Vitamin A status in preschool-age Indonesian children as assessed by the modified relative-dose-response assay

Inflammation Adjustments to Serum Retinol and Retinol-Binding Protein Improve Specificity but Reduce Sensitivity when Estimating Vitamin A Deficiency Compared with the Modified Relative Dose-Response Test in Ghanaian Children

BACKGROUND

Serum retinol and retinol-binding protein (RBP) concentrations are commonly used biomarkers of vitamin A deficiency (VAD); however, evidence indicates that they are not always accurate, especially in populations with high exposure to inflammation.

OBJECTIVE

The aim was to assess sensitivity and specificity of serum retinol and RBP concentrations to predict VAD, with and without adjustment for inflammation (using categorical and regression-adjusted approaches), using the modified relative dose-response (MRDR) as the reference standard for liver reserves.

METHODS

This secondary analysis of diagnostic accuracy used inflammation and RBP data and analyzed serum retinol and MRDR from a subsample of women of reproductive age (n = 178) and preschool children (n = 166) in the cross-sectional 2017 Ghana Micronutrient Survey.

RESULTS

Inflammation (elevated C-reactive protein and/or α1-acid glycoprotein) was present in 41% of children and 16% of women. Among children, estimates of VAD prevalence were as follows: 7% (MRDR), 40% (serum retinol), 29% (categorical-adjusted serum retinol), 24% (RBP), 13% (categorical-adjusted RBP), and 7% (regression-adjusted RBP). Sensitivity (95% CI) ranged from 22.2% (2.81%, 60.0%; both adjusted RBPs) to 80.0% (44.4%, 97.5%; serum retinol), whereas specificity ranged from 63.3% (54.7%, 71.3%; serum retinol) to 93.5% (88.0%, 97.0%; regression-adjusted RBP). Among women, VAD prevalence ranged from 1% (RBP) to 4% (all others); sensitivity was 0% and specificity was >96% for all indicators.

CONCLUSIONS

Serum retinol and RBP had varying accuracy in estimating VAD, especially in children; adjustment for inflammation increased accuracy by increasing specificity at the expense of sensitivity. Effects of inflammation adjustment in the context of high inflammation and VAD prevalence need to be further explored. Especially in populations with high inflammation, the MRDR test should accompany serum retinol or RBP measurements in a subsample of subjects in population-based surveys. This trial was registered with the Open Science Framework registry (doi: 10.17605/OSF.IO/J7BP9).

Systematic Review and Meta-Analysis of the Relative Dose-Response Tests to Assess Vitamin A Status

Vitamin A (VA) is an essential nutrient often lacking in the diets of people in developing countries. Accurate biomarkers of VA status are vital to inform public health policy and monitor interventions. The relative dose-response (RDR) and modified-RDR (MRDR) tests are semi-quantitative screening tests for VA deficiency that have been used in Demographic and Health Surveys and VA intervention studies. A systematic review and meta-analysis of sensitivity and specificity were conducted to summarize the physiological evidence to support the RDR tests as methods to assess VA status and investigate the impact of different pathological and physiological states on the tests. A total of 190 studies were screened for inclusion, with 21 studies comparing the RDR tests with the gold-standard biomarker, liver VA concentration (68% and 80% sensitivity and 85% and 69% specificity for the RDR and MRDR, respectively). Nearly all studies with VA interventions in VA-deficient populations demonstrated a response of the tests to VA intake that would be expected to improve VA status. The impacts of chronic liver disease, protein malnutrition, age, pregnancy and lactation, infection and inflammation, and various other conditions were examined in 51 studies. The RDR and MRDR tests were reported to have been used in 39 observational studies, and the MRDR has been used in at least 6 national micronutrient surveys. The RDR and MRDR are sensitive tests for determining population VA status and assessing VA interventions. Although they are robust to most physiological and pathological states, caution may be warranted when using the tests in neonates, individuals with chronic liver disease, and those with protein or iron malnutrition. Research on further improvements to the tests to increase accessibility, such as sampling breast milk instead of blood or using intramuscular doses in subjects with malabsorption, will allow wider adoption. This review was registered with PROSPERO as CRD42019124180.

Relation between Timing of High-Dose Vitamin A Supplementation and Modified-Relative-Dose-Response Values in Children 12-23 Months in Uganda

BACKGROUND

High-dose vitamin A (VA) supplements (VAS) can temporarily affect VA status. Hence, micronutrient surveys might need to be timed around VAS campaigns to accurately estimate VA deficiency (VAD) prevalence. Little is known about optimal timing of micronutrient surveys when the modified-relative-dose-response (MRDR) is used as a VA indicator.

