Vitamin A deficiency and xerophthalmia among school-aged children in Southeastern Asia

Vitamin A supplementation coverage and its associated factors among children aged 6-59 months in West Azernet Berbere Woreda, South West Ethiopia

BACKGROUND

Vitamin A deficiency is one of the major public health problems in low and middle-income countries including Ethiopia. Despite this fact, little attention was given to routine vitamin A supplementation in hard-to-reach rural areas and districts. Therefore, this study aimed to assess vitamin A supplementation coverage and its associated factors among children aged 6-59 months in West Azernet Berbere woreda, southern Ethiopia, 2021.

METHODS

A community-based cross-sectional study was conducted from April to May 2021. A total sample size of 471 study participants was involved in the study area. A simple random sampling technique was used to recruit the study subject. A pretested structured interviewer-administered questionnaire was used. Bivariable and multivariable logistic regression analyses were done to identify variables having a significant association with vitamin A supplementation. The variables having a p-value ≤ 0.05 with 95% CI were used to declare an association between factors and a dependent variable.

RESULTS

In this study, a total of 471 respondents were successfully interviewed with a response rate of 97.3%. The coverage of vitamin A supplementation was found to be 58.0%. Family monthly income [AOR = 2.565, 95% CI(1.631,4.032)], having PNC visit [AOR = 1.801, 95% CI (1.158, 2.801)], husbands disapproval about vitamin A supplementation [AOR = 0.324, 95% CI (0.129, 0.813)], information about vitamin A supplementation [AOR = 2.932, 95% CI (1.893, 4,542)] and ANC follow-up [AOR = 1.882, 95% CI (1.084, 3.266)] were factors significantly associated to vitamin A supplementation.

CONCLUSION

Vitamin A supplementation was found to be low and it is strongly associated with family monthly income, postnatal care, husband's disapproval of vitamin A supplementation, antenatal care follow-up, and information about vitamin A supplementation. Based on our findings, it is recommended to improve the monthly income of the household by actively engaging in various income-generating activities, enhance health information dissemination among mothers, particularly those who are underprivileged by using different strategies like local health campaigns, and mass media, advocacy of antenatal, and postnatal follow-up and promote the involvement of males/husband in childhood immunization service.

Nutrition in school-age children: a rationale for revisiting priorities

Middle childhood and early adolescence have received disproportionately low levels of scientific attention relative to other life stages, especially as related to nutrition and health. This is partly due to the justified emphasis on the first 1000 days of life, and the idea that early deficits and consequences may not be fully reversible. In addition, these stages of life may superficially appear less "eventful" than infancy or late adolescence. Finally, there has been historical ambiguity and inconsistency in terminology, depending on whether viewing "childhood" through physiologic, social, legal, or other lenses. Nevertheless, this age bracket, which encompasses most of the primary education and basic schooling years for most individuals, is marked by significant changes, inflection points, and sexually driven divergence in somatic and brain growth and development trajectories. These constitute transformative changes, and thus middle childhood and early adolescence represents a major and last opportunity to influence long-term health and productivity. This review highlights the specificities of growth and development in school age, with a focus on middle childhood and early adolescence (5 years-15 years of age, for the purposes of this review), the role of nutrition, the short- and long-term consequences of inadequate nutrition, and the current global status of nutrition in this age group. Adequate attention and emphasis on nutrition in the school-age years is critical: (a) for maintaining an adequate course of somatic and cognitive development, (b) for taking advantage of this last major opportunity to correct deficits of undernutrition and "catch-up" to normal life course development, and (c) for addressing the nutritional inadequacies and mitigating the longer-term consequences of overnutrition. This review summarizes and provides a rationale for prioritizing nutrition in school-age children, and for the need to revisit priorities and focus on this part of the life cycle to maximize individuals' potential and their contribution to society.

Xerophthalmia and Its Associated Factors among School-Age Children in Amba Giorgis Town, Northwest Ethiopia, 2018

INTRODUCTION

Xerophthalmia is a general term applied to all the ocular manifestations from night blindness through complete corneal destruction (keratomalacia) due to vitamin A deficiency. Xerophthalmia is the main contributing factors for childhood blindness in developing countries. However, there is limited evidence that can implicate the current situation. This study aimed to determine the magnitude of xerophthalmia and associated factors among school-age children in Northwest Ethiopia.

METHODS

A community-based cross-sectional study was conducted on 490 children, age range of 6 to 12 years. The study participants were selected through systematic random sampling method. Data were collected using a pretested structured questionnaire and ophthalmic examination with different ophthalmic instruments. The analyzed result was summarized and presented using descriptive statistics. Binary logistic regression was used to determine the factors associated with xerophthalmia. Variables with a p value of <0.05 in the multivariable logistic regression analysis were considered as statistically significant.

RESULTS

A total of 484 study participants with a response rate of 98.8 were involved in this study, and their median age was 8 years with IQR of 4 years. The prevalence of xerophthalmia was 8.26% (95% CI: 5.8, 10.7). Family income less than 1000 Ethiopian birr (AOR = 4.65, 95% CI: 1.31, 16.4), presence of febrile illness (AOR = 2.8, 95% CI: 1.49, 6.11), poor consumption of fruits and vegetables (AOR = 3.18, 95% CI: 1.30, 7.80), and nonimmunized status (AOR = 3.43, 95% CI: 1.49, 7.89) were significantly associated with xerophthalmia.

CONCLUSIONS AND RECOMMENDATIONS

The prevalence of xerophthalmia was high as compared to the World Health Organization criteria for public health significance. Factors identified for xerophthalmia in this study are low income, the poor dietary practice of fruits and vegetables, and the presence of febrile illness and not immunized. Hence, it is a public problem that needs attention.

