Comparison of the effects of supplemental red palm oil and sunflower oil on maternal vitamin A status

Supplementation of red palm olein-enriched biscuits improves levels of provitamin A carotenes, iron, and erythropoiesis in vitamin A-deficient primary schoolchildren: a double-blinded randomised controlled trial

PURPOSE

Vitamin A deficiency (VAD) remains a significant contributor to childhood morbidity and mortality in developing countries; therefore, the implementation of sustainable and cost-effective approaches to control VAD is of utmost pertinence. This study aims to investigate the efficacy of red palm olein (RPO)-enriched biscuit supplementation in improving vitamin A, haematological, iron, and inflammatory status among vitamin A-deficient schoolchildren.

METHODS

We conducted a double-blinded, randomised controlled trial involving 651 rural primary schoolchildren (8-12 years) with VAD in Malaysia. The schoolchildren were randomised to receive either RPO-enriched biscuits (experimental group, n = 334) or palm olein-enriched biscuits (control group, n = 317) for 6-month duration.

RESULTS

Significant improvements in retinol and retinol-binding protein 4 levels were observed in both groups after supplementation (P < 0.001). The improvement in retinol levels were similar across groups among subjects with confirmed VAD (P = 0.40). Among those with marginal VAD, greater improvement in retinol levels was recorded in the control group (P < 0.001) but lacked clinical significance. The levels of α- and β-carotenes, haematological parameters (haemoglobin, packed cell volume, mean corpuscular volume and mean corpuscular haemoglobin) and iron enhanced more significantly in the experimental group (P < 0.05). The significant reduction in the prevalence of microcytic anaemia (- 21.8%) and high inflammation (- 8.1%) was only observed in the experimental group.

CONCLUSION

The supplementation of RPO-enriched biscuits enhanced levels of provitamin A carotenes, iron, and erythropoiesis, and exhibited anti-inflammatory effects. Therefore, the incorporation of RPO into National Nutritional Intervention Programs may be a potential measure to improve the health status of vitamin A-deficient children, among various other interventions.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT03256123).

Influence of Fresh Palm Fruit Sterilization in the Production of Carotenoid-Rich Virgin Palm Oil

Palm oil is known to be rich in carotenoids and other phytonutrients. However, the carotenoids and phytonutrients degrade due to high heat sterilization of oil palm fruits. The present study was conducted to produce carotenoid-rich virgin palm oil (VPO) using cold-press extraction. Herein, the influence of sterilization of oil palm fresh fruits in the production of cold-pressed VPO was determined with varying sterilization temperatures, times, and amounts of palm fruits in sterilization. The experimental sterilization conditions were optimized using response surface methodology (RSM) based on the maximum VPO yield and minimum FFAs in cold-pressed VPO. The optimal sterilization experimental conditions of oil palm fruits were determined to be a sterilization temperature of 62 °C, a time of 90 min, and an amount of oil palm fruits of 8 kg. Under these experimental conditions, the maximum cold-pressed VPO yield and the minimal content of free fatty acids (FFAs) obtained were 27.94 wt.% and 1.32 wt.%, respectively. Several analytic methods were employed to determine cold-pressed VPO quality and fatty acids compositions and compared with the crude palm oil. It was found that cold-pressed VPO contains higher carotenoids (708 mg/g) and unsaturated fatty acids compared with the carotenoid (343 mg/g) and fatty acid compositions in CPO. The findings of the present study reveal that the sterilization temperature potentially influences the carotenoid and nutrient contents in VPO; therefore, the optimization of the sterilization conditions is crucial to producing carotenoid- and phytonutrient-rich VPO.

The Triad Mother-Breast Milk-Infant as Predictor of Future Health: A Narrative Review

The benefits of human milk for both mother and infant are widely acknowledged. Human milk could represent a link between maternal and offspring health. The triad mother-breast milk-infant is an interconnected system in which maternal diet and lifestyle might have effects on infant's health outcome. This link could be in part explained by epigenetics, even if the underlining mechanisms have not been fully clarified yet. The aim of this paper is to update the association between maternal diet and human milk, pointing out how maternal diet and lifestyle could be associated with breast-milk composition, hence with offspring's health outcome.

Nutritional supplements and mother's milk composition: a systematic review of interventional studies

BACKGROUND

This study aims to systematically review the effects of maternal vitamin and/or mineral supplementation on the content of breast milk.

METHODS

We systematically searched electronic databases including Medline via PubMed, Scopus and ISI Web of Science till May 24, 2018. The following terms were used systematically in all mentioned databases: ("human milk" OR "breast milk" OR "breast milk composition" OR "human breast milk composition" OR "composition breast milk" OR "mother milk" OR "human breast milk" OR "maternal milk") AND ("vitamin a" OR "retinol" OR "retinal" OR "retinoic acid" OR "beta-carotene" OR "beta carotene" OR "ascorbic acid" OR "l-ascorbic acid" OR "l ascorbic acid" OR "vitamin c" OR "vitamin d" OR "cholecalciferol" OR "ergocalciferol" OR "calciferol" OR "vitamin e" OR "tocopherol" OR "tocotrienol" OR "alpha-tocopherol" OR "alpha tocopherol" OR "α-tocopherol" OR "α tocopherol" OR "vitamin k" OR "vitamin b" OR "vitamin b complex" OR "zinc" OR "iron" OR "copper" Or "selenium" OR "manganese" OR "magnesium") and we searched Medline via Medical subject Headings (MeSH) terms. We searched Google Scholar for to increase the sensitivity of our search. The search was conducted on human studies, but it was not limited to the title and abstract. Methodological quality and risk of bias of included studies were evaluated by Jadad scale and Cochrane risk of bias tools, respectively.

RESULTS

This review included papers on three minerals (zinc, iron, selenium) and 6 vitamins (vitamin A, B, D, C, E and K) in addition to multi-vitamin supplements. Although studies had different designs, e.g. not using random allocation and/or blinding, our findings suggest that maternal use of some dietary supplements, including vitamin A, D, vitamin B1, B2 and vitamin C might be reflected in human milk. Vitamin supplements had agreater effect on breast milk composition compared to minerals. Higher doses of supplements showed higher effects and they were reflected more in colostrum than in the mature milk.

CONCLUSION

Maternal dietary vitamin and/or mineral supplementation, particularly fat- soluble vitamins, vitamin B1, B2 and C might be reflected in the breast milk composition. No difference was found between mega dose and single dose administration of minerals.

What is food-to-food fortification? A working definition and framework for evaluation of efficiency and implementation of best practices

Food-to-food fortification (FtFF) is an emerging food-based strategy that can complement current strategies in the ongoing fight against micronutrient deficiencies, but it has not been defined or characterized. This review has proposed a working definition of FtFF. Comparison with other main food-based strategies clearly differentiates FtFF as an emerging strategy with the potential to address multiple micronutrient deficiencies simultaneously, with little dietary change required by consumers. A review of literature revealed that despite the limited number of studies (in vitro and in vivo), the diversity of food-based fortificants investigated and some contradictory data, there are promising fortificants, which have the potential to improve the amount of bioavailable iron, zinc, and provitamin A from starchy staple foods. These fortificants are typically fruits and vegetables, with high mineral as well as ascorbic acid and β-carotene contents. However, as the observed improvements in micronutrient bioavailability and status are relatively small, measuring the positive outcomes is more likely to be impactful only if the FtFF products are consumed as regular staples. Considering best practices in implementation of FtFF, raw material authentication and ingredient documentation are critical, especially as the contents of target micronutrients and bioavailability modulators as well as the microbiological quality of the plant-based fortificants can vary substantially. Also, as there are only few developed supply chains for plant-based fortificants, procurement of consistent materials may be problematic. This, however, provides the opportunity for value chain development, which can contribute towards the economic growth of communities, or hybrid approaches that leverage traditional premixes to standardize product micronutrient content.

