Prevalence of ocular signs and subclinical vitamin A deficiency and its determinants among rural pre-school children in India

Clinical vitamin A deficiency among preschool aged children in southwest Ethiopia

Background

The clinical manifestations of vitamin A deficiency (VAD) involve night blindness, bitot's spots, corneal xerosis, and corneal scars. It is the most important cause of preventable childhood blindness among children and causes morbidity and mortality. Even though Ethiopia implemented high-potency vitamin A supplements, the occurrence of VAD remains significant. This study was to identify determinants of clinical VAD among preschool-aged children (PSC) in southwest Ethiopia.

Method

A community-based survey was conducted among 411 randomly selected PSCs. A pretested and structured questionnaire coupled with clinical observation for signs of vitamin A deficiency by a trained ophthalmologist was used to collect the data. An anthropometric measurement of height was taken and analyzed using WHO Anthro to calculate Z-scores for each index. The public health significance of VAD was declared after comparison with international references. A bi-variable and multi-variable logistic analysis was done. We reported the adjusted odds ratio (AOR), 95% confidence interval, and p-value.

Result

A total of 411 children were screened for clinical VAD, and the overall prevalence was 2.2% (95% CI: 1.5-2.5). Of which, night blindness affects 1.2%, bitot's spots affects 0.7%, and corneal xerosis affects 0.2%, indicating a major public health problem compared to the international reference. The odds of clinical VAD were 81% lower among children who received vitamin A supplementation (VAS; AOR = 0.19, 95% CI: 0.04-0.92). On the other hand, PSC of mothers who had attended ANC visits were 89% less likely to develop clinical VAD (AOR = 0.11, 95% CI: 0.02-0.53). In addition, the study revealed that the odds of developing clinical VAD are 82% lower among PSC aged 36 to 47 months (AOR = 0.18; 95% CI: 0.03-0.97).

Conclusion

The prevalence of clinical VAD among PSC is a public health problem and is associated with ANC visits, VAS status, and the age of the child, which could be used to target interventions to further reduce existing VAD. Further studies using reliable dietary intake and biomarker data could further depict the burden of subclinical VAD.

Etiology, Epidemiology, Pathophysiology, Signs and Symptoms, Evaluation, and Treatment of Vitamin A (Retinol) Deficiency

Vitamin A, also known as retinol, is a non-water-soluble vitamin. Vitamin A is very important for the proper functioning of the human body. Retinol, especially in the form of retinyl ester, can be found in many animal-based products and is essential for the efficient operation of many physiological processes. Fruits and vegetables are also excellent sources of vitamin A; the majority of them include carotenoids, which are precursors to vitamin A. The human body has the ability to convert natural retinols like retinyl ester, retinoic acid, and provitamin A into biologically active forms that interact with a variety of molecular targets like nuclear receptors and retinal opsins. This review article provides knowledge regarding retinol deficiency in humans. It provides brief information about the sources, etiology, epidemiology, pathophysiology, and treatment of vitamin A deficiency.

Vitamin A deficiency and associated risk factors in children aged 12-59 months living in poorest municipalities in the South Region of Brazil

OBJECTIVE

To estimate the prevalence of vitamin A deficiency (VAD) in children and associated risk factors.

DESIGN

Analysis of data from a cross-sectional multicentre study performed in the primary care units of the municipalities from January to June 2015. The children's legal guardians answered a socio-economic questionnaire, and the children's blood samples were obtained by venipuncture. Plasma retinol was determined by HPLC. Plasma retinol values of <0·70 μmol/l were considered VDA. Poisson multiple regression with robust variance was used. Values of P < 0·05 were considered significant. The data were analysed in the SPSS software, 21.0.

SETTING

Forty-eight poorest municipalities in the South Region of Brazil.

PARTICIPANTS

Children (n 1503) aged 12-59 months.

RESULTS

The prevalence of VAD in the sample was 1·9 % (95 % CI (0·5, 6·8)). The following risk factors were associated with the outcome in the final explanatory model: family received Bolsa Familia program benefits (PR = 3·19; 95 % CI (1·69, 6·02)), child was not being breastfed (PR = 5·22; 95 % CI (1·68, 16·18)) and stunting (PR = 4·75; 95 % CI (2·10, 10·73)).