Nutritional Status and Basic Hygiene Practices of Rural School Age Children of Savar Region, Dhaka, Bangladesh

Introduction

School children in the developing countries are susceptible to nutrition related health problems due to demographic and socio-economic factors, as well as limited access to food. Since BMI is a common proxy measure used to evaluate nutritional status, the aim of this study was to investigate the BMI categories in school-aged children in Dhaka, Bangladesh.

Methods

A cross sectional study of 155 children, aged 6–12 years was conducted at Jahangirnagar University School in Dhaka, Bangladesh. The data collection was performed by in-person interviews and semi-structured questionnaires. Descriptive statistics, χ2 test, Fisher’s exact test, and One-Way ANOVA test were performed to compare the variables based on BMI percentiles. Data were analyzed using the Microsoft Excel program (version 2010).

Results

Mean BMI of the students was 17.27 (SD=3.16). The prevalence of underweight and overweight/obesity was 11.0% and 25.8%, respectively. Categories of BMI percentiles were associated with birth order (p=0.026), personal hygiene practices (washing hands after coming home from outside (p<0.001) and before meal (p=0.045)), brushing teeth (p<0.001), the number of food items consumed daily (p<0.001), and mothers’ occupation (p=0.006). In context of basic hygiene practice, 61.3 % of respondents washed hands after coming home from outside, and 93.5 % reported washing hands before the meals.

Conclusions

This study revealed that more than one third of the students had abnormal BMI. BMI screening in rural schools needs to be recommended in early grades for all children.

Plasma proteins associated with circulating carotenoids in Nepalese school-aged children

Carotenoids are naturally occurring pigments that function as vitamin A precursors, antioxidants, anti-inflammatory agents or biomarkers of recent vegetable and fruit intake, and are thus important for population health and nutritional assessment. An assay approach that measures proteins could be more technologically feasible than chromatography, thus enabling more frequent carotenoid status assessment. We explored associations between proteomic biomarkers and concentrations of 6 common dietary carotenoids (α-carotene, β-carotene, lutein/zeaxanthin, β-cryptoxanthin, and lycopene) in plasma from 500 6-8 year old Nepalese children. Samples were depleted of 6 high-abundance proteins. Plasma proteins were quantified using tandem mass spectrometry and expressed as relative abundance. Linear mixed effects models were used to determine the carotenoid:protein associations, accepting a false discovery rate of q < 0.10. We quantified 982 plasma proteins in >10% of all child samples. Among these, relative abundance of 4 were associated with β-carotene, 11 with lutein/zeaxanthin and 51 with β-cryptoxanthin. Carotenoid-associated proteins are notably involved in lipid and vitamin A transport, antioxidant function and anti-inflammatory processes. No protein biomarkers met criteria for association with α-carotene or lycopene. Plasma proteomics may offer an approach to assess functional biomarkers of carotenoid status, intake and biological function for public health application. Original maternal micronutrient trial from which data were derived as a follow-up activity was registered at ClinicalTrials.gov: NCT00115271.

Subclinical inflammation influences the association between vitamin A- and iron status among schoolchildren in Ghana

BACKGROUND AND OBJECTIVE

In resource-poor settings, micronutrient deficiencies such as vitamin A deficiency may co-exist with iron-deficiency. In this study we assessed the iron and vitamin A status of schoolchildren and the association between vitamin A and iron status.

METHODS

A cross-sectional design using the baseline data of a dietary intervention trial conducted among randomly selected 5-12 years old schoolchildren (n = 224) from 2 rural schools in northern Ghana. Hemoglobin (Hb), serum ferritin (SF) and serum transferrin receptor (sTfR) concentrations were used as measures of iron status. Retinol binding protein (RBP) was used as a measure of vitamin A status. Subclinical inflammation (SCI) was measured using C-reactive protein (CRP) and α1-acid glycoprotein (AGP) concentrations. We examined the cross-sectional association between vitamin A and iron status biomarkers with multiple linear regressions.

RESULTS

The proportions of schoolchildren with anemia (WHO criteria), iron-deficiency (ID, SF <15μg/l and/or sTfR >8.5mg/l) and iron-deficiency anemia (IDA, concurrent anemia and ID) were 63.8%, 68.3% and 46.4% respectively. Low or marginal vitamin A status (0.70 μmol/l ≤ RBP < 1.05μmol/l) was present in 48.2% while 37.5% of the schoolchildren had vitamin A deficiency (VAD, RBP <0.70 μmol/l). The prevalence of SCI as well as concurrent VAD and ID were 48.7% and 25% respectively. RBP was associated with Hb (β = 7.2, P = 0.05) but not SF (β = 20.7, P = 0.33) and sTfR concentration (β = 12.0, P = 0.63). In the presence of SCI, RBP was not associated with hemoglobin status but a significant positive association was observed among children without SCI.

CONCLUSIONS

The study shows that RBP is significantly associated with Hb concentration but not with SF and sTfR. The observed relationship between RBP and Hb is only significant in the absence of SCI.

Biomarkers of Nutrition for Development (BOND)-Vitamin A Review

The Biomarkers of Nutrition for Development (BOND) project is designed to provide evidence-informed advice to anyone with an interest in the role of nutrition in health. The BOND program provides information with regard to selection, use, and interpretation of biomarkers of nutrient exposure, status, function, and effect, which will be especially useful for readers who want to assess nutrient status. To accomplish this objective, expert panels are recruited to evaluate the literature and to draft comprehensive reports on the current state of the art with regard to specific nutrient biology and available biomarkers for assessing nutritional status at the individual and population levels. Phase I of the BOND project includes the evaluation of biomarkers for 6 nutrients: iodine, folate, zinc, iron, vitamin A, and vitamin B-12. This review of vitamin A is the current article in this series. Although the vitamin was discovered >100 y ago, vitamin A status assessment is not trivial. Serum retinol concentrations are under homeostatic control due in part to vitamin A's use in the body for growth and cellular differentiation and because of its toxic properties at high concentrations. Furthermore, serum retinol concentrations are depressed during infection and inflammation because retinol-binding protein (RBP) is a negative acute-phase reactant, which makes status assessment challenging. Thus, this review describes the clinical and functional indicators related to eye health and biochemical biomarkers of vitamin A status (i.e., serum retinol, RBP, breast-milk retinol, dose-response tests, isotope dilution methodology, and serum retinyl esters). These biomarkers are then related to liver vitamin A concentrations, which are usually considered the gold standard for vitamin A status. With regard to biomarkers, future research questions and gaps in our current understanding as well as limitations of the methods are described.