Differing responses in milk composition from introducing rapeseed and naked oats to conventional and organic dairy diets

Dairy products are often considered challenging for health due to their saturated fatty acid content, yet they also provide beneficial nutrients, some unique to ruminants. The degree of fat saturation is influenced by cows’ diets; grazing pasture enhances unsaturated fatty acids in milk compared with conserved forages. These benefits can be partially mimicked by feeding oilseeds and here we consider the impact on milk composition in a 2 × 2 trial, feeding rapeseed to both conventional and organic cows, finding very differing lipid metabolism in the 4 experimental groups. For milk fat, benefits of organic rather than conventional management (+39% PUFA, +24% long chain omega-3 and +12% conjugated linoleic acid (CLA)) appear complementary to those from feeding rape (+43% MUFA, +10% PUFA, +40% CLA), combining to produce milk 16% lower SFA and higher in MUFA (43%), PUFA (55%) and CLA (59%). Organic and rape feeding provide less omega-3 PUFA than the conventional and control diets, yet contrary to expectations, together they almost doubled (+94%) the omega-3 concentration in milk, implying a 3.8 fold increase in net transfer from diet into milk. Organic and rape feeding also gave lower trace-elements and antioxidants in milk. Greater understanding of these phenomena might enhance the sustainability of dairying.

Status of Retinoids and Carotenoids and Associations with Clinical Outcomes in Maternal-Infant Pairs in Nigeria

Vitamin A is an essential nutrient in pregnancy, and other carotenoids have been independently associated with maternal-infant outcomes. The objective of this study was to quantify the status of vitamin A and carotenoids in Nigerian maternal-infant pairs at delivery, compare these to a cohort from a developed nation, and determine the impact on clinical outcomes. Maternal and cord blood samples were collected in 99 Nigerian mother-infant pairs. Concentrations of lutein + zeaxanthin, β-cryptoxanthin, lycopene, α- and β-carotenes, and retinol were measured using HPLC. Descriptive statistics were calculated and Spearman coefficients were used to assess correlations between maternal and cord measurements; Mann-Whitney tests were used to compare median plasma values between dichotomous variables. Linear regression models were used to adjust for relevant confounders. A p < 0.05 was considered statistically significant. Thirty-five percent of mothers had plasma retinol concentrations ≤0.70 µmol/L; 82% of infants had plasma retinol concentrations ≤0.70 µmol/L at delivery. Maternal and infant concentrations of vitamin A compounds were highly correlated and were associated with newborn growth and Apgar scores. Despite plasma concentrations of pro-vitamin A carotenoids higher than those reported in other populations, pregnant Nigerian women have a high prevalence of vitamin A deficiency. As vitamin A related compounds are modifiable by diet, future research determining the clinical impact of these compounds is warranted.

Lajis AF, Habi Mat Dian NL, Kanagaratnam S, Lai OM. Optimization of process parameters in preparation of tocotrienol-rich red palm oil-based nanoemulsion stabilized by Tween80-Span 80 using response surface methodology

Red palm oil (RPO) is a natural source of Vitamin E (70–80% tocotrienol). It is a potent natural antioxidant that can be used in skin-care products. Its antioxidant property protects skin from inflammation and aging. In our work, a tocotrienol-rich RPO-based nanoemulsion formulation was optimized using response surface methodology (RSM) and formulated using high pressure homogenizer. Effect of the concentration of three independent variables [surfactant (5–15 wt%), co-solvent (10–30 wt%) and homogenization pressure (500–700 bar)] toward two response variables (droplet size, polydispersity index) was studied using central composite design (CCD) coupled to RSM. RSM analysis showed that the experimental data could be fitted into a second-order polynomial model and the coefficients of multiple determination (R²) is 0.9115. The optimized formulation of RPO-based nanoemulsion consisted of 6.09 wt% mixed surfactant [Tween 80/Span 80 (63:37, wt)], 20 wt% glycerol as a co-solvent via homogenization pressure (500 bar). The optimized tocotrienol-rich RPO-based nanoemulsion response values for droplet size and polydispersity index were 119.49nm and 0.286, respectively. The actual values of the formulated nanoemulsion were in good agreement with the predicted values obtained from RSM, thus the optimized compositions have the potential to be used as a nanoemulsion for cosmetic formulations.

Red palm olein supplementation on cytokines, endothelial function and lipid profile in centrally overweight individuals: a randomised controlled trial

BACKGROUND/OBJECTIVES

The consumption of antioxidant-rich cooking oil such as red palm olein may be cardioprotective from the perspective of subclinical inflammation and endothelial function.

SUBJECTS/METHODS

Using a crossover design, we conducted a randomised controlled trial in 53 free-living high-risk abdominally overweight subjects, comparing the effects of incorporating red palm olein (with palm olein as control) in a supervised isocaloric 2100 kcal diet of 30% en fat, two-thirds (45 g/day) of which were derived from the test oil for a period of 6 weeks each.

RESULTS

We did not observe a significant change in interleukin-6 (IL-6), in parallel with other pro-inflammatory (tumour necrosis factor-β, interleukin-1β, IL-1β, high sensitivity C-reactive protein, hsCRP) and endothelial function (soluble intercellular adhesion molecules, sICAM, soluble intravascular adhesion molecules, sVCAM) parameters. Interestingly, we observed a significant reduction in oxidised LDL levels (P < 0.0386) while on the red palm olein diet, together with the increase in plasma alpha tocopherol (P < 0.0002), alpha carotene (P < 0.0001) and beta carotene (P < 0.0001) concentrations compared with palm olein diet.

CONCLUSION

Red palm olein did not improve subclinical inflammation and endothelial function despite profound increase in antioxidant levels. The positive improvement in oxidised LDL merits further attention in this group of subjects at risk of developing cardiovascular disease.

Health-promoting effects of red palm oil: evidence from animal and human studies

The fruit of the oil palm tree (Elaeis guineesis) is the source of antioxidant-rich red palm oil. Red palm oil is a rich source of phytonutrients such as tocotrienols, tocopherols, carotenoids, phytosterols, squalene, and coenzyme Q10, all of which exhibit nutritional properties and oxidative stability. Mutagenic, nutritional, and toxicological studies have shown that red palm oil contains highly bioavailable β-carotene and vitamin A and is reasonably stable to heat without any adverse effects. This review provides a comprehensive overview of the nutritional properties of red palm oil. The possible antiatherogenic, antihemorrhagic, antihypertensive, anticancer, and anti-infective properties of red palm oil are examined. Moreover, evidence supporting the potential effectiveness of red palm oil to overcome vitamin A deficiency in children and pregnant women, to improve ocular complications of vitamin A deficiency, to protect against ischemic heart disease, to promote normal reproduction in males and females, to aid in the management of diabetes, to ameliorate the adverse effects of chemotherapy, and to aid in managing hypobaric conditions is presented.

The Effect of Red Palm Oil on Vitamin A Deficiency: A Meta-Analysis of Randomized Controlled Trials

Red palm oil (RPO) has been investigated for preventing or alleviating vitamin A deficiency (VAD). Previous data has offered inconclusive and inconsistent results about the effects of RPO in patients with VAD. Our objective was to undertake a meta-analysis to assess the effects of RPO in preventing VAD in the population. After conducting a comprehensive literature search, nine randomized controlled trials (RCTs) were included. Overall, when trial results were pooled, the results indicated that RPO reduced the risk of VAD (relative risk (RR) (95% confidence interval (CI)) = 0.55 (0.37, 0.82), p = 0.003), increasedserum retinol levels in both children (p < 0.00001) and adults (p = 0.002), and increased β-carotene levels (p = 0.01). However, RPO supplementation did not have a significant overall effect on serum α-carotene levels (p = 0.06), body weight (p = 0.45), and haemoglobin levels (p = 0.72). The results also showed that low level of PRO intake (≤8 g RPO) could increase serum retinol concentrations whereas PRO intake above 8 g did not lead to further increase of serum retinol concentrations. This meta-analysis demonstrated that RPO might be effective for preventing or alleviating VAD.

