid synthesis. GL restored the balance of retinol metabolism in NAFLD/NASH mice by metabolizing to GA.

Evaluating Provitamin A Carotenoids and Polar Metabolite Compositions during the Ripening Stages of the Agung Semeru Banana (Musa paradisiaca L. AAB)

Banana cultivars that are rich in provitamin A carotenoids and other nutrients may offer a potential food source to help alleviate vitamin A deficiencies, particularly in developing countries. The local plantain type banana, Agung Semeru (Musa paradisiaca L.), was investigated, in order to analyse the changes in the compositions of the provitamin A carotenoids and metabolite compounds, including the amino acids, organic acids, and sugars, during the ripening stage as this banana is widely processed for food products in either the unripe, ripe, or overripe stages. The bananas that had reached the desired ripening stages were subjected to high-performance liquid chromatography (HPLC) analysis, and the results indicated that the total provitamin A carotenoid concentrations ranged between 4748.83 μg/100 g dry weight (dw) and 7330.40 μg/100 g dw, with the highest level of vitamin A activity at 457.33 ± 5.18 μg retinol activity equivalents (RAE)/100 g dw. Compared to the Cavendish variety, which is consumed worldwide, the Agung Semeru banana had vitamin A activity that was 40 to 90 times higher, dependent on the stage of ripening. The breakdown of the starch during the ripening stages resulted in an increase of its sugar compounds, such as sucrose, fructose, and glucose, as well as its dominant organic acids, such as malic acid, oxalic acid, and citric acid, which were observed using gas chromatography-mass spectrometry (GC-MS) during the ripening stages. The findings of this study show that the Agung Semeru banana is a promising fruit that could be widely produced as a nutritional and energy food resource, due to its high levels of vitamin A activity and sugars.

Improving nutritional quality of rice for human health

This review surveys rice nutritional value, mainly focusing on breeding achievements via adoption of both genetic engineering and non-transgenic strategies to improve key nutrients associated with human health. Rice (Oryza sativa) is an essential component of the diets and livelihoods of over 3.5 billion people. Polished rice is mostly consumed as staple food, fulfilling daily energy demands and part of the protein requirement. Brown rice is comparatively more nutritious, containing more lipids, minerals, vitamins, dietary fiber, micronutrients, and bioactive compounds. In this article, we review the nutritional facts about rice including the level of γ-aminobutyric acid, resistant starch, lysine, iron, zinc, β-carotene, folate, anthocyanin, various carotenoids, and flavonoids, focusing on their synthesis and metabolism and the advances in their biofortification via adoption of both conventional and genetic engineering strategies. We conclude that besides representing a staple food, rice has the potential to become a source of various essential nutrients or bioactive compounds through appropriate genetic improvements to benefit human health and prevent certain chronic diseases. Finally, we discuss the available, non-genetically engineering strategies for the nutritional improvement of rice, including their main strengths and constraints.

Retinol, Retinoic Acid, and Retinol-Binding Protein 4 are Differentially Associated with Cardiovascular Disease, Type 2 Diabetes, and Obesity: An Overview of Human Studies

Vitamin A is a fat-soluble essential nutrient obtained from plant- and animal-based sources that has roles in growth, vision, and metabolism. Vitamin A circulates mainly as retinol bound to retinol-binding protein 4 (RBP4), and is delivered to tissues and converted to retinoic acid, which is a ligand for several nuclear receptors. In recent years, aspects of vitamin A metabolism have been under scrutiny with regards to the development of metabolic and lifestyle diseases including cardiovascular disease (CVD), type 2 diabetes mellitus (T2DM), and overweight and obesity in humans. Studies have mainly focused on RBP4 in this context, whereas the major circulating form, retinol, and the major bioactive form, retinoic acid, have been overlooked in this regard until recently. As one of the main roles of RBP4 is to deliver retinol to tissues for biological action, the associations of retinol and retinoic acid with these diseases must also be considered. In this review, we summarize and discuss recent and available evidence from human studies with focus on retinol, retinoic acid, and RBP4 and provide an overview of these crucial components of vitamin A metabolism in CVD, T2DM, and obesity. In summary, retinol was found to be both inversely and positively associated with CVD whereas the associations with T2DM and obesity were less clear. Although only a few studies have been published on retinoic acid, it was inversely associated with CVD. In contrast, serum RBP4 was mostly found to be positively associated with CVD, T2DM, and obesity. At present, it is difficult to ascertain why the reported associations differ depending on the compound under study, but there is a clear imbalance in the literature in disfavor of retinol and retinoic acid, which needs to be considered in future human studies.