Provitamin A-biofortified maize increases serum β-carotene, but not retinol, in marginally nourished children: a cluster-randomized trial in rural Zambia

BACKGROUND

Vitamin A deficiency remains a nutritional concern in sub-Saharan Africa. Conventionally bred maize hybrids with high provitamin A carotenoid concentrations may have the potential to improve vitamin A status in maize-consuming populations.

OBJECTIVE

We evaluated the efficacy of regular provitamin A carotenoid-biofortified "orange" maizemeal (∼15 μg β-carotene/g) consumption in improving vitamin A status and reducing vitamin A deficiency in children.

DESIGN

This was a cluster-randomized controlled trial in the rural farming district of Mkushi, Zambia. All 4- to 8-y-old children in an ∼400-km(2) area were identified and grouped by proximity into clusters of ∼15-25 children. We randomly assigned clusters to 1) orange maizemeal (n = 25), 2) white maizemeal (n = 25), or 3) a parallel, nonintervention group (n = 14). Children in intervention clusters (n = 1024) received 200 g maizemeal for 6 d/wk over 6 mo; the maizemeal was prepared according to standardized recipes and served in cluster-level kitchens. Staff recorded attendance and leftovers. We collected venous blood before and after the intervention to measure serum retinol, β-carotene, C-reactive protein, and α1-acid glycoprotein.

RESULTS

Intervention groups were comparable at baseline, and vitamin A status was better than anticipated (12.1% deficient on the basis of serum retinol <0.7 μmol/L). Although attendance at meals did not differ (85%), median daily maize intake was higher in white (154 g/d) than in orange (142 g/d) maizemeal clusters. At follow-up, mean serum β-carotene was 0.14 μmol/L (95% CI: 0.09, 0.20 μmol/L) higher in orange maizemeal clusters (P < 0.001), but mean serum retinol (1.00 ± 0.33 μmol/L overall) and deficiency prevalence (17.1% overall) did not differ between arms.

CONCLUSION

In this marginally nourished population, regular biofortified maizemeal consumption increased serum β-carotene concentrations but did not improve serum retinol. This trial was registered at clinicaltrials.gov as NCT01695148.

Comparison on the status of vitamin A in 6- to 13- year-old children between 2002 and 2012 in China

BACKGROUND

Vitamin A deficiency is recognized as a major public-health nutrition issue in the developing countries. Limited hospital sources and sample sizes are available in most of the existing studies associated with healthy school-age children. The aim of this study was to compare vitamin A status of 6- to 13-year-old healthy children in China between 2002 and 2012.

METHODS

According to China National Nutrition and Health Survey 2002 (CHNNS2002) and CHNNS2010-2013, we choose 6- to 13-year-old children as the research object. We measure the serum retinol concentrations of the children using high performance liquid chromatography (HPLC). The children were divided into two groups: 6- to 9-year-old and 10- to 13-year-old. The areas were divided into urban and rural area.

RESULTS

Total number of the children (6- to 13-year old) was 8170 in 2002 survey, and it was 6016 in 2012 survey. In 2012, the vitamin A level of the children was higher than that in 2002 (t = 39.26, p = 0.000). The level of vitamin A in 10- to 13-year-old group was higher than that in 6- to 9-year-old group across areas and genders between 2002 and 2012. There was no difference on the incidence of vitamin A deficiency in all the children between 2002 and 2012, but in 2012 the incidence of vitamin A deficiency in the urban children was higher than that in 2002 (x (2) = 45.456,p = 0.000). The incidence of vitamin A deficiency in 10- to 13-year-old group was lower than that in 10- to 13-year-old group across areas and genders between 2002 and 2012. In 2012, the incidence of marginal vitamin A deficiency in the children was lower than that in 2002 (x (2) = 861.604, p = 0.000). Similar phenomena were also found in across area groups. The incidence of marginal vitamin A deficiency in 10- to 13-year-old group was lower than that in 6- to 9-year-old group across areas and genders between 2002 and 2012. There was no difference in vitamin A status of the children across the area, gender and age groups between 2002 and 2012.

CONCLUSION

Vitamin A nutritional status of the children in 2012 has been significantly improved compared with that in 2002. However, vitamin A deficiency was still a moderate public health problem in Chinese children, especially in younger school-age children. Consequently, controlling the incidence of vitamin a deficiency is imperative for promoting Chinese children's health.

A Changing Landscape for Vitamin A Programs: Implications for Optimal Intervention Packages, Program Monitoring, and Safety

BACKGROUND

Vitamin A deficiency (VAD) remains a widespread public health problem in the developing world, despite changes in under-5 mortality rates, morbidity patterns, and intervention options.

OBJECTIVE

This article considers the implications of a changing epidemiologic and programmatic landscape for vitamin A (VA) programs.

METHODS

We review progress to prevent VAD and its health consequences, assess gaps in VA status and intervention coverage data, and assess data needed to guide decisions regarding the optimal mix, targeting, and dose of VA interventions to maximize benefit and minimize risk.

RESULTS

Vitamin A supplementation programs have contributed to the reduction in under-5 mortality rates, but alone, do not address the underlying problem of inadequate dietary VA intakes and VAD among preschool-aged children in the developing world. A combination of VA interventions (eg, supplementation, fortified foods, multiple micronutrient powders, and lipid-based nutrient supplements) will be required to achieve VA adequacy in most settings. Current efforts to measure the coverage of multiple VA interventions, as well as whether and how much VA children are receiving, are few and fragmented.