CONCLUSIONS

VAD did not represent a public health problem for children living in socio-economically vulnerable municipalities in the South Region of Brazil, suggesting a new panorama of this nutritional deficiency even in regions of low socio-economic conditions in these three states. Thus, in view of the current nutritional transition scenario, it is necessary to continuously monitor and improve public policies related to vitamin A supplementation in the country.

Delayed Processing of Chilled Whole Blood for 24 Hours Does Not Affect the Concentration of the Majority of Micronutrient Status Biomarkers

BACKGROUND

The measurement of micronutrient status is essential to understand the health of individuals and populations, but there are limited data on the stability of micronutrients in whole blood.

OBJECTIVES

The objective was to investigate the effects of delayed processing of whole blood on the stability of 25 micronutrient and selected clinical biomarkers.

METHODS

Blood from 16 healthy adults was collected into EDTA, lithium heparin (LH), or serum tubes. Samples were processed within 2 hours of collection ("2-hour processed") or mailed overnight (boxed with frozen cold packs) before processing ("24-hour processed"). Micronutrient and clinical biomarker concentrations were quantified with validated methods. The concentration percentage difference between the 2- and 24-hour processed samples was calculated and was compared against quality specifications determined from intra- and interindividual variations.

RESULTS

All analytes had a sample type where the percentage difference concentration between 2-hour and 24-hour processed samples was ≤4% and was acceptable based on calculated limits, including for biomarkers of vitamin A, vitamin D, thiamin, folate, vitamin B-12, iron (ferritin), and zinc status and for selected clinical markers, C-reactive protein, HDL and total cholesterol, and triglycerides. EDTA plasma vitamin C was lower compared to the 2-hour processed sample (geometric mean, 43%; 95% CI: 36%-49%). Pyridoxal-5-phosphate (vitamin B-6 biomarker) decreased, with differences from the 2-hour processed samples of -8% (95% CI: -13% to -2%) and -14% (95% CI: -18% to -9%) in LH plasma and serum, respectively.

CONCLUSIONS

In blood collected from adult participants, delayed processing of chilled whole blood for 24 hours did not materially affect the measured concentrations of the majority of micronutrients and selected clinical biomarkers. This suggests that for these analytes, adherence to a 2-hour processing protocol may be unnecessary. This knowledge is valuable and may help to simplify logistics for sample transport and processing of blood samples for micronutrient status assessment.

Prevalence of vitamin A deficiency and dietary inadequacy in Indian school-age children and adolescents

PURPOSE

There are no representative estimates of vitamin A deficiency (VAD) and risk of vitamin A (VA) dietary inadequacy in Indian children and adolescents. To evaluate, from national surveys, the prevalence of VAD measured by serum retinol concentrations (< 0.7 µmol/L or < 20 µg/dL), and the risk of VA dietary inadequacy and excess intake beyond the tolerable upper limit (TUL).

METHODS

National and state-level VAD prevalence adjusted for inflammation was estimated in school-age children (5-9 years: 10,298) and adolescents (10-19 years: 9824) from the Comprehensive National Nutrition Survey (CNNS 2016-18). The risk of dietary inadequacy against age-specific average VA requirements, and excess intake against the TUL, was assessed from the National Sample Survey Office (NSSO 2014) data.

RESULTS

Serum retinol concentrations increased with age (5-19 years) in both genders and were significantly lower in school-age children (1.02 µmol/L, CI: 1.01-1.03) compared to adolescents (1.13 µmol/L, CI 1.12-1.15). The inflammation-adjusted prevalence of VAD in school-age children and adolescents was 19.3% (CI 18.8-19.9) and 14.4% (CI 13.9-14.9) respectively, and this was > 20% in seven and four states for children and adolescents, respectively. The prevalence of VAD was significantly higher among children with lower socio-economic status. The risk of dietary VA inadequacy, from the NSSO survey, was 69 and 78% in children and adolescents, respectively. This risk reduced to 6 and 17% with VA fortified oil and milk intake, while the proportion of intakes exceeding the TUL became 6 and 0.5% in children and adolescents, respectively.

CONCLUSIONS

The national prevalence of VAD in school-age children and adolescents in India was just less than 20%. The risk of dietary VA deficiency is likely to decline substantially with VA fortified food intake, but a risk of excessive intake also begins to appear; therefore, a careful assessment of the risk of hypervitaminosis A is required at these ages.