Macro- and Micronutrients of Human Milk Composition: Are They Related to Maternal Diet? A Comprehensive Systematic Review

BACKGROUND

This study aims at systematically reviewing the observational and interventional studies on the association of maternal macro- and micronutrient intake with breast milk content.

METHODS

We systematically searched the Medline via PubMed, Scopus, and ISI Web of Knowledge till October 2016 with the following search strategy: ("human milk" OR "breast milk" OR "breast milk composition" OR "human breast milk composition" OR "composition breast milk" OR "mother milk" OR "human breast milk") AND ("maternal diet" OR "maternal nutrition"). We also searched Google scholar for increasing the sensitivity of our search. The search was not limited to title and abstract due to the possibility that the desired outcome might have been considered a secondary aim. We excluded conference papers, editorials, letters, commentary, short survey, and notes. The search was refined to English language, and we did not consider any time limitation. To increase the sensitivity and to select more studies, the reference list of the published studies was checked as well.

RESULTS

This review included 59 observational and 43 interventional studies on maternal diet related to breast milk composition. Different studies determined the associations and effects of some maternal dietary intake of micro and macronutrients and its reflection in human milk.

CONCLUSION

Maternal dietary intake, particularly fatty acids, and some micronutrients, including fat soluble vitamins, vitamin B₁, and vitamin C, was related to their content in breast milk composition.

Red Palm Oil Supplementation: A Feasible Diet-Based Approach to Improve the Vitamin A Status of Pregnant Women and Their Infants

This double-blinded, randomized, controlled study was designed to study the effect of dietary supplementation with red palm oil during pregnancy on maternal and neonatal vitamin A status. A total of 170 women were recruited at 16 to 24 weeks of gestation and randomly assigned to an experimental group that received red palm oil to supply approximately one recommended dietary amount (RDA) (2,400 μg) of β-carotene or to a control group that received an equivalent volume of groundnut oil. The women received the oils for a period of 8 weeks, starting at 26 to 28 weeks of gestation and extending to 34 to 36 weeks of gestation. The mean postintervention (34 to 36 weeks) levels of serum retinol were 1.20 ± 0.22 (SD) μmol/L (95% CI, 1.15–1.25) in women receiving red palm oil and 0.73 ± 0.15 μmol/L (95% CI, 0.69–0.77) in their infants; these levels were significantly higher than those in women receiving groundnut oil (1.07 ± 0.26 μmol/L; 95% CI, 1.01–1.13; p < .01) and their infants (0. 62 ± 0.17 μmol/L; 95% CI, 0.57–0.67; p < .001). A significantly lower proportion of women in the red palm oil group than in the control group had vitamin A deficiency (serum retinol levels < 0.7 μmol/L) after intervention (1.5% vs. 9.7%). The proportion of women having anemia was significantly lower (p < .01) in the red palm oil-supplemented group (80.6%) than in the control group (96.7%). The mean birthweight and gestational age of the infants did not differ significantly between the two groups. An increased risk of low birthweight (p = . 003) and preterm delivery (p = . 000) was observed with decreasing serum retinol levels in the third trimester of pregnancy. These results show that red palm oil supplementation significantly improved maternal and neonatal vitamin A status and reduced the prevalence of maternal anemia. Maternal vitamin A status in the later part of pregnancy is significantly associated with fetal growth and maturation. Hence red palm oil, a rich source of bioavailable vitamin A, could be used as a diet-based approach for improving vitamin A status in pregnancy.

Short-Term Daily Consumption of Provitamin A Carotenoid-Biofortified Maize Has Limited Impact on Breast Milk Retinol Concentrations in Zambian Women Enrolled in a Randomized Controlled Feeding Trial

BACKGROUND

Provitamin A carotenoid-biofortified maize is a conventionally bred staple crop designed to help prevent vitamin A deficiency. Lactating women are a potential target group, because regularly eating biofortified maize may increase vitamin A in breast milk-a critical source of vitamin A for breastfeeding infants.

OBJECTIVE

We assessed whether daily consumption of biofortified orange maize would increase the retinol concentration in the breast milk of Zambian women.

METHODS

Lactating women (n = 149) were randomly assigned to receive orange maize delivering 600 μg retinol equivalents (REs)/d as carotenoid plus placebo (OM), low-carotenoid white maize plus 600 μg REs/d as retinyl palmitate (VA), or white maize plus placebo (WM). Boiled maize (287 g dry weight/d) was served as 2 meals/d, 6 d/wk for 3 wk. We measured initial and final breast milk plasma retinol and β-carotene concentrations, and plasma inflammatory protein concentrations.

RESULTS

Groups were comparable at enrollment, with an overall geometric mean milk retinol concentration of 0.95 μmol/L (95% CI: 0.86, 1.05 μmol/L); 56% of samples had milk retinol <1.05 μmol/L. Median capsule and maize intake was 97% and 258 g dry weight/d, respectively. Final milk β-carotene did not vary across groups (P = 0.76). Geometric mean (95% CI) milk retinol concentration tended to be higher in the OM [1.15 μmol/L (0.96, 1.39 μmol/L)] and VA [1.17 μmol/L (0.99, 1.38 μmol/L)] groups than in the WM group [0.91 μmol/L (0.72, 1.14 μmol/L); P = 0.13], and the proportion of women with milk retinol <1.05 μmol/L was 52.1%, 42.9%, and 36.7% in the WM, OM, and VA groups, respectively (P-trend = 0.16).

CONCLUSIONS

Daily biofortified maize consumption did not increase mean milk retinol concentration in lactating Zambian women; however, there was a plausible downward trend in the risk of low milk retinol across intervention groups. This trial was registered at clinicaltrials.gov as NCT01922713.

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.

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.

Lipid-Based Nutrient Supplements Providing Approximately the Recommended Daily Intake of Vitamin A Do Not Increase Breast Milk Retinol Concentrations among Ghanaian Women

BACKGROUND

Vitamin A deficiency remains a global public health problem. Daily supplementation with a lipid-based nutrient supplement (LNS) has potential for increasing milk vitamin A concentrations.

OBJECTIVE

The objective of this study was to determine whether daily supplementation with approximately the recommended daily intake of vitamin A in an LNS or a multiple-micronutrient supplement (MMN) during pregnancy and the first 6 mo postpartum has an effect on breast milk retinol concentration at 6 mo postpartum.

METHODS

Women ≤20 wk pregnant (n = 1320) were randomly assigned to receive either the MMN providing 18 micronutrients, including 800 μg retinol equivalents of vitamin A, or the LNS with the same nutrients as the MMN group, plus 4 minerals and macronutrients, until 6 mo postpartum; a control group received iron and folic acid during pregnancy and a placebo (calcium tablet) during the first 6 mo postpartum. Breast milk samples collected at 6 mo postpartum were analyzed for retinol and fat concentrations by HPLC and creamatocrit, respectively, in a subsample of 756 women.

RESULTS

The breast milk retinol concentration was (mean ± SD) 56.3 ± 2.1 nmol/g fat, with no significant differences between groups [iron and folic acid (n = 243): 59.1 ± 2.8; MMN (n = 260): 55.4 ± 2.5; LNS (n = 253): 54.7 ± 2.5 nmol/g fat; P = 0.45], regardless of whether the woman had or had not received a high-dose vitamin A supplement (200,000 IU) soon after childbirth. Around 17% of participants had low milk retinol (≤28 nmol/g fat). We estimated that 41% of infants were potentially receiving vitamin A at amounts above the Tolerable Upper Intake Level (600 μg retinol activity equivalents/d), with no group differences in percentages with low or high milk retinol concentration.