CONCLUSIONS

Where intervention overlap exists, further effort is needed to monitor VA intakes, ensuring that targeted groups are consuming adequate amounts but not exceeding the tolerable upper intake level. Vitamin A status data will also be critical for navigating the changing landscape of VA programs. Data from these monitoring efforts will help to guide decisions on the optimal mix, targeting, and exposure to VA interventions to maximize public health benefit while minimizing any potential risk.

Associations between low consumption of fruits and vegetables and nutritional deficiencies in Brazilian schoolchildren

Objective

We examined associations between the frequency of fruit and vegetable (F&V) consumption and nutritional deficiencies among Brazilian schoolchildren.

Design

A cross-sectional, population-based study was performed. A short FFQ was used to assess consumption of fruits and vegetables (F&V) over the past month. The prevalence ratios (PR) and 95 % confidence intervals for stunting, obesity, anaemia, vitamin A and folate deficiencies, vitamin E and vitamin D insufficiencies were estimated for low F&V consumption frequency (vegetables ≤3 times/month and fruits ≤3 times/week) and compared with children with usual F&V consumption frequency (vegetables ≥1 time/week and fruits ≥4 times/week).

Setting

Acrelândia, Western Brazilian Amazon.

Subjects

A total of 702 children aged 4–10 years.

Results

Only 5 % of children consumed F&V ≥5 times/d. Prevalence of deficiency was 31 %, 15 %, 9 % and 2 % for vitamins D, A, E and folate, respectively. Overall, 6·3 % of children were anaemic, 3·3 % were stunted, 2·7 % were obese and 33 % had multiple nutritional deficiencies. Low frequency of F&V consumption was associated with lower plasma concentrations of carotenoids and vitamin E. Nutritional deficiencies were higher among non-consumers of F&V when compared with usual consumers: anaemia (PR=1·9; 95 % CI 1·0, 3·7), vitamin E insufficiency (PR=2·5; 95 % CI 1·5, 4·2), vitamin D insufficiency (PR=1·5; 95 % CI 1·1, 1·9) and stunting (PR=2·6; 95 % CI 1·1, 6·1).

Conclusions

In our study, the occurrence of nutritional deficiencies in children with low F&V consumption was twice as high as in children with usual F&V consumption, reinforcing the importance of effective actions to promote the consumption of F&V.

Micronutrient deficiencies are common in 6- to 8-year-old children of rural Nepal, with prevalence estimates modestly affected by inflammation

Subclinical micronutrient deficiencies remain a hidden aspect of malnutrition for which comprehensive data are lacking in school-aged children. We assessed the micronutrient status of Nepalese children, aged 6 to 8 y, born to mothers who participated in a community-based antenatal micronutrient supplementation trial from 1999 to 2001. Of 3305 participants, plasma indicators were assessed in a random sample of 1000 children. Results revealed deficiencies of vitamins A (retinol <0.70 μmol/L, 8.5%), D (25-hydroxyvitamin D <50 nmol/L, 17.2%), E (α-tocopherol <9.3 μmol/L, 17.9%), K (decarboxy prothombin >2 μg/L, 20%), B-12 (cobalamin <150 pmol/L, 18.1%), B-6 [pyridoxal-5'-phosphate (PLP) <20 nmol/L, 43.1%], and β-carotene (41.5% <0.09 μmol/L), with little folate deficiency (6.2% <13.6 nmol/L). Deficiencies of iron [ferritin <15 μg/L, 10.7%; transferrin receptor (TfR) >8.3 mg/L, 40.1%; TfR:ferritin >500 μg/μg, 14.3%], iodine (thyroglobulin >40 μg/L, 11.4%), and selenium (plasma selenium <0.89 μmol/L, 59.0%) were observed, whereas copper deficiency was nearly absent (plasma copper <11.8 μmol/L, 0.7%). Hemoglobin was not assessed. Among all children, 91.7% experienced at least 1 micronutrient deficiency, and 64.7% experienced multiple deficiencies. Inflammation (α-1 acid glycoprotein >1 g/L, C-reactive protein >5 mg/L, or both) was present in 31.6% of children, affecting the prevalence of deficiency as assessed by retinol, β-carotene, PLP, ferritin, TfR, selenium, copper, or having any or multiple deficiencies. For any nutrient, population deficiency prevalence estimates were altered by ≤5.4% by the presence of inflammation, suggesting that the majority of deficiencies exist regardless of inflammation. Multiple micronutrient deficiencies coexist in school-aged children in rural Nepal, meriting more comprehensive strategies for their assessment and prevention.

Gestational vitamin A deficiency: a novel cause of sensorineural hearing loss in the developing world?

Hearing loss is a substantial public health problem with profound social and economic consequences in the developing world. The World Health Organization (WHO) estimates that there are 360 million people living with disabling hearing loss globally, and 80% of these individuals are from low- and middle-income countries. The epidemiology of hearing impairment remains poorly defined in most impoverished societies. Middle ear infections in childhood are a key determinant; however, congenital anomalies may also comprise an important etiology and may arise from gestational malnutrition. While evidence exists that preventable vitamin A deficiency exacerbates the severity of ear infections and, consequently, hearing loss, antenatal vitamin A deficiency during sensitive periods of fetal development may represent an etiologically distinct and virtually unexplored causal pathway. Evidence from multiple animal systems clearly shows that fetal inner ear development requires adequate vitamin A nutriture to proceed normally. Inner ear malformations occur in experimentally imposed maternal vitamin A deficiency in multiple species in a dose-response manner. These anomalies are likely due to the loss of retinoic acid-dependent regulation of both hindbrain development and otic morphogenic processes. Based on in vivo evidence in experimental animals, we hypothesize that preventable gestational vitamin A deficiency, especially during early stages of fetal development, may predispose offspring to inner ear malformations and sensorineural hearing loss. As vitamin A deficiency affects an estimated 20 million pregnant women globally, we hypothesize that, in undernourished settings, routine provision of supplemental vitamin A at the recommended allowance throughout pregnancy may promote normal inner ear development and reduce risk of an as yet unknown fraction of sensorineural hearing loss. If our hypothesis proves correct, gestational vitamin A deficiency would represent a potentially preventable etiology of sensorineural hearing loss of substantial public health significance.