Vitamin A deficiency among children younger than 5 y in India: an analysis of national data sets to reflect on the need for vitamin A supplementation

BACKGROUND

Biochemical vitamin A deficiency (VAD) is believed to be a serious public health problem (low serum retinol prevalence >20%) in Indian children, justifying universal high-dose vitamin A supplementation (VAS).

OBJECTIVE

To evaluate in Indian children younger than 5 y the risk of biochemical VAD from the Comprehensive National Nutrition Survey, as well as dietary vitamin A inadequacy and excess over the tolerable upper limit of intake (TUL) from national and subnational surveys, factoring in fortification and VAS.

METHODS

Child serum retinol data, corrected for inflammation, were examined to evaluate national- and state-level prevalence of VAD. Simultaneously, dietary intakes from the National Sample Survey Office and the National Nutrition Monitoring Bureau were examined for risk of dietary vitamin A deficiency against its average requirement (AR) derived for Indian children. Theoretical estimates of risk reduction with oil and milk vitamin A fortification were evaluated along with the risk of exceeding the TUL, as well as when combined with intake from VAS.

RESULTS

The national prevalence of biochemical VAD measured in 9563 children was 15.7% (95% CI: 15.2%, 16.3%), and only 3 states had prevalence significantly >20%. The AR of vitamin A was 198 and 191 µg/d for boys and girls; the risk of dietary inadequacy was ∼70%, which reduced to 25% with oil and milk fortification. Then, the risk of exceeding the TUL was 2% and 1% in 1- to 3-y-old and 4- to 5-y-old children, respectively, but when the VAS dose was added to this intake in a cumulative 6-mo framework, the risk of exceeding the TUL rose to 30% and 8%, respectively.

CONCLUSION

The national prevalence of VAD risk is below 20% in Indian children. Because there is risk of excess intake with food fortification and VAS, serious consideration should be given to a targeted approach in place of the universal VAS program in India.

Retention, stability, iron bioavailability and sensory evaluation of extruded rice fortified with iron, folic acid and vitamin B12

Fortification of rice with micronutrients using extrusion technology is considered a sustainable strategy to prevent nutritional deficiencies in general population. The objective of the present study is to assess the retention, stability and iron bioavailability from indigenously developed triple fortified rice (iron, folic acid and vitamin B12 ) during rinsing and different cooking methods. Further, we also assessed the acceptability of fortified rice in adult human volunteers. The retention of iron during rinsing with excess water was ≥90%, whereas folic acid and vitamin B12 levels were reduced by ~25% during rinsing. Watertight cooking of rice (in electric cooker or on flame) had no additional effect on the nutrient levels as compared with rinsed rice, implying their stability during cooking. However, cooking with excess water followed by decanting led to loss of 45% iron and ≥70% folic acid and vitamin B12 . The dialyzable iron and ferritin synthesis in Caco-2 cells was significantly (P < .01) higher from fortified rice compared with unfortified rice. In addition, inclusion of ascorbic acid significantly (P < .01) increased the iron bioavailability from the fortified rice. Triangle tests in adult human subjects revealed that there are no significant sensory differences among fortified and unfortified rice. Further, fortified rice consumption appears to bridge the gaps in dietary iron intake deficits in children and women of reproductive age. These results suggest that the iron-, folic acid- and vitamin B12 -fortified rice has higher retention and stability of fortified nutrients and is acceptable for consumption in adult human volunteers.

Prevalence and Associated Factors of Clinical Vitamin A Deficiency Among Pre-School Children 1-5 Years of Age in Rural Kebeles in Farta District, South Gondar Zone, Ethiopia: A Mixed Methods Study

Background

Globally, pre-school children are the most at-risk population groups for vitamin A deficiency (VAD). The 2009 World Health Organization (WHO) report stated that one-third (190 million) of pre-school children worldwide are deficient in vitamin A. Both clinical and subclinical VAD have been a long-standing problem in developing countries. In Ethiopia, VAD was recognized as a public health problem 4–5 decades before. Since then, researches conducted in other parts of the country still showed varied and high prevalence, which is 2–8 times higher than WHO cut-off points. This community-based study was therefore conducted on pre-school children of rural kebeles in Farta district to determine the prevalence of clinical VAD (Bitot’s spot and night blindness) and associated factors.

