Vitamin A Deficiency

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Vitamin A Deficiency

• By Caroline Delori
• and Shira Lipsky

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Malnutrition

• Millions of mothers and children die each day
  from malnutrition.
• 83 of children die due to mild or moderate
  malnourishment.
• 1/3rd of worlds population is micronutrient
  deficient
• The global economy produces enough food to feed
  the entire world population.
• Result of several factors combined.
• www.info.usaid.gov/pop_health/nmh

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What is Vitamin A?

• Organic compounds that are present in small
  amounts in foods that are not digested, but
  absorbed through small intestine.
• VA Functions metabolic, photosensitive pigments
  of retinal cells, differentiation of epithelia.
• Fat soluble and any excess cannot be excreted in
  the urine.
• Most common preformed vitamin found in food is
  retinol.
• Found in animal products, such as fish oils,
  milk, and butter.
• Carotenoids are converted by the body into
  retinol.
• Found in dark leafy vegetables, such as sweet
  potatoes and yellow fruits and palm oil, and in
  red chili. It is the red pigment present in
  carrots.
• Half of biological activity of VA because of low
  conversion rate.

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The VAD Story!

• 230 million children are at risk for VAD.
• Over one million VAD childhood associated deaths
  in one year.
• VAD is prevalent in over 75 countries distributed
  in S.E. Asia and Africa
• VAD leads to
• Infant and child mortality
• Keratinization- dry skin and cracking of mucous
  membranes
• Xerophthalmia- dryness of the eye, blindness
• Diarrheal disease and respiratory infections
• Strong link between VAD and infection.

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What is VA good for?

• VA is most beneficial for infants, young
  children, pregnant and lactating mothers.
• VA programs have shown to impact
• Xerophthalmia
• Measles
• Child Survival
• Growth
• Other infections

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Estimated Numbers of People At-risk and Affected
by VAD

• Region VA At Risk VA Affected (Xerophthalmia)
• Africa 52 1.0
• Americas 16 0.1
• South East Asia 125 1.5
• Eastern Mediterranean 16 0.1
• Western Pacific 42 0.1
• Total (millions) 251 2.8
• http//www.sph.emory.edu/PAMM/Ih552/Jan28fortifica
  tion/

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A Little History

• 1904- First epidemic of xerophthalmia in Japan
• 1947- Industrial VA synthesis
• 1964- First global survey of VAD
• 1980s- Importance of VA in child survival was
  shown
• 1990- Summit for children
• 1991- Ending Hidden Hunger Conference
• 1992- International Conference on Nutrition
• www.sightandlife.or/info/slides/slidesp16-30.pdf
• www.worldbank.org/html/extdr/hnp/nutrition

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How to Combat VAD

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Supplementation

• Short-term solution
• Therapeutic, targeted, or universal
• Liquid filled gelatin capsules
• Given orally or intravenously
• .02 cents each capsule
• 1.64- 2.20 per child for VA program

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VA Distribution Schedule

• Age Recommended Dosage Schedule
• 0-6 mo. 25, 000 IU every 4 weeks
• 6-11 mo. 100, 000 IU every 3-6 mo.
• 1-6 yrs. 200, 000 IU every 3-6 mo.
• Pregnant women 10, 000 IU every day during
  gestation
• Lactating mothers200, 000 IU once
• www.sightandlife.org/info/manual/salManchap10.pdf

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Food Fortification

• Medium-term solution
• Increase nutrients in specific foods
• Margarine, milk, sugar
• Identify food vehicle fortificant
• Requires commitment from government, food
  industries, legislation, consumers, and research
  facilitation.
• .36 cents per person
• http//www.jsi.com/intl/omni/sugr_pt1.htm

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Selecting a VA Food Vehicle

• Must be consumed by a large proportion of the
  population.
• Little day to day and inter-individual variation
  occurs in the amount of the food vehicle
  consumed which will ensure VA intake remains
  within a safe range.
• Food vehicle must go through a process in which
  VA can be added under controlled conditions and
  at a minimum cost.
• Must be able to track the delivery of fortified
  food.
• www.jsi.com/intl/omni/sugr_pt1.htm

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Selecting a VA Fortificant

• Miscible in the food vehicle
• Must not change the smell, color or taste of the
  food
• No chemical interaction with the food resulting
  in damage of the original food
• Stable
• No significant increase in cost of food to the
  consumer.
• www.jsi.com/intl/omni/sugr_pt1.htm

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Process of Food Fortification

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• www.jsi.com/intl/omni/sugr_pt1/htm

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Diet Diversification

• Long-term solution
• Should run parallel with other short-term
  solutions
• Increases the variety and frequency of
  micronutrient rich food sources
• Modifies food production, consumption and
  distribution
• Red palm oil
• Sweet potatoes, 1998
• Cost effective and wont lead to
  hypervitaminosis.
• Through nutritional education, home gardens and
  improved methods of food preparations,
  preservation and cooking.
• No medicalization of food
• www.jsi.com/intl/omni/sugr_pt1.htm

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Nutrition Education

• Long-term commitment from the participants.
• Education of mother and children on how to eat a
  more well balanced diet filled nutrients
• Improved local access to VA-rich foods
• Economic and social payoffs are as high as 84
  times the program costs
• Requires economic, political, operational,
  behavioral sustainability.