OBJECTIVES

We evaluated the association between days since the end of a VAS campaign and MRDR values in children aged 12-23 mo in Uganda.

METHODS

We pooled data from 2 cross-sectional, population-based surveys in eastern Uganda conducted in 2015-2016 (n = 118 children). We estimated the prevalence of VAD (MRDR ≥0.060). Days since the end of a VAS campaign ("days since VAS") was calculated as the interview date minus the end date of the VAS campaign. The MRDR value was assessed using HPLC. We excluded children whose MRDR values were below the limit of detection (<0.007). We used linear regression to evaluate the association between days since VAS and log-transformed MRDR. In adjusted analyses, we controlled for potential confounders. Statistical analyses accounted for the surveys' complex design.

RESULTS

The prevalence of VAD was 5.2% (95% CI: 1.1%, 9.3%). Mean days since VAS was 54.1 d (range 39-68 d). Days since VAS was not associated with log-transformed MRDR in unadjusted analyses ($\hat{\beta } = \ $0.0055; 95% CI: -0.009, 0.020; P = 0.45) or adjusted analyses ($\hat{\beta } = $ -0.0073; 95% CI: -0.024, 0.010; P = 0.39).

CONCLUSIONS

MRDR measurement through a nutrition survey began as early as 1.3 mo after the end of a VAS campaign in eastern Uganda. Days since the end of a VAS campaign was not associated with MRDR in Ugandan children aged 12-23 mo. Future studies should consider longitudinal designs and evaluate time since VAS and MRDR in children of different ages and in regions with higher VAD prevalence.

Adequate vitamin A liver stores estimated by the modified relative dose response test are positively associated with breastfeeding but not vitamin A supplementation in Senegalese urban children 9-23 months old: A comparative cross-sectional study

Vitamin A supplementation (VAS) in 6-59-month-old children is recommended but its sustainability is currently questioned. In Senegal, available data suggest that VAS should be maintained, but geographic and age-related specificities need to be addressed to better implement and target VAS programming. The objective of this comparative cross-sectional study, conducted in urban settings of Dakar, was to compare the vitamin A liver stores (VALS) assessed using the modified-relative dose response (MRDR) test between supplemented and non-supplemented 9-23 month-old children and to study their relationship with VAS. The supplemented group (n = 119) received VAS (either 100 000 UI or 200 000 UI) 2 to 6 months before evaluation while the non-supplemented group (n = 110) had not received VAS during the past 6 months. In addition to MRDR, serum retinol concentrations (SR), and biomarkers of subclinical inflammation were measured. Children's health-related data and feeding patterns were collected. Mean MRDR values (VAS: 0.030 ± 0.017, non-VAS: 0.028 ± 0.016, P = 0.389) and inflammation-adjusted SR (VAS: 1.34 ± 0.37, non-VAS: 1.3 ± 0.35, P = 0.515) of children were adequate. Low prevalence of VALS (VAS: 5.2%, non-VAS: 5.4%) and inflammation-adjusted VAD (VAS: 2.6%, non-VAS: 0.9%) were detected despite high presence of infections and inflammation. Children were mostly still being breastfed (VAS: 85.7%, non-VAS: 77.3%) and complementary feeding indicators were similar in both groups. Only breastfeeding was associated with VALS and was found to reduce by 76% at least, the odds of VAD (adjusted OR = 0.24, 95% CI: 0.07-0.8, P = 0.020). Based on MRDR values, VAS was not related to improved VALS and SR as well as VAD reduction among these children with adequate VALS. Reinforcing breastfeeding advocacy and morbidity prevention/control are essential in this setting. Scaling-back VAS in this subpopulation should be examined regarding the risk of hypervitaminosis A after an evaluation of dietary vitamin A intake sufficiency and a more quantitative assessment of VALS.

Potential Use of Red Palm Oil in Combating Vitamin A Deficiency in India

Vitamin A deficiency is widespread among pre-school children in India. Severe forms of vitamin A deficiency lead to nutritional blindness. Massive-dose vitamin A prophylaxis has been in operation in India since the early 1970s to prevent nutritional blindness. with a decline in the severe forms of vitamin A deficiency, the emphasis has shifted to a food-based approach to control the still widespread mild to moderate forms of vitamin A deficiency by promoting consumption of carotene-rich foods such as fruits and vegetables, especially green leafy vegetables. Compared with these sources, red palm oil is a richer source of carotenes, with 500–600 μg of carotenes per gram of oil. Further, the carotenes in red palm oil may be better absorbed than carotenes from other plant sources because they are in an oil medium. the value of red palm oil as a rich source of carotenes to cure and prevent vitamin A deficiency was recognized and studied in India as far back as the mid-1930s. Later, during the 1980s, systematic studies in both animals and humans established the safety, acceptability, and nutritional potential of crude red palm oil as a rich source of provitamin A. During the early 1990s, community studies were carried out with edible-grade crude palm oil to improve the vitamin A status of children and mothers. with the current availability of highly refined edible-grade red palm oil, its use as a source of provitamin A at home and in feeding programmes for children should pose no problem, because it is more acceptable than crude palm oil. It can indeed prove to be a potential source of carotene to eradicate vitamin A deficiency in the country.