CONCLUSION

Daily consumption of approximately the recommended intake of vitamin A did not increase breast milk retinol concentrations in this sample of Ghanaian women. This trial was registered at clinicaltrials.gov as NCT00970866.

Red palm oil-supplemented and biofortified cassava gari increase the carotenoid and retinyl palmitate concentrations of triacylglycerol-rich plasma in women

Boiled biofortified cassava containing β-carotene can increase retinyl palmitate in triacylglycerol-rich plasma. Thus, it might alleviate vitamin A deficiency. Cassava requires extensive preparation to decrease its level of cyanogenic glucosides, which can be fatal. Garification is a popular method of preparing cassava that removes cyanogen glucosides. Our objective was to compare the effectiveness of biofortified gari to gari prepared with red palm oil. The study was a randomized crossover trial in 8 American women. Three gari preparations separated by 2-week washout periods were consumed. Treatments (containing 200-225.9 g gari) were as follows: biofortified gari (containing 1 mg β-carotene), red palm oil-fortified gari (1 mg β-carotene), and unfortified gari with a 0.3-mg retinyl palmitate reference dose. Blood was collected 6 times from -0.5 to 9.5 hours after ingestion. Triacylglycerol-rich plasma was separated by ultracentrifugation and analyzed by high-performance liquid chromatography (HPLC) with diode array detection. Area under the curve for β-carotene, α-carotene, and retinyl palmitate increased after the fortified meals were fed (P < .05), although the retinyl palmitate increase induced by the red palm oil treatment was greater than that induced by the biofortified treatment (P < .05). Vitamin A conversion was 2.4 ± 0.3 and 4.2 ± 1.5 μg pro-vitamin A carotenoid/1 μg retinol (means ± SEM) for red palm oil and biofortified gari, respectively. These results show that both treatments increased β-carotene, α-carotene, and retinyl palmitate in triacylglycerol-rich plasma concentrations in healthy well-nourished adult women, supporting our hypothesis that both interventions could support efforts to alleviate vitamin A deficiency.

Estimating the Effective Coverage of Programs to Control Vitamin A Deficiency and Its Consequences Among Women and Young Children in Cameroon

BACKGROUND

To compare the cost-effectiveness of nutrition programs, the anticipated nutritional benefits of each intervention must be expressed using a common metric.

OBJECTIVE

We present the methodology for estimating the benefits of vitamin A (VA)-related interventions among women and children in Cameroon.

METHODS

We estimated "reach" (proportion of the population that receives a program), "coverage" (proportion that is deficient and receives a program), and "effective coverage" (proportion that "converts" from inadequate to adequate VA intake following an intervention) using dietary data collected during a national survey in 3 macro-regions of Cameroon (North, South, and Yaoundé/Douala). Effective coverage of programs such as (bio)fortification and micronutrient powders was estimated by adding the dietary VA contributed by the intervention to baseline VA intakes, including the contribution of increased maternal VA intake to infant VA intake through increases in breast milk VA. For interventions that provide VA-related benefits through other pathways (eg, periodic high-dose VA supplements and deworming), we developed alternative methods of estimating "daily VA intake equivalents. "

RESULTS

Baseline VA intakes and intervention reach varied by geographic macro-region. On average, estimates of program reach were greater than the effective coverage estimates by ∼50%. Effective coverage varied by intervention package and macro-region, ranging from <20 000 (deworming, Yaoundé/Douala) to >400 000 (micronutrient powder or VA supplement, North) children effectively covered per year.

CONCLUSION

These estimates of effective coverage, along with macro-region-specific information on the costs of each intervention package, serve as inputs into an economic optimization model to identify the most cost-effective package of VA interventions for each macro-region of Cameroon.

Vitamin A supplementation during pregnancy for maternal and newborn outcomes

BACKGROUND

The World Health Organization recommends routine vitamin A supplementation during pregnancy or lactation in areas with endemic vitamin A deficiency (where night blindness occurs), based on the expectation that supplementation will improve maternal and newborn outcomes including mortality, morbidity and prevention of anaemia or infection.  

OBJECTIVES

To review the effects of supplementation of vitamin A, or one of its derivatives, during pregnancy, alone or in combination with other vitamins and micronutrients, on maternal and newborn clinical outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 March 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

All randomised or quasi-randomised trials, including cluster-randomised trials, evaluating the effect of vitamin A supplementation in pregnant women.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We reviewed 106 reports of 35 trials, published between 1931 and 2015. We included 19 trials including over 310,000 women, excluded 15 trials and one is ongoing. Overall, seven trials were judged to be of low risk of bias, three were high risk of bias and for nine it was unclear. 1) Vitamin A alone versus placebo or no treatmentOverall, when trial results are pooled, vitamin A supplementation does not affect the risk of maternal mortality (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.65 to 1.20; four trials Ghana, Nepal, Bangladesh, UK, high quality evidence), perinatal mortality (RR 1.01, 95% CI 0.95 to 1.07; one study, high quality evidence), neonatal mortality, stillbirth, neonatal anaemia, preterm birth (RR 0.98, 95% CI 0.94 to 1.01, five studies, high quality evidence), or the risk of having a low birthweight baby.Vitamin A supplementation reduces the risk of maternal night blindness (RR 0.79, 95% CI 0.64 to 0.98; two trials). There is evidence that vitamin A supplements may reduce maternal clinical infection (RR 0.45, 95% CI 0.20 to 0.99, five trials; South Africa, Nepal, Indonesia, Tanzania, UK, low quality evidence) and maternal anaemia (RR 0.64, 95% CI 0.43 to 0.94; three studies, moderate quality evidence). 2) Vitamin A alone versus micronutrient supplements without vitamin AVitamin A alone compared to micronutrient supplements without vitamin A does not decrease maternal clinical infection (RR 0.99, 95% CI 0.83 to 1.18, two trials, 591 women). No other primary or secondary outcomes were reported 3) Vitamin A with other micronutrients versus micronutrient supplements without vitamin AVitamin A supplementation (with other micronutrients) does not decrease perinatal mortality (RR 0.51, 95% CI 0.10 to 2.69; one study, low quality evidence), maternal anaemia (RR 0.86, 95% CI 0.68 to 1.09; three studies, low quality evidence), maternal clinical infection (RR 0.95, 95% CI 0.80 to 1.13; I² = 45%, two studies, low quality evidence) or preterm birth (RR 0.39, 95% CI 0.08 to 1.93; one study, low quality evidence).In HIV-positive women vitamin A supplementation given with other micronutrients was associated with fewer low birthweight babies (< 2.5 kg) in the supplemented group in one study (RR 0.67, 95% CI 0.47 to 0.96; one study, 594 women).

AUTHORS' CONCLUSIONS

The pooled results of three large trials in Nepal, Ghana and Bangladesh (with over 153,500 women) do not currently suggest a role for antenatal vitamin A supplementation to reduce maternal or perinatal mortality. However, the populations studied were probably different with regard to baseline vitamin A status and there were problems with follow-up of women. There is good evidence that antenatal vitamin A supplementation reduces maternal night blindness, maternal anaemia for women who live in areas where vitamin A deficiency is common or who are HIV-positive. In addition the available evidence suggests a reduction in maternal infection, but these data are not of a high quality.

Vitamin E supplementation in pregnancy

BACKGROUND

Vitamin E supplementation may help reduce the risk of pregnancy complications involving oxidative stress, such as pre-eclampsia. There is a need to evaluate the efficacy and safety of vitamin E supplementation in pregnancy.