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DEBATE

• Which program would be most effective in the
  country you selected for your MCH proposal?
  Discuss the issues involved in implementing a
  program solution. Use the list of pros and cons.

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Different Programs Must Consider

• Survey the extent of the problem
• Severity of the deficiency
• Distribution of the deficiency
• based on age, gender, urban, rural,
  agriculture, socioeconomic
• Identifying target population
• Screening for VAD
• www.jsi.com/intl/omni/sugr_pt1.htm

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Program Issues Supplementation

• Most common vehicle is EPI
• What will happen when polio is eradicated?
• Timing of intervention and cost
• Scope of population reached
• Procurement or production VA capsules- UNICEF
• Monitoring of VA program
• Requires foreign currency
• An efficient, sustainable distribution system
• Shared responsibility by immunization and
  nutrition sectors.
• National Micronutrient Day in Niger
• http//dcc2.bumc.bu.edu/IH887/IH887A1.htm

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Program Issues Food Fortification

• Identify food vehicle and fortificant the high
  cost of fortificant
• Field testing of fortificant must be done at many
  locations in one country due to differing
  environmental conditions.
• There might not be a food vehicle, in which case,
  one must be created.
• Need technologically developed food industry,
  field testing and appropriate monitoring.
• Micronutrient losses may occur at each point in
  distribution chain and at household levels during
  storage and preparation.
• Social marketing of the fortified food
• Harmonization between different sectors involved
• Sangkap Pinoy Seal Program in Philippines
• Zambia, May 1998
• Swaziland, June 1999

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Program Issues Diet Diversification

• Home gardening issues
• available technology- seeds, assistance
• cultural acceptability and sensitivity
• land suitable for gardening
• time
• Requires community involvement
• Requires nutritional education of consumers
• Challenging to coordinate and requires much
  cooperation
• Labor intensive operation
• Costly economically and logistically
• Results arent readily seen
• http//dcc2/bumc.bu.edu/IH887/IH887A1.htm

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Cost Analysis of Programs

• Summary of cost-effectiveness of three VA
  interventions in Guatemala, 1991.
• Program Persons reached High-risk person
  reached
• Fortification 0.287 0.653
• Capsule Distribution 1.524 1.524
• Food Production/Education 1.191 2.707
• (long-term effect)
• Phillips, M, Sanghvi T, Suarez R, McKingney J,
  and Fiedler J. The Costs and Effectiveness of
  Three Vitamin A Interventions in Guatemala. Soc
  Sci Med.1996.42(12)1661-1668

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Controversy Issues

• VA is a known teratogen
• Difficult to evaluate if maternal mortality rate
  is effected by VAD
• Side effects of hypervitaminosis
• Malformation
• Schizophrenia
• Head ache and loss of appetite
• Bulging Fontanelle

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More Controversies

• There are pros and cons to all interventions,
  therefore difficult to assess which one to
  implement.
• Protection afforded by prophylactic large doses
• Dosage amount
• Associated with the increase in severity of the
  infection
• Ghana Study
• Selection of target population- high-risk, medium
  risk, and low risk populations
• Multiple micronutrient fortification
• Which food vehicles and fortificants to use
• Reports that dark vegetables and fruits do not
  provide as much carotenoids as was assumed.

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Biotechnology

• You provide the idea and theyll make it!
• Genetically Engineered Rice
• You can target very precisely the kind of crops
  needed
• Increase agricultural production time
• The potential benefits of VA in a grain of rice
  are greater than the possible risks.
• Requires cooperation among scientists and funding
  institutions
• Rarely managed correctly
• Unforeseen negative effects
• Risks range from human health effects through
  eating the foods to environmental impacts-
  spreading genes through cross pollination to
  other plants
• Many people opposed to idea because of possible
  issues
• Need global forum for governments, NGOs and
  industries to discuss risks and benefits of
  biotechnology
• http//www.cgiar.org/ifpri/media/innews/2052099.ht
  m

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New Technology

• CIP (International Potato Center)- sweet potatoes
  varieties increase intake of VA
• Swiss Federal Institute of Technology-
  genetically engineered rice
• Plants that fortify themselves and deliver VA
  through their seeds.
• MI and UNICEF- developing and testing new dropper
  to administer VA
• WHO and UNICEF-
• IMCI (Integrated Management of the Sick Child)-
  treat VAD to reduce diseases
• IMCI- taking advantage of the contact made when a
  sick child comes in for care

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Conclusions

• Different countries require various solutions,
  sometimes a combination of two
• Middle income countries- Philippines, Zambia and
  other Latin Am. countries
• Food fortification
• Low income countries- Urban
• Food fortification and government subsidies
• Low income countries- Nepal, Bangladesh, and
  rural Indonesia
• Supplementation used
• Extreme measures
• Evaluation of supplementation programs with a
  case control study.
• Biotechnology is an option, but must look at the
  different environments to see what should be
  implemented
• Must answer if should implement program even if
  not all at risk or unknown
• Focus should be on reduction of infections
  improving primary health care, sanitation, water
  supply, and reducing poverty.