High prevalence of vitamin A deficiency is detected by the modified relative dose-response test in six-month-old Senegalese breast-fed infants

To alleviate vitamin A (VA) deficiency (VAD) in Senegal, understanding the relationship between VA status of lactating women and their 6-mo-old infants is important. This study measured 6-mo-old infants' VA intake from human milk and assessed the VA status of mothers and infants. A comprehensive study was undertaken in 34 mother-infant pairs. Nonpregnant lactating women and their infants were included. None of the infants had received a VA supplement. Mothers were grouped as supplemented with 2 doses of 200,000 iu (60,000 μg; 210 μmol) retinol as retinyl palmitate (n = 13) or nonsupplemented (n = 19) after delivery. Breast milk intake was measured by the deuterium dilution technique. Plasma and breast milk retinol concentrations were measured by HPLC. Infants' VA liver stores were assessed by the modified relative dose-response (MRDR) test. Plasma retinol detected 15% VAD among infants and the MRDR test (≥0.06) indicated 73.5% with low VA liver stores. Infants' milk VA intakes were close to estimated requirements (375 μg/d). No correlation was found between infants' plasma retinol and MRDR value. Infants' MRDR value was lower in the group from supplemented mothers (0.055 ± 0.017 vs. 0.073 ± 0.017; P = 0.009), but no difference was observed between plasma retinol concentrations of both groups of mothers; 8.8% of mothers were VA deficient based on plasma retinol (≤0.7 μmol/L). Low VA liver stores were prevalent among Senegalese infants at the beginning of the complementary feeding period. Postpartum VA-supplemented mothers significantly enhanced their infants' VA liver stores.

Vitamin A: biomarkers of nutrition for development

Vitamin A is essential for multiple functions in mammals. Without vitamin A, mammals cannot grow, reproduce, or fight off disease. Because of its numerous functions in humans, biomarkers of vitamin A status are quite diverse. Assessment of liver reserves of vitamin A is considered the gold standard because the liver is the major storage organ. However, this measure is not feasible in human studies. Alternative biomarkers of status can be classified as biological, functional, histologic, and biochemical. Historically, signs of xerophthalmia were used to determine vitamin A deficiency. Before overt clinical damage to the eye, individuals who suffer from vitamin A deficiency are plagued by night blindness and longer vision-restoration times. These types of assessments require large population-based evaluations. Therefore, surrogate biochemical measures of vitamin A status, as defined by liver reserves, have been developed. Serum retinol concentrations are a common method used to evaluate vitamin A deficiency. Serum retinol concentrations are homeostatically controlled until liver reserves are dangerously low. Therefore, other biochemical methods that respond to liver reserves in the marginal category were developed. These included dose-response tests and isotope dilution assays. Dose-response tests work on the principle that apo-retinol-binding protein builds up in the liver as liver reserves become depleted. A challenge dose of vitamin A binds to this protein, and serum concentrations increase within a few hours if liver vitamin A concentrations are low. Isotope dilution assays use stable isotopes as tracers of total body reserves of vitamin A and evaluate a wide range of liver reserves. Resources available and study objectives often dictate the choice of a biomarker.

Plasma turnover of 3,4-didehydroretinol (vitamin A2) increases in vitamin A-deficient rats fed low versus high dietary fat

Relationships between increased adiposity and fat-soluble vitamin storage and metabolism are poorly understood. To examine these associations, 6% or 21% dietary fat was fed to rats for 11 weeks and tissue vitamin A storage determined. Two levels of supplemental vitamin A were administered. At the end of the tenth week, 3,4-didehydroretinol (DR) was administered orally, and its kinetics were followed for 1 week in serum and tissues. Model-based compartmental analysis was applied to these data. Kidney total retinol (R) concentrations were elevated in rats fed 6% compared with 21% dietary fat (n = 24/group). The fractional transfer coefficient (FTC) describing the movement of tracer from plasma to extravascular stores was two times higher in the 6% compared with the 21% fat group. Consistent with the elevated renal R in 6% fat fed rats, there was a 2-fold increase in the FTC representing tracer distribution from plasma to kidney in the 6% compared with 21% fat group. Taken together with a fat main effect on renal vitamin A, our data support the evidence that faster turnover of kidney R may help set the mechanism governing vitamin A tissue distribution during deficiency. Rats fed 21% versus 6% dietary fat conserved hepatic R more efficiently.

