Breast Milk-Derived Retinol Is a Potential Surrogate for Serum in the 13C-Retinol Isotope Dilution Test in Zambian Lactating Women with Vitamin A Deficient and Adequate Status

A Correlation Study of Plasma and Breast Milk Retinol Concentrations in Breastfeeding Women in China

Retinol in breast milk is related to plasma concentration among breastfeeding women, but the linear or curvilinear relationships between the two remains unclear. We conducted a cross-sectional study in 403 Chinese breastfeeding women at 42 ± 7 days postpartum. Plasma and breast milk samples were assayed using high performance liquid chromatography to determine the concentration of retinol. Partial Spearman correlation and multivariable fractional polynomial regression were used to examine the relationships between the two retinol concentrations and between plasma retinol concentration and milk-to-plasma (M/P) retinol. The median (interquartile range, IQR) of the retinol concentration in the plasma was 1.39 (1.21, 1.63) μmol/L and 1.15 (0.83, 1.49) μmol/L in the breast milk, respectively. The partial correlation coefficient between them was 0.17 (p < 0.01). A linear relationship was observed with an adjusted regression coefficient of 0.34 (95% CI: 0.19, 0.49). The relationship between the plasma retinol and M/P ratio was nonlinear and segmented at 1.00 μmol/L of plasma retinol. The regression coefficients, below and above the segmented point, were -1.69 (95% CI: -2.75, -0.62) and -0.29 (95% CI: -0.42, -0.16), respectively. Plasma and breast milk retinol were positively correlated, whereas women with a low concentration of plasma retinol showed a stronger capacity of transferring retinol to breast milk.

Comparison of Total Body Vitamin A Stores Using Individual versus Population 13C-Natural Abundance of Serum Retinol in Preschool Children and Women Residing in 6 Diverse African Countries

BACKGROUND

Stable isotope techniques using 13C to assess vitamin A (VA) dietary sources, absorption, and total body VA stores (TBSs) require determination of baseline 13C abundance. 13C-natural abundance is approximately 1.1% total carbon, but varies with foods consumed, supplements taken, and food fortification with synthetic retinyl palmitate.

OBJECTIVES

We determined 13C variation from purified serum retinol and the resulting impact on TBSs using pooled data from preschool children in Burkina Faso, Cameroon, Ethiopia, South Africa, Tanzania, and Zambia and Zambian women.

METHODS

Seven studies included children (n = 639; 56 ± 25 mo; 48% female) and one in women (n = 138; 29 ± 8.5 y). Serum retinol 13C-natural abundance was determined using GC-C-IRMS. TBSs were available in 7 studies that employed retinol isotope dilution (RID). Serum CRP and α1-acid-glycoprotein (AGP) were available from 6 studies in children. Multivariate mixed models assessed the impact of covariates on retinol 13C. Spearman correlations and Bland-Altman analysis compared serum and milk retinol 13C and evaluated the impact of using study- or global-retinol 13C estimates on calculated TBSs.

RESULTS

13C-natural abundance (%, median [Q1, Q3]) differed among countries (low: Zambia, 1.0744 [1.0736, 1.0753]; high: South Africa, 1.0773 [1.0769, 1.0779]) and was associated with TBSs, CRP, and AGP in children and with TBSs in women. 13C-enrichment from serum and milk retinol were correlated (r = 0.52; P = 0.0001). RID in children and women using study and global estimates had low mean bias (range, -3.7% to 2.2%), but larger 95% limits of agreement (range, -23% to 37%).

CONCLUSIONS

13C-natural abundance is different among human cohorts in Africa. Collecting this information in subgroups is recommended for surveys using RID. When TBSs are needed on individuals in clinical applications, baseline 13C measures are important and should be measured in all enrolled subjects.

Direct Use of Plasma or Milk Vitamin A Specific Activity Data to Model Retinol Kinetics and Predict Vitamin A Stores in Theoretical Lactating Women

BACKGROUND

Many applications of the Simulation, Analysis and Modeling software use data on the fraction of an orally administered tracer dose (FD) in plasma; thus, researchers must scale-up measured analyte concentration to the total plasma pool. For studies in lactating women, estimating breast milk pool size is challenging.

OBJECTIVES

The objectives were to determine whether the standard vitamin A modeling approach using FD data could be modified to use vitamin A specific activity in milk (SAm) and/or plasma (SAp) for compartmental analysis of vitamin A kinetics and status in theoretical lactating women.