OBJECTIVES

To assess the effects of vitamin E supplementation, alone or in combination with other separate supplements, on pregnancy outcomes, adverse events, side effects and use of health services.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials evaluating vitamin E supplementation in pregnant women. We excluded interventions using a multivitamin supplement that contained vitamin E.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

Twenty-one trials, involving 22,129 women were eligible for this review. Four trials did not contribute data. All of the remaining 17 trials assessed vitamin E in combination with vitamin C and/or other agents. Overall the risk of bias ranged from low to unclear to high; 10 trials were judged to be at low risk of bias, six trials to be at unclear risk of bias and five trials to be at high risk of bias. No clear difference was found between women supplemented with vitamin E in combination with other supplements during pregnancy compared with placebo for the risk of stillbirth (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.88 to 1.56, nine studies, 19,023 participants, I² = 0%; moderate quality evidence), neonatal death (RR 0.81, 95% CI 0.58 to 1.13, nine trials, 18,617 participants, I² = 0%), pre-eclampsia (average RR 0.91, 95% CI 0.79 to 1.06; 14 trials, 20,878 participants; I² = 48%; moderate quality evidence), preterm birth (average RR 0.98, 95% CI 0.88 to 1.09, 11 trials, 20,565 participants, I² = 52%; high quality evidence) or intrauterine growth restriction (RR 0.98, 95% CI 0.91 to 1.06, 11 trials, 20,202 participants, I² = 17%; high quality evidence). Women supplemented with vitamin E in combination with other supplements compared with placebo were at decreased risk of having a placental abruption (RR 0.64, 95% CI 0.44 to 0.93, seven trials, 14,922 participants, I² = 0%; high quality evidence). Conversely, supplementation with vitamin E was associated with an increased risk of self-reported abdominal pain (RR 1.66, 95% CI 1.16 to 2.37, one trial, 1877 participants) and term prelabour rupture of membranes (PROM) (average RR 1.77, 95% CI 1.37 to 2.28, two trials, 2504 participants, I² = 0%); however, there was no corresponding increased risk for preterm PROM (average RR 1.27, 95% CI 0.93 to 1.75, five trials, 1999 participants, I² = 66%; low quality evidence). There were no clear differences between the vitamin E and placebo or control groups for any other maternal or infant outcomes. There were no clear differing patterns in subgroups of women based on the timing of commencement of supplementation or baseline risk of adverse pregnancy outcomes. The GRADE quality of the evidence was high for preterm birth, intrauterine growth restriction and placental abruption, moderate for stillbirth and clinical pre-eclampsia, and low for preterm PROM.

AUTHORS' CONCLUSIONS

The data do not support routine vitamin E supplementation in combination with other supplements for the prevention of stillbirth, neonatal death, preterm birth, pre-eclampsia, preterm or term PROM or poor fetal growth. Further research is required to elucidate the possible role of vitamin E in the prevention of placental abruption. There was no convincing evidence that vitamin E supplementation in combination with other supplements results in other important benefits or harms.

Maternal nutrition: how is Eastern and Southern Africa faring and what needs to be done?

BACKGROUND

The progress in key maternal health indicators in the Eastern and Southern Africa Region (ESAR) over the past two decades has been slow.

OBJECTIVE

This paper analyzed available information on nutrition programs and nutrition-specific interventions targeting maternal nutrition in the ESAR and proposes steps to improve maternal nutrition in this region.

METHODS

Search was conducted in relevant databases. Meta-analysis was done where there was sufficient data, while data from the nutrition programs was abstracted for objectives, settings, beneficiaries, stakeholders, impact of interventions and barriers encountered during implementation.

RESULTS

Findings from our review suggest that multiple nutrition programs are in place in the ESAR; including programs that directly address nutrition indicators and those that integrate corresponding sectors like agriculture, health, education, and water and sanitation. However, their scale and depth differ considerably. These programs have been implemented by a diverse range of players including respective government ministries, international agencies, non government organisations and the private sector in the region. Most of these programs are clustered in a few countries like Kenya, Uganda and Ethiopia while others e.g. Comoros, Somalia and Swaziland have only had a limited number of initiatives.

CONCLUSION

These programs have been associated with some improvements in overall maternal health and nutritional indicators; however these are insufficient to significantly contribute to the progress in the region. Efforts should be prioritized in countries with the greatest burden of maternal undernutrition and associated risk factors with a focus on existing promising interventions to improve maternal nutrition.

Supplementation with red palm oil increases β-carotene and vitamin A blood levels in patients with cystic fibrosis

Patients with cystic fibrosis (CF) show decreased plasma concentrations of antioxidants due to malabsorption of lipid soluble vitamins and consumption by chronic pulmonary inflammation. β-Carotene is a major source of retinol and therefore is of particular significance in CF. The aim of this study was to investigate the effect of daily intake of red palm oil (RPO) containing high amounts of β-carotene on the antioxidant levels in CF patients. Sixteen subjects were recruited and instructed to enrich their food with 2 to 3 tablespoons of RPO (~1.5 mg of β-carotene) daily over 8 weeks. Carotenoids, retinol, and α-tocopherol were measured in plasma at baseline and after intervention. In addition β-carotene, lycopene, α-tocopherol, and vitamin C were measured in buccal mucosa cells (BMC) to determine the influence of RPO on antioxidant tissue levels. Eleven subjects completed the study properly. Plasma β-carotene, retinol, and α-carotene of these patients increased, but plasma concentrations of other carotenoids and α-tocopherol as well as concentrations of β-carotene, lycopene, α-tocopherol, and vitamin C in BMC remained unchanged. Since RPO on a daily basis did not show negative side effects the data suggest that RPO may be used to elevate plasma β-carotene in CF.

The effects of daily consumption of β-cryptoxanthin-rich tangerines and β-carotene-rich sweet potatoes on vitamin A and carotenoid concentrations in plasma and breast milk of Bangladeshi women with low vitamin A status in a randomized controlled trial

BACKGROUND

The potential of β-cryptoxanthin (CX)-rich foods to form vitamin A (VA) in humans in not well understood.

OBJECTIVE

We measured the effects of consuming CX- and β-carotene (BC)-rich foods on plasma and breast milk VA and carotenoids in lactating women with low VA status.

DESIGN

Participants were randomly assigned to 4 groups (n = 34, 34, 34, and 33, respectively) receiving orange-fleshed sweet potatoes (OFSPs) (12 mg BC/d), tangerines (5.3 mg CX/d), white-fleshed sweet potatoes (WFSPs) with a VA supplement (0.5 mg/d), or WFSPs 2 times/d, 6 d/wk for 3 wk. All except the VA group received placebo capsules identical in appearance to VA supplements. Changes in plasma and breast milk VA, BC, and CX were measured.

RESULTS

Plasma retinol increased in the VA group. Plasma BC in the OFSP group and CX in the tangerine group increased 250% and 830%, respectively; apparent relative absorption in the CX group, considering the amounts consumed, was 4 times that in the BC group. Mean (±SEM) changes in milk VA in the OFSP (0.028 ± 0.074 μmol/L) and tangerine (0.067 ± 0.091 μmol/L) groups did not differ from those in the control (-0.077 ± 0.068 μmol/L) or VA (0.277 ± 0.094 μmol/L) group. Milk CX increased in the tangerine group.

CONCLUSIONS

VA capsules increased plasma and milk VA concentrations. The greater change in CX concentrations in the tangerine group than in BC concentrations in the OFSP group suggests that CX in tangerines was better absorbed, but both foods failed to increase milk VA concentrations. This trial was registered at clinicaltrials.gov as NCT01420406.