Prenatal vitamin A deficiency impairs adaptive immune responses to pentavalent rotavirus vaccine (RotaTeq®) in a neonatal gnotobiotic pig model

Vitamin A deficiency (VAD) is associated with increased childhood mortality and morbidity in impoverished Asian and African countries, but the impact of VAD on rotavirus (RV) vaccine or infection is poorly understood. We assessed effects of gestational and dietary induced pre- and post-natal VAD and vitamin A supplementation on immune responses to a pentavalent rotavirus vaccine, RotaTeq(®) in a neonatal gnotobiotic pig model. Vaccine efficacy was assessed against virulent G1P[8] human rotavirus (HRV) challenge. VAD and vitamin A sufficient (VAS) piglets were derived from dietary VAD and VAS sows, respectively. VAD piglets had significantly lower levels of hepatic vitamin A compared to that of VAS piglets. RotaTeq(®)-vaccinated VAD piglets had 350-fold higher fecal virus shedding titers compared to vaccinated VAS piglets post-challenge. Only 25% of vaccinated non-vitamin A supplemented VAD piglets were protected against diarrhea compared with 100% protection rate in vaccinated non-supplemented VAS piglets post-challenge. Intestinal HRV specific immune responses were compromised in VAD piglets. Vaccinated VAD piglets had significantly lower ileal HRV IgG antibody secreting cell (ASC) responses (pre-challenge) and duodenal HRV IgA ASC responses (post-challenge) compared to vaccinated VAS piglets. Also, intestinal HRV IgA antibody titers were 11-fold lower in vaccinated VAD compared to vaccinated VAS piglets post-challenge. Persistently elevated levels of IL-8, a pro-inflammatory mediator, and lower IL-10 responses (anti-inflammatory) in vaccinated VAD compared to VAS piglets suggest more severe inflammatory responses in VAD piglets post-challenge. Moreover higher IFN-γ responses pre-challenge were observed in VAD compared to VAS piglets. The impaired vaccine-specific intestinal antibody responses and decreased immunoregulatory cytokine responses coincided with reduced protective efficacy of the RV vaccine against virulent HRV challenge in VAD piglets. In conclusion, VAD impaired antibody responses to RotaTeq(®) and vaccine efficacy. Oral supplementation of 100,000 IU vitamin A concurrent with RV vaccine failed to increase the vaccine efficacy in VAD piglets.

Vitamin A—Fortified Vegetable Oil Exported from Malaysia and Indonesia Can Significantly Contribute to Vitamin A Intake Worldwide

Background

Vitamin A deficiency is a public health problem worldwide, affecting approximately 190 million preschool-aged children and 19.1 million pregnant women. Fortification of vegetable oils with vitamin A is an effective, low-cost technology to improve vitamin A intake.

Objective

To examine the potential contribution of fortification of vegetable oils with vitamin A in Indonesia and Malaysia to increasing vitamin A consumption in these two countries and in countries to which oil is exported .

Methods

Detailed interviews were administered and a desk review was conducted. We also estimated potential vitamin A intakes from fortified vegetable oil.

Results

Malaysia and Indonesia are two of the largest producers and exporters of vegetable oil. Fortification of vegetable oil in both countries has the potential to be used as a tool for control of vitamin A deficiency. Both countries have the capacity to export fortified vegetable oil. Vegetable oil fortified at a level of 45 IU/g could provide 18.8% of the Estimated Average Requirement (EAR) for an Ethiopian woman, 30.9% and 46.9% of the EAR for a Bangladeshi child and woman, respectively, and 17.5% of the EAR for a Cambodian woman. Although concerns about obesity are valid, fortification of existing vegetable oil supplies does not promote overconsumption of oil but rather promotes consumption of vegetable oil of higher nutrient quality.

Conclusions

Fortifying vegetable oil on a large scale in Malaysia and Indonesia can reach millions of people globally, including children less than 5 years old. The levels of fortification used are far from reaching the Tolerable Upper Intake Level (UL). Vegetable oil fortification has the potential to become a global public health intervention strategy.

Cognitive and motor skills in school-aged children following maternal vitamin A supplementation during pregnancy in rural Nepal: a follow-up of a placebo-controlled, randomised cohort

OBJECTIVE

To determine the effects of maternal vitamin A supplementation from preconception through postpartum on cognitive and motor development of children at 10-13 years of age in rural Nepal.

DESIGN

Follow-up assessment of children born to women randomly assigned by a village to receive either supplemental vitamin A (7000 µg retinol equivalents) or placebo weekly during a continuous 3.5-year period from 1994-1997. The participants came from 12 wards, a subset of 270 wards in the original trial. Trained staff tested children for cognition by the Universal Nonverbal Intelligence Test (UNIT) and motor ability using four subtests from the Movement Assessment Battery for Children (MABC). Data on schooling, home environment and nutritional and socioeconomic status were also collected.

SETTING

Southern plains district of Sarlahi, Nepal.

PARTICIPANTS

390 Nepalese children 10-13 years of age.

MAIN OUTCOME MEASURES

Raw scores on UNIT and square-root transformed scores on an abridged version of the MABC tests, expressed as cluster-summarised (mean±SD) values to account for the design of the original trial.

