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Nuredin A, Melis T, Abdu AO. Clinical vitamin A deficiency among preschool aged children in southwest Ethiopia. Front Nutr 2024; 11:1267979. [PMID: 38450229 PMCID: PMC10914950 DOI: 10.3389/fnut.2024.1267979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 02/12/2024] [Indexed: 03/08/2024] Open
Abstract
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.
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Affiliation(s)
- Abdilwahid Nuredin
- College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Tamirat Melis
- College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Abdu Oumer Abdu
- School of Public Health, College of Medicine and Health Sciences, Haramaya University, Harar, Ethiopia
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Patil S, Zamwar UM, Mudey A. Etiology, Epidemiology, Pathophysiology, Signs and Symptoms, Evaluation, and Treatment of Vitamin A (Retinol) Deficiency. Cureus 2023; 15:e49011. [PMID: 38111435 PMCID: PMC10726094 DOI: 10.7759/cureus.49011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/18/2023] [Indexed: 12/20/2023] Open
Abstract
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.
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Affiliation(s)
- Shraddha Patil
- Endocrinology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Udit M Zamwar
- Endocrinology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Abhay Mudey
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Zhang H, Ren X, Yang Z, Lai J. Vitamin A Concentration in Human Milk: A Meta-Analysis. Nutrients 2022; 14:nu14224844. [PMID: 36432530 PMCID: PMC9699574 DOI: 10.3390/nu14224844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/09/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022] Open
Abstract
Humans require vitamin A (VA). However, pooled VA data in human milk is uncommon internationally and offers little support for dietary reference intake (DRIs) revision of infants under 6 months. As a result, we conducted a literature review and a meta-analysis to study VA concentration in breast milk throughout lactation across seven databases by August 2021. Observational or intervention studies involving nursing mothers between the ages of 18 and 45, with no recognized health concerns and who had full-term infants under 48 months were included. Studies in which retinol concentration was expressed as a mass concentration on a volume basis and determined using high-, ultra-, or ultra-fast performance liquid chromatography (HPLC, UPLC, or UFLC) were chosen. Finally, 76 papers involving 9171 samples published between 1985 and 2021 qualified for quantitative synthesis. Results from the random-effects model showed that the VA concentration of healthy term human milk decreased significantly as lactation progressed. VA (µg/L) with 95% CI at the colostrum, transitional, early mature and late mature stages being 920.7 (744.5, 1095.8), 523.7 (313.7, 733.6), 402.4 (342.5, 462.3) and 254.7 (223.7, 285.7), respectively (X2 = 71.36, p < 0.01). Subgroup analysis revealed no significant differences identified in VA concentration (µg/L) between Chinese and non-Chinese samples at each stage, being 1039.1 vs. 895.8 (p = 0.64), 505.7 vs. 542.2(p = 0.88), 408.4 vs. 401.2 (p = 0.92), 240.0 vs. 259.3 (p = 0.41). The findings have significant implications for the revision of DRIs for infants under six months.