A comparison of retinyl palmitate and red palm oil β-carotene as strategies to address Vitamin A deficiency

Vitamin A deficiency continues to be an international public health problem with several important health consequences including blindness and overall increased rates of morbidity and mortality. To address this widespread issue, a series of strategies have been put into place from dietary diversification to supplementation and fortification programs. Retinyl palmitate has been used successfully for decades as a supplement as well as a way to fortify numerous foods, including vegetable oil, rice, monosodium glutamate, cereal flours and sugar. Recently, there has been rising interest in using a natural source of carotenoids, β-carotene from red palm oil (RPO), for fortification. Although RPO interventions have also been shown to effectively prevent Vitamin A deficiency, there are numerous challenges in using beta-carotene from RPO as a fortification technique. β-Carotene can induce significant changes in appearance and taste of the fortified product. Moreover, costs of fortifying with beta-carotene are higher than with retinyl palmitate. Therefore, RPO should only be used as a source of Vitamin A if it is produced and used in its crude form and regularly consumed without frying. Furthermore, refined RPO should be fortified with retinyl palmitate, not β-carotene, to ensure that there is adequate Vitamin A content.

Vitamin A and carotenoids during pregnancy and maternal, neonatal and infant health outcomes: a systematic review and meta-analysis

Vitamin A (VA) deficiency during pregnancy is common in low-income countries and a growing number of intervention trials have examined the effects of supplementation during pregnancy on maternal, perinatal and infant health outcomes. We systematically reviewed the literature to identify trials isolating the effects of VA or carotenoid supplementation during pregnancy on maternal, fetal, neonatal and early infant health outcomes. Meta-analysis was used to pool effect estimates for outcomes with more than one comparable study. We used GRADE criteria to assess the quality of individual studies and the level of evidence available for each outcome. We identified 23 eligible trials of which 17 had suitable quality for inclusion in meta-analyses. VA or beta-carotene (βC) supplementation during pregnancy did not have a significant overall effect on birthweight indicators, preterm birth, stillbirth, miscarriage or fetal loss. Among HIV-positive women, supplementation was protective against low birthweight (<2.5 kg) [risk ratio (RR) = 0.79 [95% confidence interval (CI) 0.64, 0.99]], but no significant effects on preterm delivery or small-for-gestational age were observed. Pooled analysis of the results of three large randomised trials found no effects of VA supplementation on neonatal/infant mortality, or pregnancy-related maternal mortality (random-effects RR = 0.86 [0.60, 1.24]) although high heterogeneity was observed in the maternal mortality estimate (I(2) = 74%, P = 0.02). VA supplementation during pregnancy was found to improve haemoglobin levels and reduce anaemia risk (<11.0 g/dL) during pregnancy (random-effects RR = 0.81 [0.69, 0.94]), also with high heterogeneity (I(2) = 52%, P = 0.04). We found no effect of VA/βC supplementation on mother-to-child HIV transmission in pooled analysis, although some evidence suggests that it may increase transmission. There is little consistent evidence of benefit of maternal supplementation with VA or βC during pregnancy on maternal or infant mortality. While there may be beneficial effects for certain outcomes, there may also be potential for harm through increased HIV transmission in some populations.

Micronutrient status in lactating mothers before and after introduction of fortified flour: cross-sectional surveys in Maela refugee camp

Background

Deficiency of micronutrients is common in refugee populations.

Objectives

Identify deficiencies and whether provided supplements and wheat flour fortified with 10 micronutrients impacts upon status among breast-feeding women from Maela refugee camp.

Methods

Two sequential cross-sectional studies were conducted in different groups of lactating mothers at 12 weeks postpartum. The first survey was before and the second 4–5 months after micronutrient fortified flour (MFF) had been provided to the camp (in addition to the regular food basket). Iron status and micronutrients were measured in serum, whole blood, and in breast milk samples.

Results

Iron and zinc deficiency and anemia were highly prevalent while low serum retinol and thiamine deficiency were rarely detected. Iron and zinc deficiency were associated with anemia, and their proportions were significantly lower after the introduction of MFF (21 vs. 35% with soluble transferrin receptor (sTfR) >8.5 mg/L, P = 0.042, and 50 vs. 73% with serum zinc <0.66 mg/L, P = 0.001). Serum sTfR, whole-blood thiamine diphosphate (TDP) and serum β-carotene were significant predictors (P < 0.001) of milk iron, thiamine and β-carotene, respectively. Lower prevalence of iron deficiency in the MFF group was associated with significantly higher iron and thiamine in breast milk.

Conclusions

High whole-blood TDP and breast milk thiamine reflected good compliance to provided thiamine; high prevalence of iron deficiency suggested insufficient dietary iron and low acceptance to ferrous sulfate supplements. MFF as an additional food ration in Maela refugee camp seemed to have an effect in reducing both iron and zinc deficiency postpartum.

Moving from efficacy to effectiveness: red palm oil's role in preventing vitamin A deficiency

Vitamin A deficiency is one of the most widespread nutritional deficiencies worldwide. Hundreds of millions of children and tens of millions of women living in Sub-Saharan Africa and Southeast Asia are at particularly high risk of the adverse health consequences associated with this largely preventable condition. Red palm oil comes from oil palms that are traditionally grown in tropical regions of West Africa and are now cultivated on a large-scale commercial basis in Southeast Asia. Red palm oil is the richest naturally occurring source of beta-carotene, a carotenoid that the human body can convert into usable vitamin A (retinol). This paper reviews a series of key intervention studies designed to investigate the impact of using red palm oil-based interventions to improve vitamin A status. These included studies from Africa, Asia, and Latin America in which red palm oil was used (or proposed for use) (1) as a dietary supplement, (2) as an in-home fortificant, (3) to fortify foods used for distribution in targeted supplementary feeding programs, and (4) to fortify staple food products. Overall, the results suggest that red palm oil is highly efficacious in improving vitamin A status among populations at risk of vitamin A deficiency. The time has come to move beyond trials of biological efficacy and focus on conducting operational research projects, effectiveness trials, and cost-benefit analyses that will help expand the use of red palm oil in areas where it is likely to be well accepted but remains underutilized as a dietary source of provitamin A.

Vitamin A supplementation during pregnancy for maternal and newborn outcomes

BACKGROUND

The World Health Organization recommends routine vitamin A supplementation during pregnancy or lactation in areas with endemic vitamin A deficiency (where night blindness occurs), based on the expectation that supplementation will improve maternal and newborn outcomes including mortality, morbidity and prevention of anaemia or infection.  

OBJECTIVES

To review the effects of supplementation of vitamin A, or one of its derivatives, during pregnancy, alone or in combination with other vitamins and micronutrients, on maternal and newborn clinical outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (15 July 2010).

SELECTION CRITERIA

All randomised or quasi-randomised trials, including cluster-randomised trials, evaluating the effect of vitamin A supplementation in pregnant women.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all studies for inclusion and resolved any disagreement through discussion with a third person. We used pre-prepared data extraction sheets.

MAIN RESULTS

We examined 88 reports of 31 trials, published between 1931 and 2010, for inclusion in this review. We included 16 trials, excluded 14, and one is awaiting assessment.Overall when trial results are pooled, Vitamin A supplementation does not affect the risk of maternal mortality (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.55 to 1.10, 3 studies, Nepal, Ghana,UK ), perinatal mortality, neonatal mortality, stillbirth, neonatal anaemia, preterm birth or the risk of having a low birthweight baby. Vitamin A supplementation reduces the risk of maternal night blindness (risk ratio (RR) 0.70, 95% CI 0.60 to 0.82, 1 trial Nepal). In vitamin A deficient populations and HIV-positive women, vitamin A supplementation reduces maternal anaemia (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.43 to 0.94, 3 trials, Indonesia, Nepal,Tanzania ). There is evidence that vitamin A supplements may reduce maternal clinical infection (RR 0.37, 95% CI 0.18 to 0.77, 3 trials, South Africa, Nepal and UK).In HIV-positive women vitamin A supplementation given with other micronutrients was associated with fewer low birthweight babies (< 2.5 kg) in the supplemented group in one study (RR 0.67, CI 0.47 to 0.96).