RESULTS

There were no differences in UNIT (79.61±5.99 vs 80.69±6.71) or MABC (2.64±0.07 vs 2.49±0.09) test scores in children whose mothers were exposed to vitamin A vs placebo (mean differences: -1.07, 95% CI -7.10 to 9.26, p=0.78; 0.15, 95% CI 0.43 to -0.08, p=0.15), respectively. More children in the placebo group had repeated a grade in school (28% of placebo vs 16.7% of vitamin A, p=0.01).

CONCLUSIONS

Preconceptional to postpartum maternal vitamin A supplementation, in an undernourished setting, does not improve cognition or motor development at ages 10-13 years.

An evidence-based systematic review of vitamin A by the natural standard research collaboration

An evidence-based systematic review of vitamin A by the Natural Standard Research Collaboration consolidates the safety and efficacy data available in the scientific literature using a validated and reproducible grading rationale. This paper includes written and statistical analysis of clinical trials, plus a compilation of expert opinion, folkloric precedent, history, pharmacology, kinetics/dynamics, interactions, adverse effects, toxicology, and dosing.

Fortification of Indonesian unbranded vegetable oil: public-private initiative, from pilot to large scale

BACKGROUND

Despite improved economic conditions, vitamin A deficiency remains a public health problem in Indonesia.

OBJECTIVE

This paper aims to describe the development of the Indonesian unbranded cooking oil fortification program and to discuss lessons learned to date and future steps necessary for implementation of mandatory, large-scale oil fortification with vitamin A.

METHODS

An historic overview of the steps involved in developing the Indonesian unbranded cooking oil fortification program is given, followed by a discussion of lessons learned and next steps needed.

RESULTS

Indonesia's low-income groups generally consume unbranded vegetable oil, with an average consumption of approximately 25 g/day. Unbranded oil constitutes approximately 70% of the total oil traded in the country. In 2007-10, a pilot project to fortify unbranded vegetable oil was carried out in Makassar, and an effectiveness study found that the project significantly improved the serum retinol concentrations of schoolchildren. In 2010, the pilot was expanded to two provinces (West Java and North Sumatra) involving the biggest two national refineries. In 2011, a draft national standard for fortified oil was developed, which is currently under review by the National Standard Body and is expected to be mandated nationally in 2013 as announced officially by the Government of Indonesia in national and international meetings.

CONCLUSIONS

Indonesia is a leading world supplier of cooking oil. With stakeholder support, the groundwork has been laid and efforts are moving forward to implement mandatory fortification. This project could encourage Indonesian industry to fortify more edible oils for export, thus expanding their market potential and potentially reducing vitamin A deficiency in the region.

Xerophthalmia in a traditional Quran boarding school in Sudan

Purpose:

To determine the prevalence of xerophthalmia at a traditional boarding school where children do not receive a diet adequate in vitamin A.

Materials and Methods:

A cross-sectional survey of 406 males residing in a Quranic traditional school was conducted using the World Health Organization xerophthalmia checklist. The association between the prevalence of night blindness and proportion of students staying at the school for 6 consecutive months and those eating solely at the school was investigated. The difference in age between children with night blindness and those without was investigated. Statistical significance was indicated by P<0.05.

Results:

The prevalence of night blindness, conjunctival xerosis and Bitot's spots was 24%, 12.5% and 1%, respectively. None of the boys had corneal ulceration, corneal scars and corneal xerosis. No significant association was observed between the differences in mean age and development of night blindness (P=0.657). There was a significant association between the duration of stay (cut-off of 6 months continuously) at the institute and the development of night blindness (P=0.023). There was no statistical significance between regularly eating at the maseed and outside the “maseed” and the development of night blindness (P=0.75).

Conclusion:

Children residing at a traditional school are vulnerable to developing xerophthalmia where the diet is inadequate in vitamin A. Institutional caregivers should be made aware of the importance of providing a balanced diet rich in vitamin A. Institutional caregivers should also be educated on the signs and symptoms of vitamin A deficiency for early detection of xerophthalmia.

The effect of a 1-year multiple micronutrient or n-3 fatty acid fortified food intervention on morbidity in Indian school children

BACKGROUND/OBJECTIVES

Few studies have shown that supplementation with micronutrients (MNs) or n-3 fatty acids may have health benefits such as reduced morbidity in schoolchildren. The effect of a combination of these nutrients has never been investigated. This study aimed to determine the effect of a combination of two different doses of MN and n-3 fatty acids on morbidity in schoolchildren in Bangalore, India.

SUBJECTS/METHODS

In all 598 children (6-10 years) received foods fortified with either high (100% recommended dietary allowance) or low (15% recommended dietary allowance) MN, combined with either high (900 mg α-linolenic acid (ALA) plus 100 mg docosahexaenoic acid) or low (140 mg ALA) n-3 fatty acids for 1 year. Morbidity was measured by weekly self-reports using a structured questionnaire. Poisson regression analyses of episodes/child/year and duration/episode adjusted for age and sex were performed on clusters of symptoms, including upper and lower respiratory tract infections (URTI and LRTI), gastrointestinal complaints (GI) and general symptoms of illness to observe MN and n-3 fatty acid treatment effects.

RESULTS

Children consuming high n-3 fatty acids had significantly fewer episodes of URTI/child/year (relative risk (RR)=0.88, 95% confidence interval (CI): 0.79, 0.97) and significantly shorter duration/episode of URTI (RR=0.81, 95% CI: 0.78, 0.85), LRTI (RR=0.91, 95% CI: 0.85, 0.97), GI complaints (RR=0.79, 95% CI: 0.74, 0.85) and general symptoms (RR=0.90, 95% CI: 0.82, 0.98) compared with children who received low n-3 fatty acid intervention. The high MN intervention reduced the duration of general symptoms (RR=0.89, 95% CI: 0.82, 0.98).