Retinol deficiency in animals: Etiopathogenesis and consequences

Infertility is widespread for all species of animals and causes significant economic losses to livestock due to the loss and shortage of offspring, their reduced viability and, consequently, increased morbidity and mortality. Alimentary-deficiency factors are among the commonest causes of infertility, from which A-vitamin deficiency should be singled out. The precursor of vitamin A in the body is carotene, which is an unstable compound which is easily destroyed even under the influence of moderate factors of influence, in connection with which its deficiency is global, especially at the end of the winter – stall period of keeping animals. Accordingly it is the leading etiological factor of retinol deficiency infertility. As a result, the body has two negatives that act in parallel: carotene / vitamin A deficiency adversely affects the organs, the constituent and major functional unit of which is the secretory epithelial cell, and the free radical oxides formed in high concentration are extremely effective in destroying the cells, weakening antioxidant protection. Vitamin A has a significant effect on the reproductive function of animals both directly and indirectly. It is necessary to ensure the structure and functioning of the epithelial tissues of the organs of regulation and performance of sexual function, and therefore the physiological development of the fetus and the course of pregnancy, parturition and postpartum period, ovo- and spermiogenesis, the manifestation of sexual reflexes. Instead, its deficiency underlies the etiology and pathogenesis of retinol deficiency infertility of animals, causing changes in individual indices of homeostasis and prooxidate-antioxidant system, morphostructure of the reproductive and endocrine organs, hormonal status, sperm quality and reproductive function. The consequence is the emergence and development of gynecological, andrological, mammological and perinatal (ante-, intra-, post- and neo-) pathologies. At the same time, the addition of carotene or retinol to the diets of animals or their oral administration in cases of deficiency of vitamin A prevents impaired reproductive function. The study of the features of the etiopathogenesis of retinol deficiency infertility of animals allows programs of complex diagnostics, therapy and prevention to be developed which provide determination of carotene and vitamin A content and replenishment of the organism in cases of their deficiency.

Perspective: Integration to Implementation (I-to-I) and the Micronutrient Forum-Addressing the Safety and Effectiveness of Vitamin A Supplementation

An ongoing challenge to our ability to address the role of food and nutrition in health promotion and disease prevention is how to design and implement context-specific interventions and guidance that are safe, efficacious, and avoid unintended consequences. The integration to effective implementation (I-to-I) concept is intended to address the complexities of the global health context through engagement of the continuum of stakeholders involved in the generation, translation, and implementation of evidence to public health guidance/programs. The I-to-I approach was developed under the auspices of the Micronutrient Forum and has been previously applied to the question of safety and effectiveness of interventions to prevent and treat nutritional iron deficiency. The present article applies the I-to-I approach to questions regarding the safety and utility of large-dose vitamin A supplementation programs, and presents the authors' perspective on key aspects of the topic, including coverage of the basic and applied biology of vitamin A nutrition and assessment, clinical implications, and an overview of the extant data with regard to both the justification for and utility of available intervention strategies. The article includes some practical considerations based on specific country experiences regarding the challenges of implementing vitamin A-related programs. This is followed by an overview of some challenges associated with engagement of the enabling communities that play a critical role in the implementation of these types of public health interventions. The article concludes with suggestions for potential approaches to move this important agenda forward.

A prospective cohort analysis of gut microbial co-metabolism in Alaska Native and rural African people at high and low risk of colorectal cancer

BACKGROUND

Alaska Native (AN) people have the world's highest recorded incidence of sporadic colorectal cancer (CRC) (∼91:100,000), whereas rural African (RA) people have the lowest risk (<5:100,000). Previous data supported the hypothesis that diet affected CRC risk through its effects on the colonic microbiota that produce tumor-suppressive or -promoting metabolites.

OBJECTIVES

We investigated whether differences in these metabolites may contribute to the high risk of CRC in AN people.

METHODS

A cross-sectional observational study assessed dietary intake from 32 AN and 21 RA healthy middle-aged volunteers before screening colonoscopy. Analysis of fecal microbiota composition by 16S ribosomal RNA gene sequencing and fecal/urinary metabolites by 1H-NMR spectroscopy was complemented with targeted quantification of fecal SCFAs, bile acids, and functional microbial genes.

RESULTS

Adenomatous polyps were detected in 16 of 32 AN participants, but not found in RA participants. The AN diet contained higher proportions of fat and animal protein and less fiber. AN fecal microbiota showed a compositional predominance of Blautia and Lachnoclostridium, higher microbial capacity for bile acid conversion, and low abundance of some species involved in saccharolytic fermentation (e.g., Prevotellaceae, Ruminococcaceae), but no significant lack of butyrogenic bacteria. Significantly lower concentrations of tumor-suppressive butyrate (22.5 ± 3.1 compared with 47.2 ± 7.3 SEM µmol/g) coincided with significantly higher concentrations of tumor-promoting deoxycholic acid (26.7 ± 4.2 compared with 11 ± 1.9 µmol/g) in AN fecal samples. AN participants had lower quantities of fecal/urinary metabolites than RA participants and metabolite profiles correlated with the abundance of distinct microbial genera in feces. The main microbial and metabolic CRC-associated markers were not significantly altered in AN participants with adenomatous polyps.