AUTHORS' CONCLUSIONS

The pooled results of two large trials in Nepal and Ghana (with almost 95,000 women) do not currently suggest a role for antenatal vitamin A supplementation to reduce maternal or perinatal mortality. However the populations studied were probably different with regard to baseline vitamin A status and there were problems with follow-up of women. There is good evidence that antenatal vitamin A supplementation reduces maternal anaemia for women who live in areas where vitamin A deficiency is common or who are HIV-positive. In addition the available evidence suggests a reduction in maternal infection, but these data are not of a high quality.

Vitamin A supplementation for postpartum women

BACKGROUND

In vitamin A deficient populations, the amount of vitamin A may be insufficient for maintenance of maternal health and levels in breast milk may be insufficient for breastfeeding infants' needs.

OBJECTIVES

To assess the effects of postpartum maternal vitamin A supplementation on maternal and infant health.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2010), LILACS (1982 to July 2010), Web of Science (1945 to July 2010) and Biological Abstracts (1998 to July 2010).

SELECTION CRITERIA

Randomised controlled trials evaluating the effects of postpartum maternal vitamin A supplementation.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the studies independently.

MAIN RESULTS

We included 12 trials at moderate risk of bias, enrolling 25,465 mother-baby pairs and comparing several postpartum doses (200,000-400,000 IU) of vitamin A or 7.8 mg daily beta-carotene, with placebo, iron or no supplement; or higher (400,000 IU) versus lower dose (200,000 IU). The majority of infants in all studies were at least partially breastfed for six months.Maternal: we observed no impact of vitamin A on maternal mortality (two trials of 9,126 women), morbidity (one trial of 50 women) or adverse effects (subset of 786 women in one trial). Vitamin A enhanced serum and breast milk retinol at three months in five trials, but these improvements were generally not sustained.Infant: we observed no significant differences for infant mortality RR 1.14 95% CI 0.84 to 1.57 (five trials (6,170 infants) or morbidity (three trials) except for fewer episodes of fever with vitamin A in one small trial. No significant differences in infant vitamin A status were seen with maternal vitamin A supplementation (five trials).No beneficial effects for maternal or infant health were associated with higher compared to lower doses of vitamin A in two trials.

AUTHORS' CONCLUSIONS

The lack of effect on maternal and infant mortality and morbidity, with exception of some improved infant morbidity in one small study, and the improvement in maternal vitamin A status, suggest that maternal postpartum vitamin A supplementation offers limited benefits.

Effect of vitamin supplements on HIV shedding in breast milk

BACKGROUND

Supplementation in lactating HIV-1-infected women with preformed vitamin A and β-carotene (VA/BC) increases the risk of mother-to-child transmission of HIV through breastfeeding. Identifying a biological mechanism to explain this unexpected finding would lend support to a causal effect.

OBJECTIVE

The aim of the study was to evaluate the effect of VA/BC or multivitamin (B complex, vitamin C, and vitamin E) supplementation of HIV-infected women on HIV shedding in breast milk during the first 2 y postpartum.

DESIGN

We quantified viral (cell-free) and proviral (cell-associated) HIV loads in breast-milk samples collected ≤15 d after delivery and every 3 mo thereafter from 594 Tanzanian HIV-1-infected women who participated in a randomized trial. Women received 1 of the following 4 daily oral regimens in a 2 × 2 factorial fashion during pregnancy and throughout the first 2 y postpartum: multivitamin, VA/BC, multivitamin including VA/BC, or placebo.

RESULTS

The proportion of breast-milk samples with detectable viral load was significantly higher in women who received VA/BC (51.3%) than in women who were not assigned to VA/BC (44.8%; P = 0.02). The effect was apparent ≥6 mo postpartum (relative risk: 1.34; 95% CI: 1.04, 1.73). No associations with proviral load were observed. The multivitamin had no effects. In observational analyses, β-carotene but not retinol breast-milk concentrations were significantly associated with an increased viral load in milk.

CONCLUSIONS

VA/BC supplementation in lactating women increases the HIV load in breast milk. This finding contributes to explaining the adverse effect of VA/BC on mother-to-child transmission. β-Carotene appears to have an effect on breast-milk viral load, independent of preformed vitamin A. This trial was registered at clinicaltrials.gov as NCT00197756.

Cardiovascular effects of edible oils: a comparison between four popular edible oils

Edible oils form an essential part of the modern diet. These oils play a role as an energy source, and provide the diet with many beneficial micronutrients. Although a popular conception may be that fat should be avoided, certain edible oils as a dietary supplement may play an important role in the improvement of cardiovascular health. CVD has become one of the leading causes of death worldwide. Dietary supplementation with different oils may have beneficial effects on cardiovascular health. While olive oil and sunflower-seed oil are known to reduce serum cholesterol, fish oil has become well known for reducing potentially fatal cardiac arrhythmias. Recently, red palm oil research has shown beneficial effects on cardiac recovery from ischaemia-reperfusion injury. It is clear that dietary supplementation with edible oils may play a vital role in reducing the mortality rate due to heart disease. The specific benefits and disadvantages of these oils should, however, be explored in greater depth. The present review will attempt to identify the benefits and shortcomings of four popular edible oils, namely olive oil, sunflower-seed oil, fish oil and palm oil. Additionally the present review will aim to reveal potential areas of research which could further enhance our understanding of the effects of edible oils on cardiovascular health.

Effect of vitamin supplementation on breast milk concentrations of retinol, carotenoids and tocopherols in HIV-infected Tanzanian women

BACKGROUND/OBJECTIVE

The effect of daily prenatal and postnatal vitamin supplementation on concentrations of breast milk nutrients is not well characterized in HIV-infected women. We examined the impact of vitamin supplementation during pregnancy and lactation on breast milk concentrations of retinol, carotenoids and tocopherols during the first year postpartum among 626 HIV-infected Tanzanian women.

SUBJECTS/METHODS

We conducted a randomized, double-blind, placebo-controlled trial. Women were assigned to one of four daily oral supplements: vitamin A+beta-carotene (VA+BC); multivitamins (MV; B, C and E); MV+VA+BC or placebo. Concentrations of breast milk nutrients were determined by high-performance liquid chromatography at birth and every 3 months thereafter.

RESULTS

Supplementation with VA+BC increased concentrations of retinol, beta-carotene and alpha-carotene at delivery by 4799, 1791 and 84 nmol l(-1), respectively, compared to no VA+BC (all P<0.0001). MV supplementation did not increase concentrations of alpha-tocopherol or delta-tocopherol at delivery but significantly decreased concentrations of breast milk gamma-tocopherol and retinol. Although concentrations of all nutrients decreased significantly by 3 months postpartum, retinol, alpha-carotene and beta-carotene concentrations were significantly higher among those receiving VA+BC at 3, 6 and 12 months compared to no VA+BC. alpha-Tocopherol was significantly higher, while gamma-tocopherol concentrations were significantly lower, among women receiving MV compared to no MV at 3, 6 and 12 months postpartum.

CONCLUSIONS

Sustained supplementation of HIV-infected breastfeeding mothers with MV could be a safe and effective intervention to improve vitamin E concentrations in breast milk. VA+BC supplementation increases concentrations of breast milk retinol but it is not recommended in HIV-infected mothers due to the elevated risk of vertical transmission.

The positive impact of red palm oil in school meals on vitamin A status: study in Burkina Faso

Background

Vitamin A (VA) deficiency is widespread in sub-Saharan Africa and school-age children are a vulnerable group. In Burkina Faso, the production and consumption of red palm oil (RPO) is being promoted as a food supplement for VA. The objective of the study was to assess the impact on serum retinol of adding RPO to school lunch in two test zones of Burkina Faso.

Methods

Over one school year, 15 ml RPO was added to individual meals 3 times a week in selected primary schools in two sites. Serum retinol was measured with HPLC at baseline and exactly 12 months later to take account of seasonality. A simple pre-post test design was used in the Kaya area (north-central Burkina), where 239 pupils from 15 intervention schools were randomly selected for the evaluation. In Bogandé (eastern Burkina), 24 schools were randomised for the controlled intervention trial: 8 negative controls (G1) with only the regular school lunch; 8 positive controls (G2) where the pupils received a single VA capsule (60 mg) at the end of the school year; and 8 schools with RPO through the school year (G3). A random sample of 128 pupils in each school group took part in the evaluation.