Methods

A community-based cross-sectional mixed quantitative and qualitative study was conducted. Randomly selected 588 pre-school children participated in the study. The clinical aspect of the study investigated the presence of Bitot’s spots on the children’s eye with the aid of a magnifying loop and torch. Data on the history of night blindness were obtained from mothers/caregivers by using WHO standard questions. The qualitative study data were obtained via a key informant interview with the mothers/caregivers whose child has clinical VAD. Quantitative data were entered using Epi Data statistical software and analysed by using SPSS version 20 statistical software package. A bivariable logistic regression was employed, and variables that showed significant association with clinical VAD (P < 0.2) were entered a multivariable logistic regression model to identify independent predictors of clinical VAD.

Results

The prevalence of Bitot’s spot and night blindness was 0.8% and 1.2%, respectively. Pre-school children who were from highland (AOR: 3.71; 95% CI: 1.01–13.68), a mother having antenatal care (ANC) visit during pregnancy of a child (AOR: 8.63; 95% CI: 2.58–28.79), family monthly income (AOR: 8.63; 95% CI: 2.58–28.79) and handwashing frequency were found to be determinants of VAD (p < 0.05).

Conclusion

Clinical vitamin A deficiency in the study area is of public health concern because the prevalence of Bitot’s and night blindness was above the WHO threshold level. Accordingly, effective preventive measures should be designed to reduce VAD prevalence.

Does India Need a Universal High-Dose Vitamin A Supplementation Program?

High dose vitamin A (HDVA) concentrate began to be distributed in India in 1970 as a short-term, stop-gap approach to reduce clinical signs of vitamin A deficiency. As this problem declined globally, the purpose of distributing them changed to the reduction of young child mortality. However, their impact on this has also declined, if not disappeared, as suggested in India by the enormous DEVTA study. This may be because of improved protection against and treatment of the main morbidity involved, measles and diarrhea. At the same time, semi-annual provision of mega-doses of vitamin A is not without risks, in particular linked to children's vaccination status. While a single dose is inexpensive, large-scale implementation of HDVA programs is expensive, particularly the opportunity cost involved in reducing the time health workers involved have to deal with their other commitments. Balancing potential benefits, risks and costs leads us to recommend an immediate cessation of the distribution of HDVA in India.

A sequential, exploratory, mixed-methods approach for development and validation of a context-specific knowledge, attitude and practice questionnaire on micronutrients for literate mothers of school-age children

OBJECTIVE

To develop and validate a context-specific comprehensive knowledge, attitude and practice (KAP) questionnaire for literate mothers on factors affecting micronutrient status of 6-10-year-old children.

DESIGN

Sequential exploratory mixed-methods study using focus group discussions (FGD) and psychometric validation.

SETTING

Seven randomly selected villages with &gt;500 households with three to five family members each, in Ghatkesar sub-district, Medchal district, Telangana state, India.ParticipantsLiterate mothers from middle-income households with at least one child (6-10 years) for FGD (n 44), for testing the internal consistency (n 80) and for test-retest reliability (n 30).

RESULTS

The themes for FGD were diet diversity, micronutrients, cooking and eating practices, national programmes and sunlight exposure. Knowledge among caregivers about sources of micronutrients, deficiency symptoms, cooking/eating practices was low, while attitude towards diet diversity and sunlight was good. Non-availability of fruits and vegetables was a barrier to diet diversity. About 72 % of the questions from the item pool were based on FGD. After content validity, 125 items were selected for the questionnaire which, upon psychometric validation, was reduced to an eighty-eight-item questionnaire with difficulty index of 0·10-0·91, discrimination index of 0·09-0·68, Cronbach's α of 0·78 (reliability of knowledge and attitude) and 0·50 (practice). A Bland-Altman plot showed good agreement between test and retest scores.

CONCLUSIONS

The questionnaire developed and validated using a sequential exploratory mixed-methods approach can be used for assessing KAP on micronutrients and factors affecting consumption of diverse diets in rural Indian households.