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Affiliation(s)
- Huanmei Zhang
- Department of Maternal and Child Nutrition, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
- China-DRIs Expert Committee on Human Milk Composition, Chinese Nutrition Society, Beijing 100050, China
| | - Xiangnan Ren
- Department of Maternal and Child Nutrition, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
- China-DRIs Expert Committee on Human Milk Composition, Chinese Nutrition Society, Beijing 100050, China
| | - Zhenyu Yang
- Department of Maternal and Child Nutrition, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
- China-DRIs Expert Committee on Human Milk Composition, Chinese Nutrition Society, Beijing 100050, China
| | - Jianqiang Lai
- China-DRIs Expert Committee on Human Milk Composition, Chinese Nutrition Society, Beijing 100050, China
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, China
- Correspondence:
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Mogaka JN, Owuor PM, Odhiambo S, Waterman C, McGuire MK, Fuchs GJ, Attia SL. Investigating the Impact of Moringa oleifera Supplemented to Kenyan Breastfeeding Mothers on Maternal and Infant Health: A Cluster Randomized Single-Blinded Controlled Pilot Trial Protocol. JPGN REPORTS 2022; 3:e237. [PMID: 37168619 PMCID: PMC10158460 DOI: 10.1097/pg9.0000000000000237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 06/22/2022] [Indexed: 05/13/2023]
Abstract
Undernutrition contributes to up to 45% of deaths globally in children <5 years, with an optimal time for intervention before 24 months of age. Breastmilk microbiome helps establish the infant intestinal microbiome and impacts infant intestinal and nutritional health. Inadequacies in breastmilk composition such as low vitamin A contribute to infant nutrient deficiencies. Changes in milk fatty acid composition (reduced saturated and increased unsaturated fatty acids) may reduce susceptibility to enteric infection and increase protective intestinal bacteria. Moringa oleifera leaves (moringa) provide high nutrient concentrations (including protein, iron, vitamin A) and increase milk production; this may enhance breastmilk quantity and quality and improve infant health. Objective To investigate the role of moringa supplementation to improve maternal and infant nutritional and intestinal health via changes in maternal milk quantity and quality. Methods Fifty mother-infant pairs exclusively breastfeeding will be enrolled in a single-blinded randomized controlled trial in Kombewa County Hospital and Chulaimbo SubCounty Hospital, Kisumu, Kenya. Intervention Dietary Supplementation of 20 g of Moringa oleifera leaf powder divided twice daily in corn porridge consumed daily for 3 months while control comparator will receive porridge daily for 3 months. Outcomes Change in infant growth and maternal milk output (primary); maternal and infant vitamin A and iron status, changes in infant and maternal intestinal health (secondary). Participating Centers Pamoja Community Based Organization, Kombewa Sub-County Hospital, and Chulaimbo Sub-County Hospital.
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Affiliation(s)
| | - Patrick Mbullo Owuor
- Pamoja Community Based Organization, Kisumu, Kenya
- Department of Anthropology, Weinberg College of Arts and Sciences, Northwestern University, Chicago, Illinois
| | | | - Carrie Waterman
- Institute of Global Nutrition, University of California, Davis, Davis, California
| | - Michelle K. McGuire
- College of Agricultural and Life Sciences, Margaret Ritchie School of Family and Consumer Sciences, University of Idaho, Moscow, Idaho
| | - George J. Fuchs
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Kentucky College of Medicine, Lexington, Kentucky
- Department of Epidemiology and Department of Preventive Medicine and Environmental Health, University of Kentucky College of Public Health, Lexington, Kentucky
| | - Suzanna L. Attia
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Kentucky College of Medicine, Lexington, Kentucky
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A Review of Portable Quantitative and Semi-quantitative Devices for Measurement of Vitamin A in Biological Samples. CURRENT RESEARCH IN BIOTECHNOLOGY 2022; 4:253-274. [PMID: 36033130 PMCID: PMC9407042 DOI: 10.1016/j.crbiot.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 11/21/2022] Open
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Moges T, Brouwer ID, Delbiso TD, Remans R, Baudron F, Belachew T, Groot JCJ. Spatial farming systems diversity and micronutrient intakes of rural children in Ethiopia. MATERNAL & CHILD NUTRITION 2022; 18:e13242. [PMID: 34223711 PMCID: PMC8710117 DOI: 10.1111/mcn.13242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 11/30/2022]
Abstract
Own production contributes much of the food supply in smallholder production systems in low- and middle-income countries like Ethiopia. Understanding the potential as well as constraints of these production systems in terms of nutrient supplies is thus a critical step to design interventions to improve nutrient intakes. The objectives of this study were (1) to assess the usual total intakes of vitamin A, iron and zinc among rural children and (2) to investigate whether the intakes these nutrients are associated with differences in the dominant farming systems between spatial clusters. Using nationally representative intake data of 4,902 children 6-35 months of age, usual intake and the proportion of inadequate intakes of vitamin A, iron and zinc were calculated. A multi-level model was used to examine the association between individual-level and cluster-level variables with the usual total dietary intakes of these nutrients. The diet was dominated by starchy foods. Consumption of animal source foods, vitamin A-rich fruits and vegetables was low. We found a high prevalence of inadequate intake of vitamin A and zinc (85.4% and 49.5%, respectively). Relatively, low prevalence of inadequate intake of iron (8.4%) was reported. The spatial farming systems diversity across the rural clusters explained 48.2%, 57.2% and 26.7% of the observed variation in the usual total dietary intakes of vitamin A, iron and zinc, respectively. Our findings indicated the importance of farming system diversity at the landscape level as one of the determinant factors for individual usual total dietary intakes of vitamin A, iron and zinc.