Effect of consumption of the nutrient-dense, freshwater small fishAmblypharyngodon molaon biochemical indicators of vitamin A status in Bangladeshi children: a randomised, controlled study of efficacy

In Bangladesh, some commonly consumed, indigenous, freshwater small fish species (eaten whole with bone, head and eyes) such as mola (Amblypharyngodon mola) are nutrient-dense, containing preformed vitamin A as retinol and especially 3,4-dehydroretinol. The objective of the present randomised, controlled efficacy study was to evaluate the effects of mola on biochemical indicators of vitamin A status. Children (n196), aged 3–7 years, with serum retinol 0·36–0·75 μmol/l, were randomly allocated to one of three treatment groups to receive a daily test meal (6 d/week for 9 weeks) of rice and vegetable curry (no vitamin A)ad libitumand 50 g fish curry consisting of: (1) mola, 600 retinol activity equivalents (RAE) (using 40 % biological activity of 3,4-dehydroretinol isomers) (experimental group,n66); (2) rui (Labeo rohita), a large fish (no vitamin A), with added retinyl palmitate, 600 RAE (positive control group,n65); or (3) rui, 0 RAE (negative control group,n65). The nutrient compositions of the dishes were analysed. After 9 weeks, no significant treatment effects were observed for serum retinol (P = 0·52) and retinol-binding protein (P = 0·81) in the experimental group compared with the negative control, whereas the positive control improved significantly (P < 0·001). The present results do not suggest conversion of the large amount of 3,4-dehydroretinol in mola curry to retinol. Further research on the functional effect of mola in humans is needed. Mola is a nutrient-dense animal-source food, rich in haem Fe, Zn and especially Ca, thus consumption of mola in Bangladesh should continue to be encouraged.

The modified-relative-dose-response values in serum and milk are positively correlated over time in lactating sows with adequate vitamin A status

The modified-relative-dose-response (MRDR) test, which requires a blood sample after dosing with 3,4-didehydroretinyl acetate (DRA), has been used to determine vitamin A (VA) status of individuals and groups worldwide. Less invasive methods using milk are in development in a swine model. Swine are a good choice for studying VA metabolism because their gastrointestinal anatomy, morphology, physiology, and VA requirements are similar to those of humans. In this study, DRA was used as a VA tracer in lactating sows to follow the metabolism of newly ingested VA. Lactating sows (n = 6) were administered 35 micromol DRA after overnight food deprivation. Blood and milk were collected at 0, 1.5, 3, 5, 7, 9, 24, and 48 h; livers were obtained at the time of killing. Samples were analyzed for didehydroretinol (DR), retinol (R), and didehydroretinyl esters (DRE). Serum DR:R was compared with that in milk and other VA indicators. DRE rapidly increased in serum, corresponding to chylomicra, whereas DR increased at a slower rate corresponding to the holo-DR:retinol-binding protein complex released from the liver. An estimated 10-20% of the dose was irreversibly lost in milk over 48 h. The mean MRDR value was 0.018 +/- 0.013 at 5 h and the mean liver VA was 0.73 +/- 0.21 micromol/g, both signifying sufficient stores. Milk and serum DR:R values were directly correlated (r = 0.64, P < 0.0001). Thus, DR:R values in milk may be a potential alternative to serum in determining VA status in lactating women. Future work is required in VA-deficient sows and women of varying VA status to determine DR trafficking and to compare DR:R values in milk with those in serum.

Validity of the relative-dose-response test and the modified-relative-dose-response test as indicators of vitamin A stores in liver

BACKGROUND

Our group and many others have used the relative-dose-response (RDR) test and the modified-RDR (MRDR) test as proxy indicators of liver stores of vitamin A. However, we have become concerned about the validity of these indicators.

OBJECTIVE

Simulation models were used to assess effects of random variations in serum retinol concentration on the RDR and to assess effects of group differences in serum retinol concentration on the distribution of RDR and MRDR values.

DESIGN

Random and independent samples were drawn from normally distributed, computer-generated numbers whose distributions simulated serum concentrations of retinol and 3,4-didehydroretinol as obtained from published reports. The resulting data sets were used to compute surrogate RDR or MRDR values. In model 1, the relation between serum concentrations of retinol and RDR was examined within a fictitious population. In models 2 and 3, fictitious populations with different distributions of serum retinol concentration were compared with respect to their RDR and MRDR values.