β-Carotene bioaccessibility from biofortified maize (Zea mays) is related to its density and is negatively influenced by lutein and zeaxanthin

Biofortification of maize with provitamin A (pro-VA) carotenoids has been successful, but the bioavailability of carotenoids needs to be explored. In the present study, we investigated the carotenoid content, micellarization and intestinal cell uptake of carotenoids from 10 maize hybrids [normal maize, quality protein maize (QPM), pro-VA carotenoid and double biofortified QPM + pro-VA maize hybrids] using a simulated in vitro digestion/Caco-2 cell model. The pro-VA carotenoid content of biofortified maize hybrids is 2-10 fold higher compared to that of normal maize. Furthermore, the ratio of non-pro-VA carotenoids lutein (LUT) plus zeaxanthin (ZEA) to the sum of pro-VA carotenoids β-cryptoxanthin (BCX), α-carotene (AC) and β-carotene (BC) in biofortified maize was much lower compared to that of normal maize. The consumption of 200 g day^-1 of biofortified Pusa-PV-16-3 (BC = 808.4 μg per 100 g; AC = 839.3 μg per 100 g; BCX = 59 μg per 100 g) and Pusa-APQH8 (BC = 345.9 μg per 100 g; AC = 1739 μg per 100 g; BCX = 644.2 μg per 100 g) maize would contribute to 52 and 64% of RDAs for adult Indian men, respectively, after adjusting for cooking losses and conversion factors. The mean efficiency of micellarization of LUT (62.2% ± 5.3), ZEA (65% ± 4.7), and BCX (54% ± 9.5) exceeded that of AC (43% ± 8.9) and BC (49.8% ± 7.8) from all the maize hybrids. Furthermore, the micellarization and uptake in Caco-2 cells during a 4 h incubation period showed high correlation (P < 0.05) with the concentration of carotenoids in the maize digesta and micellar fraction, respectively. However, the LUT + ZEA content in the maize digesta and micellar fraction was inversely (p < 0.05) related to the BC micellarization and intestinal cell uptake, respectively. These results together suggest that the enrichment of pro-VA carotenoids together with decreasing the oxygenated carotenoid metabolites such as LUT and ZEA will further improve the bioavailability of BC from maize hybrids.

Morphine and metabolites plasma levels after administration of sustained release morphine in Roux-en-Y gastric bypass subjects versus matched control subjects

BACKGROUND

Better knowledge of opioid pharmacology after Roux-en-Y gastric bypass (RYGB) is required for optimizing their use in this growing population.

OBJECTIVE

The aim of this case-controlled pharmacokinetic (PK) study was to compare morphine and its glucuronidated metabolites (morphine-3-glucuronide and morphine-6-glucuronide) plasma PKs between patients with RYGB and their controls.

SETTINGS

University hospital, Lariboisière Hospital, Paris.

METHODS

Thirty milligrams of morphine as a sustained-release formulation was orally administered in 12 women who had undergone RYGB for at least 2 years (RYGB group) and in their nonsurgical controls matched for sex, body mass index (±2 points), and age (±5 yr). Morphine, morphine-3-glucuronide, and morphine-6-glucuronide plasma concentrations over a 12-hour period were determined by a validated method using liquid chromatography mass spectrometry in tandem. Drowsiness, respiratory rate, and oxygen saturation were monitored during the PK visit.

RESULTS

Morphine oral area under the curve (for time 0-12 hr; 115.8 ± 108.0 nmol.hr/L and 86.9 ± 38.8 nmol.hr/L for RYGB group and control group, respectively, P = .71), morphine at maximal concentration, metabolites oral area under the curve (for time 0-12 hr)_, and other PK parameters were similar between groups. After drug administration, mean drowsiness was superior in RYGB group. Mean respiratory rate and oxygen saturation were similar in both groups.

CONCLUSION

No dose adjustment seems to be needed for sustained release morphine when prescribed to RYGB patients.

Dietary fat composition, food matrix and relative polarity modulate the micellarization and intestinal uptake of carotenoids from vegetables and fruits

Dietary fat increases carotenoid bioavailability by facilitating their transfer to the aqueous micellar fraction during digestion. However, the specific effect of both quantity and type of dietary fat required for optimal carotenoid absorption remained unexplored. In the present study, the effect of amount and type of vegetable oils on carotenoid micellarization from carrot, spinach, drumstick leaves and papaya using in vitro digestion/Caco-2 cell model have been assessed. Although, dietary fat (0.5-10% w/w) significantly increased the micellarization of carotenoids from all the test foods, the extent of increase was determined by the food matrix (papaya > drumstick = spinach > carrot) and polarity of carotenoids (lutein > β-carotene = α-carotene > lycopene). Among the dietary fats tested the carotenoid micellarization was twofold to threefold higher with dietary fat rich in unsaturated fatty acids (olive oil = soybean oil = sunflower oil) compared to saturated fatty acids (peanut oil = palm oil > coconut oil). Intestinal cell uptake of lutein exceeded that of β-carotene from micellar fraction of spinach leaves digested with various oils. However, cellular uptake of β-carotene is depended on the carotenoid content in micellar fraction rather than the type of fat used. Together these results suggest that food matrix, polarity of carotenoids and type of dietary fat determines the extent of carotenoid micellarization from vegetables and fruits.