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Affiliation(s)
- Tibebu Moges
- Farming Systems EcologyWageningen UniversityWageningenNetherlands
- Food Science and Nutrition Research DirectorateEthiopian Public Health InstituteAddis AbabaEthiopia
- Human Nutrition UnitJimma UniversityJimmaEthiopia
| | - Inge D. Brouwer
- Division of Human Nutrition and HealthWageningen UniversityWageningenNetherlands
| | | | | | - Frédéric Baudron
- Southern Africa Regional OfficeInternational Maize and Wheat Improvement Center (CIMMYT)HarareZimbabwe
| | | | - Jeroen C. J. Groot
- Farming Systems EcologyWageningen UniversityWageningenNetherlands
- Bioversity InternationalMaccareseItaly
- Sustainable Intensification ProgramInternational Maize and Wheat Improvement Center (CIMMYT)TexcocoMexico
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Zhou Y, Si K, Li H, Li X, Tanumihardjo SA, Liu J. Geographic and socio-demographic determinants of plasma retinol concentrations in Chinese pregnant and lactating women. Eur J Nutr 2021; 61:1561-1570. [PMID: 34860270 DOI: 10.1007/s00394-021-02759-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/25/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To examine plasma retinol status and its determinants in Chinese pregnant or lactating women. METHODS A cross-sectional study involving 1211 healthy women in mid-pregnancy, late pregnancy, or lactation was conducted in northern, central, and southern China. Plasma retinol concentration was determined by high-performance liquid chromatography. Multivariate quantile regression or modified Poisson regression was used to estimate adjusted medians, or to examine the associations of suboptimal retinol concentration (< 1.05 µmol/L) with various factors. RESULTS The overall median (interquartile range) retinol concentration was 1.25 (1.06-1.46) µmol/L. The adjusted concentration was higher in women at lactation (1.39 [1.20-1.63] µmol/L) and mid-pregnancy (1.26 [1.10-1.44] µmol/L) than late pregnancy (1.07 [0.92-1.28] µmol/L), and higher in women in the central area (1.34 [1.18-1.49] µmol/L) and the north (1.26 [1.10-1.43] µmol/L) than the south (1.19 [1.07-1.31] µmol/L). The retinol concentration was more likely to be low in women with lower pre-pregnancy BMI, younger age, less education, and in lactating women who had a caesarean birth or were breastfeeding exclusively. A total of 290 (24.0%) women had a suboptimal retinol concentration, and the prevalence was higher in women at late pregnancy, residing in the south, with younger age, and having underweight pre-pregnancy. CONCLUSION About one-fourth of pregnant or lactating women in China had suboptimal retinol concentrations that varied with phases of pregnancy and lactation, region of residence, and socio-demographic characteristics, indicating a need for population-specific public health strategies to optimize vitamin A status.