METHODS

Using 12 previously studied theoretical subjects with a wide range of assigned values for vitamin A total body stores (TBS) and the coefficient ("FaS") needed to predict TBS using a retinol isotope dilution equation, we simulated data for SAp and SAm for 49 d after oral administration of labeled vitamin A. Then we modeled datasets for SAp and SAm, as well as only SAp or SAm, incorporating a linear scaling factor to automatically convert SA to FD and including several physiologically reasonable constraints as input data. As outcomes, we compared model-predicted TBS and FaS to assigned values.

RESULTS

Scaling factors effectively adjusted SA data to adequately predict vitamin A mass in plasma and breast milk pools. Data for SAp and SAm provided model predictions of TBS that were comparable to assigned values (range: 85-107%); using only SAp, ratios ranged from 92% to 108% and for SAm from 85% to 108%. Parallel results were obtained for simulated FaS.

CONCLUSIONS

Results show that SA data from plasma and/or milk can be used directly for modeling vitamin A during lactation in theoretical subjects, providing accurate estimates of TBS and FaS. Results suggest that, in free-living lactating women, researchers might measure only SAp or only SAm and adequately describe whole-body vitamin A metabolism and status.

Breast Milk Retinol Concentrations Reflect Total Liver Vitamin A Reserves and Dietary Exposure in Thai Lactating Women from Urban and Rural Areas

BACKGROUND

Measuring vitamin A (VA) status during lactation is required to inform dietary recommendations. Limited data exist on VA stores in women.

OBJECTIVES

Our objective was to assess VA status in lactating Thai women by measuring total body VA stores (TBSs), serum and breast milk retinol concentrations, and dietary intake.

METHODS

Lactating women (n = 94), 6-8 wk postpartum, were enrolled from rural (Ayutthaya) and urban (Bangkok) areas. TBSs were measured by the 13C-retinol isotope dilution (RID) technique using 2.0 μmol 13C-retinyl acetate and a single blood sample 14 d post-dose. Natural 13C-enrichment was determined in nonenrolled women (n = 11). Estimated total liver VA reserves (TLRs) were determined using assumptions for lactation. Serum, foremilk, and hindmilk samples were analyzed for retinol by HPLC. Dietary VA intake was assessed by FFQ and 24-h dietary recalls for 3 d. Multiple regression and Pearson correlation were used to evaluate relations.

RESULTS

Median VA intakes were 51.8% of 2003 Thai daily recommendations for lactating women, with the majority from animal-source foods. Many women in Ayutthaya consumed liver weekly. Considering TLRs as 50% TBS, 20% and 11% of mothers in Ayutthaya and Bangkok, respectively, showed deficient reserves (≤0.10 μmol retinol/g). Median (quartile 1, quartile 3) serum [1.58 (1.34, 1.91) and 1.52 (1.30, 1.70) μmol/L] and milk [1.88 (1.29, 2.95) and 1.74 (0.96, 2.26) μmol/L] retinol in Ayutthaya and Bangkok, respectively, were normal. Women with deficient TLRs showed low milk retinol concentrations (≤1.0 μmol/L) and consumed less dietary VA, especially from animal-source foods. Breast milk retinol concentrations, especially hindmilk, demonstrated strong correlation with TBSs and TLRs estimated from the RID test.

CONCLUSIONS

Approximately 15% of Thai lactating women had deficient TLRs. Breast milk retinol concentrations in conjunction with dietary intake records show potential to screen mothers at risk of VA deficiency to guide interventions.The Thai Clinical Trials Registry number is TCTR20160824001 for the work in Thailand.

Compartmental Modeling of Vitamin A Stable Isotope Data from Milk or Plasma Provides Comparable Predictions of Vitamin A Stores in Theoretical Lactating Women

BACKGROUND

Previous compartmental models describing and quantifying whole-body vitamin A (VA) metabolism have been developed from plasma retinol kinetic data after human subjects ingest stable isotope-labeled VA. For humans, models based on data obtained from other sampling sites (e.g., excreta or milk) have not been proposed.

OBJECTIVES

Our objective was to determine whether comparable model predictions of VA total body stores (TBS) in theoretical lactating women were obtained using tracer data from only retinol in plasma or VA in milk.