Vitamin-A deficiency and its determinants among preschool children: a community based cross-sectional study in Ethiopia

Background

Vitamin A deficiency is the leading cause of preventable visual impairments in children. It is also an underlying cause for nearly one-fourth of global child mortality associated with measles, diarrhea, and malaria. The limited literature available in Ethiopia shows severe public health significance of vitamin-A deficiency. Hence the aim of the current study was to assess the prevalence and factors determining vitamin-A deficiency among preschool children in Dembia District, northwest Ethiopia.

Methods

A community-based cross-sectional study was conducted among preschool children of Dembia District from January to February, 2015. A multi-stage sampling, followed by a systematic sampling technique was employed to select study participants. A structured interviewer-administered questionnaire was used to collect data. Using a binary logistic regression model, multivariable analysis was fitted to identify the associated factors of vitamin-A deficiency. The adjusted odds ratio (AOR) with a 95 % confidence interval was computed to assess the strength of the association, and variables with a p value of <0.05 in multivariable analysis were considered as statistically significant.

Results

Six hundred eighty-one preschool children were included in the study, giving a response rate of 96.5 %. The overall prevalence of xerophthalmia was 8.6 %. The result of the multivariable analysis revealed that nonattendance at the antenatal care clinic [AOR 2.65,95 % CI (1.39,5.07)], being male [AOR 1.81, 95 % CI (1.01,3.24)], and in the age group of 49–59 months [AOR 3.00, 95 % CI (1.49,6.02)] were significantly associated with vitamin-A deficiency.

Conclusions

Vitamin-A deficiency is a severe public health problem in the study area. Further strengthening antenatal care utilization and giving emphasis to preschool children will help to mitigate vitamin-A deficiency in the study area.

Vitamin A supplementation for postpartum women

BACKGROUND

In areas where vitamin A deficiency (VAD) is a public health concern, the maternal dietary intake of vitamin A may be not sufficient to meet either the maternal nutritional requirements, or those of the breastfed infant, due the low retinol concentrations in breast milk.

OBJECTIVES

To evaluate the effects of vitamin A supplementation for postpartum women on maternal and infant health.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (8 February 2016), LILACS (1982 to December 2015), Web of Science (1945 to December 2015), and the reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or cluster-randomised trials that assessed the effects of vitamin A supplementation for postpartum women on maternal and infant health (morbidity, mortality and vitamin A nutritional status).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, conducted data extraction, assessed risk of bias and checked for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

Fourteen trials of mainly low or unclear risk of bias, enrolling 25,758 women and infant pairs were included. The supplementation schemes included high, single or double doses of vitamin A (200,000 to 400,000 internation units (IU)), or 7.8 mg daily beta-carotene compared with placebo, no treatment, other (iron); or higher (400,000 IU) versus lower dose (200,000 IU). In all trials, a considerable proportion of infants were at least partially breastfed until six months. Supplement (vitamin A as retinyl, water-miscible or beta-carotene) 200,000 to 400,000 IU versus control (placebo or no treatment) Maternal: We did not find evidence that vitamin A supplementation reduced maternal mortality at 12 months (hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.44 to 2.21; 8577 participants; 1 RCT, moderate-quality evidence). Effects were less certain at six months (risk ratio (RR) 0.50, 95% CI 0.09 to 2.71; 564 participants; 1 RCT; low-quality evidence). The effect on maternal morbidity (diarrhoea, respiratory infections, fever) was uncertain because the quality of evidence was very low (50 participants, 1 RCT). We found insufficient evidence that vitamin A increases abdominal pain (RR 1.28, 95% CI 0.95 to 1.73; 786 participants; 1 RCT; low-quality evidence). We found low-quality evidence that vitamin A supplementation increased breast milk retinol concentrations by 0.20 µmol/L at three to three and a half months (mean difference (MD) 0.20 µmol/L, 95% CI 0.08 to 0.31; 837 participants; 6 RCTs). Infant: We did not find evidence that vitamin A supplementation reduced infant mortality at two to 12 months (RR 1.08, 95% CI 0.77 to 1.52; 6090 participants; 5 RCTs; low-quality evidence). Effects on morbidity (gastroenteritis at three months) was uncertain (RR 6.03, 95% CI 0.30 to 121.82; 84 participants; 1 RCT; very low-quality evidence). There was low-quality evidence for the effect on infant adverse outcomes (bulging fontanelle at 24 to 48 hours) (RR 2.00, 95% CI 0.61 to 6.55; 444 participants; 1 RCT). Supplement (vitamin A as retinyl) 400,000 IU versus 200,000 IUThree studies (1312 participants) were included in this comparison. None of the studies assessed maternal mortality, maternal morbidity or infant mortality. Findings from one study showed that there may be little or no difference in infant morbidity between the doses (diarrhoea, respiratory illnesses, and febrile illnesses) (312 participants, data not pooled). No firm conclusion could be drawn on the impact on maternal and infant adverse outcomes (limited data available).The effect on breast milk retinol was also uncertain due to the small amount of information available.