CONCLUSIONS

The low-fiber, high-fat diet of AN people and exposure to carcinogens derived from diet or environment are associated with a tumor-promoting colonic milieu as reflected by the high rates of adenomatous polyps in AN participants.

How can we realise the full potential of health systems for nutrition?

Poor nutrition contributes substantially to global disease, diminishing the wellbeing of women and children in low and middle income countries, and better nutrition must be part of the universal health coverage agenda, say Rebecca Heidkamp and colleagues

Strategies to achieve adequate vitamin A intake for young children: options for Cameroon

Meeting children's vitamin A (VA) needs remains a policy priority. Doing so efficiently is a fiscal imperative and protecting at-risk children during policy transitions is a moral imperative. Using the Micronutrient Intervention Modeling tool and data for Cameroon, we predict the impacts and costs of alternative VA intervention programs, identify the least-cost strategy for meeting targets nationally, and compare it to a business-as-usual (BAU) strategy over 10 years. BAU programs effectively cover ∼12.8 million (m) child-years (CY) and cost ∼$30.1 m; ∼US$2.34 per CY effectively covered. Improving the VA-fortified oil program, implementing a VA-fortified bouillon cube program, and periodic VA supplements (VAS) in the North macroregion for 3 years effectively cover ∼13.1 m CY at a cost of ∼US$9.5 m, or ∼US$0.71 per CY effectively covered. The tool then identifies a sequence of subnational policy choices leading from the BAU toward the more efficient strategy, while addressing VA-attributable mortality concerns. By year 4, fortification programs are predicted to eliminate inadequate VA intake in the South and Cities macroregions, but not the North, where VAS should continue until additional delivery platforms are implemented. This modeling approach offers a concrete example of the strategic use of data to follow the Global Alliance for VA framework and do so efficiently.

Strengthening Routine Immunization Services in an Angolan Comuna: The Fight against the Burden of Unvaccinated Children in the Sustainable Development Goals Era

In May 2018, the non-governmental organization (NGO) Doctors with Africa CUAMM began to implement an intervention to strengthen Chiulo Hospital’s public health section to deliver immunization services in Mucope Comuna, Ombadja District. We aimed to evaluate the effect of this intervention. During the intervention period, actions such as staff training, improvement in the monitoring of vaccine stockpile, and the involvement of Community Health Workers were performed. The effects of the intervention on the number of vaccine doses administered were examined using negative binomial regression. Doses administered were 14,221 during the intervention period and 11,276 in the pre-intervention one. The number of administered doses was 26% higher (95% CI 9%–45%) in the intervention period than in the pre-intervention period. This was driven by vaccine doses administered during outreach sessions, where a statistically significant increase of 62% (95% CI 28%–107%) was observed. Regarding individual vaccines, statistically significant increases in the number of doses were observed for OPV2 (76%), OPV3 (100%), Penta3 (53%), PCV3 (53%), and Rota2 (43%). The NGO interventions led to improved delivery of immunization services in the study area. Greater increases were observed for vaccine doses that are more likely to be missed by children.

Medical reversals in low- and middle-income countries

BACKGROUND

Low- to middle-income countries (LMICs) often have limited budgets for health care, and as such, they need to prioritize health care interventions that are evidence based. However, sometimes, interventions are implemented despite a lack of supporting evidence because of a perceived biologic plausibility or because they have worked in other populations. Later, some of these interventions are shown to either lack benefit or are harmful in randomized studies, which we call a medical reversal.

MAIN BODY

In this paper, we discuss a variety of medical reversals in LMICs, ranging from tuberculosis to nutrition to malaria to septic shock. These practices were previously identified, but we wish to highlight those that are most relevant to LMICs.

CONCLUSION

Identifying and eliminating these practices will help in better allocation of limited health care resources and dollars in LMICs.

Gender Equity and Vitamin A Supplementation: Moving Beyond Equal Coverage

Background:

Vitamin A supplementation (VAS) is currently implemented in over 80 countries worldwide, but little attention has been paid to gender equity in the design or implementation of these programs.

Objective:

This article describes the ways in which gender equity can impact or be impacted by VAS programs and suggests ways to ensure these programs better support gender equity in the future.

Methods:

We undertook a desk review of research on gender equity in health services and extrapolated findings to VAS, highlighting gender equity issues throughout the VAS implementation process and across delivery platform types. We also amassed secondary data on VAS coverage from 45 surveys in 13 countries and analyzed it to examine differences in VAS coverage between boys and girls.

Results:

Despite few significant differences in coverage between boys and girls, we identify numerous ways in which gender equity can impact or be impacted by VAS programs, including through the choice of VAS distributors and the communication materials used to promote VAS campaigns. Examining these different entry points reveals that there are several missed opportunities for better integration of gender within VAS.

Conclusions:

VAS program implementers and policymakers should revisit VAS approaches to identify opportunities for advancing gender equity through this wide-reaching platform.