CONCLUSION

Although n-3 fatty acids may be beneficial for reducing illness in Indian schoolchildren, more research is needed to confirm presence of combined effect with MN.

Poor nutritional status of schoolchildren in urban and peri-urban areas of Ouagadougou (Burkina Faso)

BACKGROUND

Malnutrition is still highly prevalent in developing countries. Schoolchildren may also be at high nutritional risk, not only under-five children. However, their nutritional status is poorly documented, particularly in urban areas. The paucity of information hinders the development of relevant nutrition programs for schoolchildren. The aim of this study carried out in Ouagadougou was to assess the nutritional status of schoolchildren attending public and private schools.

METHODS

The study was carried out to provide baseline data for the implementation and evaluation of the Nutrition Friendly School Initiative of WHO. Six intervention schools and six matched control schools were selected and a sample of 649 schoolchildren (48% boys) aged 7-14 years old from 8 public and 4 private schools were studied. Anthropometric and haemoglobin measurements, along with thyroid palpation, were performed. Serum retinol was measured in a random sub-sample of children (N = 173). WHO criteria were used to assess nutritional status. Chi square and independent t-test were used for proportions and mean comparisons between groups.

RESULTS

Mean age of the children (48% boys) was 11.5 ± 1.2 years. Micronutrient malnutrition was highly prevalent, with 38.7% low serum retinol and 40.4% anaemia. The prevalence of stunting was 8.8% and that of thinness, 13.7%. The prevalence of anaemia (p = 0.001) and vitamin A deficiency (p < 0.001) was significantly higher in public than private schools. Goitre was not detected. Overweight/obesity was low (2.3%) and affected significantly more children in private schools (p = 0.009) and younger children (7-9 y) (p < 0.05). Thinness and stunting were significantly higher in peri-urban compared to urban schools (p < 0.05 and p = 0.004 respectively). Almost 15% of the children presented at least two nutritional deficiencies.

CONCLUSION

This study shows that malnutrition and micronutrient deficiencies are also widely prevalent in schoolchildren in cities, and it underlines the need for nutrition interventions to target them.

Vitamin A fortification of wheat flour: considerations and current recommendations

BACKGROUND

Vitamin A deficiency is a major public health nutrition problem, affecting an estimated 190 million preschool-aged children and 19 million pregnant and lactating women globally, and 83 million adolescents in Southeast Asia alone. Its consequences (disorders) include xerophthalmia (the leading cause of early childhood blindness), increased severity of infection, anemia, and death. Because vitamin A deficiency is largely due to chronic dietary insufficiency of preformed vitamin A and proactive carotenoids, food fortification can offer an effective approach to prevention.

OBJECTIVE

To provide guidance on fortifying wheat and maize flour milled in industrial rollers for national fortification programs in countries where vitamin A deficiency is considered a public health problem.

METHODS

Critical review of the literature on the dietary gap in vitamin A intake and levels of wheat flour intake among risk groups as a basis for determining vitamin A fortificant levels. Additional review of efficacy evidence, safety and cost considerations, and country experiences related to wheat-flour fortification with vitamin A.

RESULTS

Mill-rolled wheat flour is a technically fortifiable, centrally processed food vehicle that, where routinely and adequately consumed by target groups, should be considered a candidate for fortification. Vitamin A can be stable in flour under typical, ambient conditions, with processing losses estimated at approximately 30%, depending on source and premix conditions.

CONCLUSIONS

Factors to guide a decision to fortify flour with vitamin A include the extent of deficiency, availability of other food vehicle options, the centrality of milling, market reach and population intake distributions of the flour products, the dietary vitamin A intake required, and associated costs. Large gaps persist in knowledge of these factors, which are needed to enable evidence-based fortification in most countries, leaving most decisions to fortify guided by assumptions. Where flour can and should be fortified, guidelines are given for providing nearly 25% of the Recommended Dietary Allowance for vitamin A to vulnerable groups consuming varying ranges of flour products. The costs will vary according to the level of fortification.

Nutritional Status of Primary Schoolchildren in Garhwali Himalayan Villages of India

Background

Anemia and micronutrient deficiencies are common among Indian schoolchildren. However, past studies have narrowly focused on only a few micronutrients and have not carefully evaluated the association between sociodemographic factors and nutritional status of schoolchildren.

Objective

To assess the nutritional status of schioolchildren in Himalayan villages of India and to determine the relationships between their nutritional status, intestinal helminth infection, and sociodemographic characteristics.

Methods

A random sample of 499 children 6 to 10 years of age from 20 public primary schools was selected. Household sociodemographic data and morbidity data on children were collected through interviews with their caretakers. Height and weight were measured, and venous blood was drawn for assessment of hemoglobin, serum ferritin, soluble transferrin receptor, retinol, zinc, folic acid, vitamin B12, and C-reactive protein. Stool samples were analyzed for parasitic infections.

Results

Underweight, stunting, and wasting were present in 60.9%, 56.1%, and 12.2% of schoolchildren, respectively. Anemia, iron-deficiency anemia, and low serum concentrations of ferritin, zinc, retinol, folate, and vitamin B12 were found in 36.7%, 10.2%, 24.1%, 57.1%, 56.1%, 67.9%, and 17.4% of the children, respectively. One-fifth of the children had intestinal parasites. Being underweight was associated with lower household wealth ( p < .05). Helminth infection was associated with stunting, anemia, and low serum retinol ( p < .05). Living at higher altitude was associated with low serum levels of ferritin, retinol, and vitamin B12. There were no associations between any sociodemographic variables and serum zinc or folate.

Conclusions

Growth impairment and micronutrient deficiencies are prevalent among schoolchildren in Himalayan villages of India.