METHODS

We used Simulation, Analysis and Modeling software to simulate values for TBS and the coefficients used in the retinol isotope dilution (RID) equation TBS = FaS/SAp (Fa, fraction of dose in stores; S, retinol specific activity (SA) in plasma/SA in stores; SAp, specific activity in plasma). We compared individual subject predictions of TBS and FaS based on modeling only plasma or only milk tracer data to previous results ("assigned values") for 12 theoretical lactating women when modeling was done based on tracer data for chylomicron retinyl esters, plasma retinol, and milk VA.

RESULTS

For subjects with a wide range of TBS, model-predicted TBS based on only plasma data were comparable with assigned values (range: 94%-106%). Using only milk data, predictions ranged from 72% to 178%, but when VA intake was included in modeling, predictions were improved (97%-102%). Similar results were obtained for simulated FaS.

CONCLUSIONS

If confirmed in free-living lactating women, results indicate that, similar to models based on serial plasma sampling, a model for whole-body VA kinetics, including predictions of TBS and FaS, can be identified based on tracer data for VA in milk when VA intake is included as a modeling constraint. Milk data have not been previously used for compartmental modeling of VA in humans.

Development of a Compartmental Model for Studying Vitamin A Kinetics and Status in Theoretical Lactating Women

BACKGROUND

Low vitamin A status and suboptimal milk vitamin A concentrations are problems in many populations worldwide. However, limited research has been done on whole-body vitamin A kinetics in women of reproductive age, especially during lactation.

OBJECTIVES

Goals were to develop compartmental models describing retinol kinetics in theoretical nonlactating (NL) and lactating (L) women and to determine whether the retinol isotope dilution (RID) method accurately predicted vitamin A total body stores (TBS) in the groups and individuals.

METHODS

We adapted 12 previously-used theoretical females with assigned values for retinol kinetic parameters and TBS (225-1348 μmol); subjects were NL or L (nursing one 3- to 6-mo-old infant) during 49-d kinetic studies after isotope dosing. We used an established compartmental model, adding a compartment for chylomicrons and, for L, another for mammary gland milk with inputs from holo-retinol-binding protein and chylomicron retinyl esters and output to milk. Using compartmental analysis, we simulated tracer responses in compartments of interest and calculated TBS using the RID equation TBS =   FaS/SAp [Fa, fraction of dose in stores; S, retinol specific activity in plasma/specific activity in stores; SAp, specific activity of retinol in plasma].

RESULTS

Models for both groups were well identified. Simulated plasma tracer responses were similar for NL and L, with L always below NL; milk tracer paralleled plasma from 10 d postdosing. Geometric mean FaS ratios (L/NL) were ∼0.75 during days 2-30. Using appropriate group FaS, RID provided accurate TBS predictions for >80% of NL and L subjects after day 18 when CV% for FaS was ∼10%.

CONCLUSIONS

These new physiologically-based models for vitamin A kinetics may be useful for future research in women of reproductive age. Results indicate that, in groups like these, RID to assess an individual's vitamin A status should be done at 21-28 d after isotope dosing.

Use of Compartmental Modeling and Datasets for Theoretical Lactating Women to Determine Conditions under Which Vitamin A-Specific Activity in Breast Milk Provides Accurate Estimates of Vitamin A Total Body Stores by Retinol Isotope Dilution

BACKGROUND

Vitamin A concentrations in breast milk are related to maternal vitamin A intake and status.

OBJECTIVES

Our objective was to identify conditions under which vitamin A specific activity in breast milk (SAm) could be used instead of retinol specific activity in plasma (SAp) to predict vitamin A total body stores (TBS) by retinol isotope dilution (RID).

METHODS

We used 12 previously-studied theoretical lactating women with assigned values for TBS (219-1348 μmol) and retinol kinetic parameters; we assumed subjects ingested a dose of stable isotope-labeled vitamin A. We expanded a 9-compartment steady state tracer model to include a parallel model for tracee (unlabeled retinol) and then adapted that model so vitamin A intake entered the system in 3 meals each day. Using compartmental analysis, we first simulated SAm and SAp after an overnight fast (as in actual RID experiments) and then with vitamin A intake also restricted in sequential meals on the day before sampling for RID.