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Affiliation(s)
- Yubo Zhou
- Institute of Reproductive and Child Health/ National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, No. 38 Xueyuan Rd, Haidian District, Beijing, 100191, China.,Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Keyi Si
- Institute of Reproductive and Child Health/ National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, No. 38 Xueyuan Rd, Haidian District, Beijing, 100191, China.,Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Hongtian Li
- Institute of Reproductive and Child Health/ National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, No. 38 Xueyuan Rd, Haidian District, Beijing, 100191, China.,Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Xiucui Li
- Institute of Reproductive and Child Health/ National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, No. 38 Xueyuan Rd, Haidian District, Beijing, 100191, China.,Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Sherry A Tanumihardjo
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Jianmeng Liu
- Institute of Reproductive and Child Health/ National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, No. 38 Xueyuan Rd, Haidian District, Beijing, 100191, China. .,Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China.
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Faye MH, Diémé MMA, Idohou-Dossou N, Badiane A, Diouf A, Ndiaye Ndome NM, Tanumihardjo SA. 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. PLoS One 2021; 16:e0246246. [PMID: 33513162 PMCID: PMC7846024 DOI: 10.1371/journal.pone.0246246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/18/2021] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Mane Hélène Faye
- Faculté des Sciences et Techniques, Laboratoire de Recherche en Nutrition et Alimentation Humaine, Département de Biologie Animale, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Marie-Madeleine A. Diémé
- Faculté des Sciences et Techniques, Laboratoire de Recherche en Nutrition et Alimentation Humaine, Département de Biologie Animale, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Nicole Idohou-Dossou
- Faculté des Sciences et Techniques, Laboratoire de Recherche en Nutrition et Alimentation Humaine, Département de Biologie Animale, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Abdou Badiane
- Faculté des Sciences et Techniques, Laboratoire de Recherche en Nutrition et Alimentation Humaine, Département de Biologie Animale, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Adama Diouf
- Faculté des Sciences et Techniques, Laboratoire de Recherche en Nutrition et Alimentation Humaine, Département de Biologie Animale, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | | | - Sherry A. Tanumihardjo
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
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Cabezuelo MT, Zaragozá R, Barber T, Viña JR. Role of Vitamin A in Mammary Gland Development and Lactation. Nutrients 2019; 12:E80. [PMID: 31892157 PMCID: PMC7019238 DOI: 10.3390/nu12010080] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 11/26/2019] [Accepted: 12/19/2019] [Indexed: 12/14/2022] Open
Abstract
Vitamin A (all-trans-retinol), its active derivatives retinal and retinoic acid, and their synthetic analogues constitute the group of retinoids. It is obtained from diet either as preformed vitamin A or as carotenoids. Retinal plays a biological role in vision, but most of the effects of vitamin A are exerted by retinoic acid, which binds to nuclear receptors and regulates gene transcription. Vitamin A deficiency is an important nutritional problem, particularly in the developing world. Retinol and carotenoids from diet during pregnancy and lactation influence their concentration in breast milk, which is important in the long term, not only for the offspring, but also for maternal health. In this study, we review the role of vitamin A in mammary gland metabolism, where retinoid signaling is required not only for morphogenesis and development of the gland and for adequate milk production, but also during the weaning process, when epithelial cell death is coupled with tissue remodeling.
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Affiliation(s)
- M. Teresa Cabezuelo
- Department of Physiology, Universitat de València, Avda. Blasco Ibañez, 15, 46010 Valencia, Spain;
- University Hospital Doctor Peset, Gaspar Aguilar, 90, 46017 Valencia, Spain
| | - Rosa Zaragozá
- Department of Human Anatomy and Embryology-INCLIVA Biomedical Research Institute, Universitat de València, 46010 Valencia, Spain
| | - Teresa Barber
- Department of Biochemistry and Molecular Biology-INCLIVA Biomedical Research Institute, Universitat de València, 46010 Valencia, Spain; (T.B.); (J.R.V.)
| | - Juan R. Viña
- Department of Biochemistry and Molecular Biology-INCLIVA Biomedical Research Institute, Universitat de València, 46010 Valencia, Spain; (T.B.); (J.R.V.)
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