AUTHORS' CONCLUSIONS

There was no evidence of benefit from different doses of vitamin A supplementation for postpartum women on maternal and infant mortality and morbidity, compared with other doses or placebo. Although maternal breast milk retinol concentrations improved with supplementation, this did not translate to health benefits for either women or infants. Few studies reported on maternal and infant mortality and morbidity. Future studies should include these important outcomes.

Prevalence and associated factors of clinical manifestations of vitamin a deficiency among preschool children in asgede-tsimbla rural district, north Ethiopia, a community based cross sectional study

Background

Vitamin A Deficiency is a common form of micronutrient deficiency, globally affecting 33.3 % of preschool-age children. An estimated of 44.4 % of preschool children in Africa were at risk for vitamin A deficiency. In Ethiopia, vitamin A deficiency leads to 80,000 deaths a year and affects 61 % of preschool children. The aim of this study was to investigate the prevalence and associated factors with the night blindness, Bitot’s spot and vitamin A intake among preschool children in rural area, Asgede-Tsimbla district, North Ethiopia.

Methods

Community based cross sectional study was conducted from January 27 to March 7, 2014. A total 1230 preschool children were selected by systematic random sampling from 8 randomly selected kebelles (smallest administrative unit). Structured and pretested questionnaires adapted from relevant studies and WHO/FAO was for data collection. In addition, sex, age, and height were taken and filled to Emergency Nutrition Assessment (ENA) for Standardized Monitoring and Assessment of Relief and Transition (SMART) 2007 software to convert the nutritional data into Z-scores of the indices. The data was then transported to SPSS version 20. Bivariate and Multivariable binary logistic regressions were carried out to investigate the effect of each independent variable on the dependent variable. Statistical significance was set at p-value < 0.05.

Result

The odds of Bitot‘s spots (1.46 %) and night blindness (1.22 %) were higher than the WHO Cut-off levels used to define a public health problem. The odds of night blindness was 4 times higher among children belonging to family size greater or equal to four [Adjusted Odds Ratio (AOR) = 4.18, 95 % CI = 1.15,15.3] and 6 times higher among children of illiterate mothers [AOR = 5.96 , 95 % CI = 1.33,26.69]. The odds of Bitot‘s spots was 5.35 times higher among children belonging to family size greater or more four [AOR =5.35; 95 % CI = 1.49, 19.2], 4.75 times higher among children of illiterate mothers [AOR = 4.75, 95 % CI =1.32, 17.18] and 6 times higher in males than females [AOR = 5.8, 95 % CI = 1.65, 20.46].

Conclusions

The study revealed that night blindness and Bitot‘s spots are major nutritional problems in the study area. The independent predictors of night blindness were mother illiteracy status and large family size and also for Bitot‘s spots were mother illiteracy status, male sex of child and large family size. Therefore, the need to increase educational level of mother, use of family planning of women and emphasis on male children and children from large family size by involving the Education sector, Health sector, (Federal Ministry of Health) FMOH and (Tigray Regional Health Bureau) TRHB is crucial.