RESULTS

After an overnight fast, SAm at day 21 postdosing was lower than SAp. However, if vitamin A intake was also restricted in 1, 2, or 3 meals before sampling, SAm/SAp (mean ± SD) was 0.92 ± 0.042,  0.96 ± 0.016,  or 0.99 ± 0.004,  respectively; results for days 14 and 28 were similar. When either SAp or SAm was used to predict TBS by RID on day 21 after 1-d restriction, predictions for all subjects were within 25% of assigned TBS.

CONCLUSIONS

Results indicate that, for theoretical lactating women with a wide range of vitamin A status, SAm will accurately predict TBS by RID at 2-4 wk postdosing if vitamin A intake is restricted for 1 d before sampling. If confirmed in community settings, results suggest that vitamin A status in lactating women can be determined without collecting blood.

Time Since Dose and Dietary Vitamin A Intake Affect Tracer Mixing in the 13C-Retinol Isotope Dilution Test in Male Rats

BACKGROUND

Retinol isotope dilution (RID) estimates total liver vitamin A reserves (TLRs), the gold-standard vitamin A (VA) biomarker. RID equation assumptions are based on limited data.

OBJECTIVES

We measured the impact of tracer choice, mixing period, and VA intake on tracer mixing [ratio of tracer enrichment in serum to that in liver stores (S)] in VA-deficient, -adequate, and hypervitaminotic rats.

METHODS

Study 1 was a 3 × 2 × 3 design (18 groups, n = 5/group). Male Sprague-Dawley rats (21 d old) received 50, 100, or 3500 nmol VA/d for 21 d, were administered 52 nmol 13C2- or 13C10-retinyl acetate orally, and killed 5, 10, or 15 d later. Unlabeled VA (50 nmol/d) was given on days 11-14. Study 2 used 100 nmol VA/d for 21 d with 3 groups (n = 6-7): 52 nmol 13C2- or 13C10-retinyl acetate and 100 nmol VA/d throughout 14-d mixing, or 13C2-retinyl acetate without VA. Repeated-measures, 1-factor, and 3-factor ANOVAs were used for analysis.

RESULTS

Mean ± SD TLRs (μmol/g liver) reflected intake: 0.11 ± 0.04 (50 nmol VA/d), 0.16 ± 0.04 (100 nmol VA/d), and 5.07 ± 1.58 (3500 nmol VA/d) in Study 1 and 0.24 ± 0.08 (100 nmol VA/d) in Study 2. In Study 1, mean ± SD S was 1.65 ± 0.26 (5 d), 1.16 ± 0.09 (10 d), and 0.92 ± 0.08 (15 d). The interactions tracer*VA intake and time*VA intake were significant between days 10 and 15 (P < 0.05). In Study 2, mean ± SD S was 1.07 ± 0.02 without VA during mixing, and 0.81 ± 0.04 (13C2) and 0.79 ± 0.03 (13C10) with VA intake throughout. Estimated:measured TLRs varied by VA intake and time in Study 1 but not between groups in Study 2.

CONCLUSIONS

The 13C-content effect on RID through S is inconsistent. S is highly variable at 5 d, contraindicating early-time point RID. VA intake effects on S vary with timing and quantity. Assuming S = 0.8 at 14 d with consistent VA intake in human studies is likely appropriate.

Geographic and socio-demographic determinants of plasma retinol concentrations in Chinese pregnant and lactating women

PURPOSE

To examine plasma retinol status and its determinants in Chinese pregnant or lactating women.

METHODS

A cross-sectional study involving 1211 healthy women in mid-pregnancy, late pregnancy, or lactation was conducted in northern, central, and southern China. Plasma retinol concentration was determined by high-performance liquid chromatography. Multivariate quantile regression or modified Poisson regression was used to estimate adjusted medians, or to examine the associations of suboptimal retinol concentration (< 1.05 µmol/L) with various factors.

RESULTS

The overall median (interquartile range) retinol concentration was 1.25 (1.06-1.46) µmol/L. The adjusted concentration was higher in women at lactation (1.39 [1.20-1.63] µmol/L) and mid-pregnancy (1.26 [1.10-1.44] µmol/L) than late pregnancy (1.07 [0.92-1.28] µmol/L), and higher in women in the central area (1.34 [1.18-1.49] µmol/L) and the north (1.26 [1.10-1.43] µmol/L) than the south (1.19 [1.07-1.31] µmol/L). The retinol concentration was more likely to be low in women with lower pre-pregnancy BMI, younger age, less education, and in lactating women who had a caesarean birth or were breastfeeding exclusively. A total of 290 (24.0%) women had a suboptimal retinol concentration, and the prevalence was higher in women at late pregnancy, residing in the south, with younger age, and having underweight pre-pregnancy.