[Vitamin A deficiency among children in Brazil and worldwide]

Based on a ten-year literature review, this paper describes important aspects of Vitamin A Deficiency (VAD) among children in Brazil and worldwide. It presents VAD within a clinical and sub-clinical deficiency context, emphasizing this as a public health issue. VAD has been diagnosed in children from several parts of Brazil, especially in the Southeast and Northeast. Worldwide, the highest VAD prevalence is found in parts of parts of Africa: Mali, Ethiopia and Nigeria, and clinical indications noted especially in parts of Asia and Africa. However, no studies of clinical indications were located. Studies point to VAD as a public health issue among children, particularly in the poorest parts of the world.

Vitamin A status in Cuban children aged 6–11 years

Objective and setting

A nationwide study was performed in Cuba to assess vitamin A status and the intake of vitamin-A-providing foods in children aged 6–11 years.

Design and subjects

The sample comprised 1191 schoolchildren from first to sixth grade, both sexes, from municipalities randomly selected from the five eastern provinces of Cuba in 2002 (first semester) and from the four western and four central provinces in 2003 (first semester). A food-frequency questionnaire was completed by 2038 mother-and-child pairs.

Results

Mean (±standard deviation) plasma retinol concentrations were 1.77 ± 0.48 μmol l−1in the western, 2.01 ± 0.56 μmol l−1in the central and 1.40 ± 0.41 μmol l−1in the eastern region. No child had plasma retinol concentration below 0.35 μmol l−1, indicative of a high risk of clinical deficiency. Subclinical deficiency, plasma retinol concentration of 0.35–0.7 μmol l−1, was seen in <2% of subjects in all three regions and was <5% even in the two provinces with the worst vitamin A status (Guantánamo, 4.6%; Las Tunas, 3.0%). Adequate status (>1.05 μmol l−1) was present in >90% of subjects in all western and central provinces, and in one of the eastern provinces (Holguín), whereas in the four remaining eastern provinces, adequate status was present in >75%. Only nine fruits and vegetables were consumed frequently (>3 times per week) by >50% of children. Thirty-seven per cent regularly consumed a supplement containing vitamin A.

Conclusions

Most Cuban children aged 6–11 years had adequate vitamin A status. Consumption of foods rich in vitamin and provitamin A, especially vegetables, was frequent but limited to a small variety of foods.

Vitamin A deficiency among Brazilian school-aged children in a healthy child service

BACKGROUND/OBJECTIVES

Vitamin A deficiency (VAD) is a world public health problem contributing to the increase in childhood morbidity and mortality in developing countries and severe deficiency of vitamin A may lead to xerophthalmia and blindness. The objective of this study was to determine the prevalence of VAD among Brazilian school-aged children attended at a primary health unit and to verify if some considered risk factor was associated with VAD in this group.

SUBJECTS/METHODS

A descriptive prospective transverse study was conducted on 103 randomly selected children. A total of 54 boys and 49 girls aged 5.5-11 years had the relative dose-response (RDR) test performed on. Possible ocular alterations related to vitamin A and the status of anemia, serum zinc, some acute-phase proteins, and anthropometric situation were determinate by an analytic design.

RESULTS

No child presented xerophthalmia. Serum retinol values lower than 1.05 and 0.7 micromol l(-1), respectively were found in 26.2 and 5.8% of the children. The prevalence of hypovitaminosis detected by RDR test was 20.4%. The following variables and their relationship with VAD were evaluated: sex (P=0.33; 95% confidence interval 0.61-4.34), weight and height (P> or =0.5), hemoglobin (P=0.15), C-reactive protein (P=0.56; 95% confidence interval 0.75-18.26), alpha-1-acid-glycoprotein (P=0.56; 95% confidence interval 0.15-15.42) and serum zinc (P=0.31). None of these variables was related to VAD.

CONCLUSIONS

In this population, the prevalence of VAD detected could be considered a public health problem. School-aged children can be considered at risk for VAD mainly of a subclinical level, even without some associated risk factors.

Feasibility and Use of Vitamin A–Fortified Vegetable Oils among Consumers of Different Socioeconomic Status in Thailand

Background

Vitamin A losses in fortified vegetable oils can differ, depending upon the cooking and distribution conditions of a country.

Objective

To determine vitamin A losses in different vegetable oils during transportation, cooking, and storage among consumers of different socioeconomic status.

Methods

Soybean, rice bran, and palm oils were fortified with vitamin A palmitate at 267 μg/15 mL. The oils were packaged in 5-L metal cans and 250-mL polyethylene terephthalate (PET) bottles and then stored under light and dark conditions. Unopened and opened bottles were stored for 13 and 4 weeks, respectively. For- tified palm oil also was bulk transported in trucks and packaged in 1-kg polypropylene bags that were closed with rubber bands. Vitamin losses were measured after cooking at 120° and 170°C for 5 and 10 minutes in iron, aluminum, Teflon, and glass pans.

Results

Vitamin A losses of oils in PET bottles stored under light conditions were 20% to 25% at the 5th week and became greater than 80% after 13 weeks, whereas losses under dark conditions and in metal containers were less than 15%. Loss during bulk transportation was 25%, with no change in peroxide value. Losses in opened bottles after 4 weeks under light conditions were 50% to 90% based on the degree of oil unsaturation; however, losses under dark conditions were less than 5%. Losses after cooking at 120° and 170°C for 10 minutes were less than 5% and 15%, respectively. The type of pan did not affect the amount of loss. The peroxide values of oils in bottles increased during storage under light conditions.

Conclusions

Fortification of vegetable oils with vitamin A for consumers of different socioeconomic status is feasible; however, light protection is needed for better stability.

Clinical disorders affecting mesopic vision

Vision in the mesopic range is affected by a number of inherited and acquired clinical disorders. We review these conditions and summarize the historical background, describing the clinical characteristics alongside the genetic basis and molecular biological mechanisms giving rise to rod and cone dysfunction relevant to twilight vision. The current diagnostic gold standards for each disease are discussed and curative and symptomatic treatment strategies are summarized.