Results

In Kaya, serum retinol went from 0.77 ± 0.37 μmol/L at baseline to 1.07 ± 0.40 μmol/L one year later (p < 0.001). The rate of low serum retinol (<0.7 μmol/L) declined from 47.2% to 13.1%. In Bogandé, serum retinol increased significantly (p < 0.001) only in the capsule and RPO groups, going from 0.77 ± 0.28 to 0.98 ± 0.33 μmol/L in the former, and from 0.82 ± 0.3 to 0.98 ± 0.33 μmol/L in the latter. The rate of low serum retinol went from 46.1 to 17.1% in the VA capsule group and from 40.4% to 14.9% in the RPO group. VA-deficient children benefited the most from the capsule or RPO. Female sex, age and height-for-age were positively associated with the response to VA capsules or RPO.

Conclusion

RPO given regularly in small amounts appears highly effective in the reduction of VA deficiency. RPO deserves more attention as a food supplement for VA and as a potential source of rural income in Sahelian countries.

Xanthophyll and hydrocarbon carotenoid patterns differ in plasma and breast milk of women supplemented with red palm oil during pregnancy and lactation

Currently limited information exists on how maternal supplementation with provitamin A carotenoids might influence the carotenoid pattern in breast milk during lactation. This study was designed to investigate the effect of maternal red palm oil supplementation ( approximately 12 g/d) throughout the 3rd trimester of pregnancy and the first 3 mo postpartum on carotenoid pattern in both plasma and breast milk. Plasma and breast milk alpha- and beta-carotene concentrations increased in response to red palm oil supplementation and were different (P < 0.001) from the control group at both 1 and 3 mo postpartum. Plasma lutein and zeaxanthin concentrations were reduced (P < 0.001) from pregnancy to 1 mo postpartum and remained stable until 3 mo postpartum. However, breast milk lutein concentrations, expressed per gram of milk fat, increased (P < 0.05) in both groups from 1 to 3 mo postpartum. The results of this study show that there are proportionally more hydrocarbon carotenoids such as alpha- and beta-carotene in plasma than in breast milk, whereas xanthophylls, such as lutein and zeaxanthin, are proportionally more prevalent in breast milk. More importantly, red palm oil supplementation increases the milk concentrations of provitamin A carotenes without decreasing the milk concentrations of xanthophylls. In summary, this study demonstrates that a regulated uptake of polar carotenoids into breast milk exists and that supplementation with alpha- and beta-carotene does not negatively affect this transfer. The mechanisms behind this transport are not fully understood and merit further study.

Vitamin E supplementation in pregnancy

BACKGROUND

Vitamin E supplementation may help reduce the risk of pregnancy complications involving oxidative stress, such as pre-eclampsia. There is a need to evaluate the efficacy and safety of vitamin E supplementation in pregnancy.

OBJECTIVES

To assess the effects of vitamin E supplementation, alone or in combination with other separate supplements, on pregnancy outcomes, adverse events, side-effects and use of health services.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (23 June 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2004), MEDLINE (1966 to May 2004), Current Contents (1998 to May 2004) and EMBASE (1980 to May 2004).

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials evaluating vitamin E supplementation in pregnant women. We excluded interventions using a multivitamin supplement that contained vitamin E.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion, extracted data and assessed trial quality.

MAIN RESULTS

Four trials, involving 566 women either at high risk of pre-eclampsia or with established pre-eclampsia, were eligible for this review. All trials assessed vitamin E in combination with other supplements and two trials were published in abstract form only. No difference was found between women supplemented with vitamin E in combination with other supplements during pregnancy compared with placebo for the risk of stillbirth (relative risk (RR) was 0.77, 95% confidence intervals (CI) 0.35 to 1.71, two trials, 339 women), neonatal death (RR 5.00, 95% CI 0.64 to 39.06, one trial, 40 women), perinatal death (RR 1.29, 95% CI 0.67 to 2.48, one trial, 56 women), preterm birth (RR 1.29, 95% CI 0.78 to 2.15, two trials, 383 women), intrauterine growth restriction (RR 0.72, 95% CI 0.49 to 1.04, two trials, 383 women) or birthweight (weighted mean difference -139.00 g, 95% CI -517.68 to 239.68, one trial, 100 women), using fixed-effect models. Substantial heterogeneity was found for pre-eclampsia. Women supplemented with vitamin E in combination with other supplements compared with placebo were at decreased risk of developing clinical pre-eclampsia (RR 0.44, 95% CI 0.27 to 0.71, three trials, 510 women) using fixed-effect models; however, this difference could not be demonstrated when using random-effects models (RR 0.44, 95% CI 0.16 to 1.22, three trials, 510 women). There were no differences between women supplemented with vitamin E compared with placebo for any of the secondary outcomes.

AUTHORS' CONCLUSIONS

The data are too few to say if vitamin E supplementation either alone or in combination with other supplements is beneficial during pregnancy.

Serum Concentration of Vitamins A and E and Lipid in a Rural Population of North Cameroon

BACKGROUND

Vitamin A deficiency is still a major health problem mostly affecting people in developing countries. It contributes to increased mortality and morbidity through current infection. In Cameroon, it is a public health problem mostly in the northern part where palm oil, which is a principal source of provitamin A in the south of the country, is not consumed.

AIM

We carried out this research to discover the relationship between vitamins (A and E) and blood lipids in a normal rural population living in vitamin A-deficiency area.

DESIGN

A cross-sectional study with 81 healthy volunteers (40 men and 41 women) aged 3-61 (mean 18.32 +/- 1.63) years and living in two neighboring villages (Doyan and Larao) in the northern part of Cameroon, where previous studies revealed a prevalence of vitamin A deficiency of 33.3%.

METHODS

Serum concentrations of vitamins A and E were measured by fluorometric methods. Serum cholesterol and lipids were assayed by enzymatic methods.

RESULTS

The mean +/- standard error for vitamin A and E were 15.09 +/- 0.82; 526.99 +/- 29.57 mug/100 ml, respectively. The concentrations of the serum parameters analyzed were similar for both sexes, whereas the atherogenic ration of cholesterol (ARC) was significantly (p < 0.036) higher in women. Serum lipids (total lipids, total cholesterol, low-density lipoprotein and phospholipids) correlated with vitamins A and E (p < 0.05). Vitamins A and E were highly correlated with each other (r = 0.42, p < 0.001). Age was positively associated with vitamin A (r = 0.42, p < 0.001) and vitamin E (r = 0.29, p < 0.01). Deficiency of vitamins A and E constitutes a public health problem with more than 56% of the subjects having low levels of these vitamins, while subjects tested had a low risk for cardiovascular diseases.

CONCLUSION

In this population we noticed normal lipid levels and vitamin A deficiency probably resulting from diets poor in provitamin A.

Assessing micronutrient status in the presence of inflammation

Measurement of micronutrient status in the presence of inflammation is difficult for several reasons. Changes in levels of acute phase proteins are associated with increased plasma levels of some indicators of micronutrient status, such as ferritin, and decrease of others, such as retinol. Alterations in the plasma levels of acute phase proteins can occur from hemodilution, sequestration and increased or decreased rates of synthesis and breakdown. How much these relate to functional deficiency is not known. Assays that are less perturbed by inflammation, such as the transferrin receptor assay, and adjustment of plasma micronutrient levels according to different cutoff levels for acute phase proteins are helpful but they do not enable precise assessment of micronutrient status among individuals who are infected. Improving assessment of micronutrient status is important if micronutrient interventions are to be targeted to those with the greatest need.