CONCLUSION

About one-fourth of pregnant or lactating women in China had suboptimal retinol concentrations that varied with phases of pregnancy and lactation, region of residence, and socio-demographic characteristics, indicating a need for population-specific public health strategies to optimize vitamin A status.

Vitamin A-fortified rice increases total body vitamin A stores in lactating Thai women measured by retinol isotope dilution: a double-blind, randomized, controlled trial

BACKGROUND

Lactating women are at increased risk for vitamin A (VA) deficiency due to demands for breast milk content and limited hepatic stores for women in some countries. Previously, consumption of triple-fortified rice, which included VA, iron, and zinc, successfully improved the VA status of Thai children in whom their total body VA stores (TBSs) were doubled in 2 mo.

OBJECTIVE

This study assessed the efficacy of consuming VA-fortified rice, which delivered 500 µg retinol activity equivalents (RAEs)/d, on TBSs and estimated total liver VA reserves (TLRs) in Thai lactating women using the retinol isotope dilution (RID) test.

METHODS

A randomized controlled trial was conducted with 70 lactating women (n = 35/group) who received either VA-fortified rice (500 µg RAEs/d) or unfortified rice for 14 wk on weekdays only. Serum retinol concentrations (SRs), C-reactive protein, and TBSs were assessed before and after the intervention. The paired 13C-RID test was used to measure TBSs. After a baseline blood sample, 2.0 µmol [14,15]-13C2-retinyl acetate was administered orally. A follow-up blood sample was drawn 14 d later. The RID test was repeated after the intervention.

RESULTS

TBSs increased significantly (P < 0.05) in the intervention group from 240 (182, 316) to 331 (251, 447) [geometric means (95% CIs)] µmol retinol, and this change in TBSs was significantly higher (P < 0.05) than that in the control group [+52.9 (-74, 453) compared with -4.3 (-106, 275) µmol retinol]. Estimated TLRs indicated a high prevalence of VA deficiency among these lactating women. Initial and final SRs did not differ by group and did not change over the course of the intervention.

CONCLUSION

VA-fortified rice improved the VA status of lactating women by increasing TBSs. A targeted approach to disseminate VA interventions among vulnerable groups should be considered in some contexts. This trial was registered at clinicaltrials.gov as NCT03056625.

Biological evidence to define a vitamin A deficiency cutoff using total liver vitamin A reserves

Vitamin A is a fat-soluble vitamin involved in essential functions including growth, immunity, reproduction, and vision. The vitamin A Dietary Reference Intakes (DRIs) for North Americans suggested that a minimally acceptable total liver vitamin A reserve (TLR) is 0.07 µmol/g, which is not explicitly expressed as a vitamin A deficiency cutoff. The Biomarkers of Nutrition for Development panel set the TLR cutoff for vitamin A deficiency at 0.1 µmol/g based on changes in biological response of several physiological parameters at or above this cutoff. The criteria used to formulate the DRIs include clinical ophthalmic signs of vitamin A deficiency, circulating plasma retinol concentrations, excretion of vitamin A metabolites in the bile, and long-term storage of vitamin A as protection against vitamin A deficiency during times of low dietary intake. This review examines the biological responses that occur as TLRs are depleted. In consideration of all of the DRI criteria, the review concludes that induced biliary excretion and long-term vitamin A storage do not occur until TLRs are >0.10 µmol/g. If long-term storage is to continue to be part of the DRI criteria, vitamin A deficiency should be set at a minimum cutoff of 0.10 µmol/g and should be set higher during times of enhanced requirements where TLRs can be rapidly depleted, such as during lactation or in areas with high infection burden. In population-based surveys, cutoffs are important when using biomarkers of micronutrient status to define the prevalence of deficiency and sufficiency to inform public health interventions. Considering the increasing use of quantitative biomarkers of vitamin A status that indirectly assess TLRs, i.e. the modified-relative-dose response and retinol-isotope dilution tests, setting a TLR as a vitamin A deficiency cutoff is important for users of these techniques to estimate vitamin A deficiency prevalence. Future researchers and policymakers may suggest that DRIs should be set with regard to optimal health and not merely to prevent a micronutrient deficiency.