Food-Based Interventions to Modify Diet Quality and Diversity to Address Multiple Micronutrient Deficiency

Global data indicate a high prevalence of hidden hunger among population. Deficiencies of certain micronutrients such as folic acid, iodine, iron, and vitamin A have long lasting effects on growth and development and therefore have been a National priority from many decades. The strategy implemented so far limits to the use of supplemental sources or fortified foods in alleviating the burden of deficiencies. These approaches however undermine the food-based strategies involving dietary diversification as the long-term sustainable strategy. There is lack of understanding on the level of evidence needed to implement such strategies and the level of monitoring required for impact evaluation. Dietary diversity concerns how to ensure access for each individual to a quality and safe diet with adequate macro- and micronutrients. The key to success in using dietary diversity as a strategy to tackle hidden hunger is in integrating it with the principles of bioavailability, translated to efficient food synergies with due emphasis on food accessibility, affordability, and outdoor physical activity/life style modifications. Promoting enabling environment and sustainable agriculture is crucial for practicing dietary diversification with behavior change communication as an integral segment. It can be concluded that food-based strategies require careful understanding of the factors associated with it and moderate it to form an effective strategy for controlling multiple micronutrient deficiencies.

Dietary pattern and nutritional deficiencies among urban adolescents

INTRODUCTION

Adolescents are considered to be a nutritionally vulnerable segment of the population. There is a greater need to look into the nutritional status of adolescents but unfortunately, precise estimates of their dietary intake, dietary practices as well as nutritional deficiencies have been the least explored area. The general objective for conducting this study was to assess the dietary pattern and nutritional deficiencies among adolescents.

MATERIALS AND METHODS

A cross-sectional study was conducted among adolescents in schools and colleges in the urban areas of Jhansi district in Uttar Pradesh. The study sample consisted of 400 school children in the age group of 10-19 years. Food consumption of the subjects was assessed using a 3-day food intake recall method.

RESULTS

Mean age of the adolescents was 14.16 years. More than half of the children studied had malnutrition (53.5%). Mean intake of calorie, protein, fat, iron, and vitamins A and C were lower than the Recommended Dietary Allowances (RDAs). The habitual dietary pattern indicated poor consumption of milk, liver, and leafy vegetables. In comparison to boys (31.5%), more girls (46%) were underweight. On seeing the association, nutritional status of these adolescents within the normal limits were found to be significantly higher in those from nuclear families (P < 0.001), those with better educated parents (P < 0.000), and those from families of higher socioeconomic status (P < 0.000).

CONCLUSION

Overall, among the participants, there were both macro- and micronutrients deficiencies. Therefore, there is a need to encourage people to adopt small family norms, and a need for the sensitization of both adolescents and their parents through health and nutrition education (HNE) to improve the health and nutritional status of the adolescents.

India's vitamin A supplementation programme is reaching the most vulnerable districts but not all vulnerable children. New evidence from the seven states with the highest burden of mortality among under-5s

OBJECTIVE

To characterize the coverage of India's national vitamin A supplementation (VAS) programme and document its performance in reaching children in the districts with higher concentration of poor households (2006-2011).

DESIGN

Analysis of VAS programme coverage data collated and collected using standardized bottom-up procedures, data from India's Office of the Registrar General and Census Commissioner, and data from India's District Level Household Survey to compute exposure (poverty) and outcome (full VAS coverage) variables.

SETTING

Seven Indian states with the highest burden of mortality in children (74 % of all deaths among under-5s in the country in 2006).

SUBJECTS

Children 6-59 months old.

RESULTS

Between 2006 and 2011, the mean full VAS coverage (two VAS doses per child per year) in these seven states increased from 44·7 % to 67·3 % while the number of districts with high (≥80 %) full VAS coverage increased from twenty-four (9·4 %) to 131 (51·4 %). The highest increases in full VAS coverage figures were recorded in the districts with the highest concentration of poor households. The estimated number of poor children (i.e. children living in households classified as poor) who did not receive two VAS doses annually decreased from 8·5 million in 2006 to 5·1 million in 2011 (40·3 % decrease); 2·5 million (49·1 %) of these children lived in the districts with the lowest proportion of poor households.

CONCLUSIONS

Despite significant improvements in VAS, a large number of Indian children are not benefitting yet from this life-protecting intervention, particularly among those who are potentially the most vulnerable. Future programme action needs to give priority to sub-district level units - blocks and villages - with higher concentrations of poor households.