RESULTS

Simulated RDR values and serum retinol concentrations were negatively related. Models 2 and 3 showed that group differences in serum retinol concentrations necessarily produced group differences in mean RDR or MRDR values. A mathematical artifact may explain the negative relation reported between MRDR and serum retinol concentration, and it dictates that this relation will necessarily vary between populations with different degrees of vitamin A deficiency.

CONCLUSION

A continued search for alternative blood indicators of liver stores of vitamin A is needed.

Carotenoid and retinoid metabolism: insights from isotope studies

Use of isotopes as tracers has had an important role in elucidating key features of vitamin A and retinoid metabolism in animal models and humans. Their use has shown that beta-carotene absorption is variable, and that the appearance of beta-carotene and its metabolites in the blood by time since dosing follows characteristic patterns. Retinol formed from beta-carotene shows a different pattern, as does lutein. In this article, we summarize and discuss insights and some surprises into the absorption and metabolism of vitamin A, beta-carotene, and lutein that were gained with the use of isotope tracers in humans, rats, and cells as models.

Haematological profiles of the people of rural southern Malawi: an overview

An integrative review of the results of two published and two unpublished studies of anaemia in children, adolescent females, pregnant women and adults living in southern Malawi is presented. Anaemia was universally present in all age-groups, with the higher prevalences in infants (100%) and adolescent primigravidae (93.8%). Nutritional deficits of iron and vitamin A were major contributory factors but chronic malarial haemolysis also significantly contributed to the anaemia. Among boys, anaemia was more common among those with glucose-6-phosphate-dehydrogenase (G6PD) deficiency than in those without this deficiency (P<0.002). This enzymopathy, which occurred in 23.5% [95% confidence interval (CI)=16.7%-30.1%] of the male and 30% (CI=17.3%-42.7%) of the female infants examined, was also associated with neonatal jaundice. The overall prevalences of the-alpha(3.7)/alphaalpha and -alpha(3.7)/-alpha(3.7) thalassaemia genotypes were estimated at 41.0% (CI=28.3%-53.7%) and 8.7% (CI=1.5%-15.9%), respectively. Haemoglobin AS was present in 18.1% (CI=12.8%-23.4%) of the infants and haemoglobin SS in 2.5% (CI=1.4%-3.6%). As the prevalence of infection with Plasmodium falciparum was significantly higher in infants with haemoglobin AS than in those with AA (21.4% v. 6.7%; P<0.001), an increased risk of early-onset moderate parasitaemias in young infants probably stimulates the development of immunity, protecting older heterozygotes from severe malarial infection. Innovative community approaches are required to break the cycle of ill health that anaemia supports in those living in rural areas of southern Malawi. Interventions in adolescent girls could be of particular importance, as they could break the cycle in both pregnant women and their infants.

Adjustments to the modified relative dose response (MRDR) test for assessment of vitamin A status minimize the blood volume used in piglets

The modified relative dose response (MRDR) test is widely used in public health research to assess vitamin A (VA) status of populations and individuals. However, method adjustments intended to make the test more useful in large field studies and/or less invasive have not been systematically verified. To compare the similarity between modified tests and the standard MRDR test, and validate both modified and standard tests against liver reserves of VA, we used a piglet model. Following the typical MRDR procedure, piglets (n = 10) were dosed with 5.3 micromol 3,4-didehydroretinyl acetate. Method adjustments were made to the postdose blood sample collection time to decrease both the amount of serum analyzed and sample throughput time. We collected 3 blood samples/piglet at 3, 5, and 7 h or 4, 6, and 8 h postdose. Postdose blood samples obtained between 4 and 7 h gave MRDR values that did not differ. Serum volumes as small as 200 microL, half the volume of the standard method, yielded accurate MRDR values. Method adjustments to reduce sample throughput time require further investigation. In conclusion, because 200 microL of serum can be used in the test, only 0.5 mL, as opposed to 1 mL of blood has to be collected from an individual. This adjustment allows for easier application of the test to individuals, especially infants, from whom it is difficult to obtain a large venous blood sample, thus increasing the utility of the test for researchers.

Detection of vitamin A deficiency in Brazilian preschool children using the serum 30-day dose–response test

BACKGROUND

Vitamin A deficiency (VAD) is endemic in Brazil and health professionals have difficulty in recognizing its subclinical form. In addition, serum retinol concentrations do not always represent vitamin A status in the organism.

OBJECTIVE

To identify VAD in preschool children by the serum 30-day dose-response test (+S30DR) and to examine its potential as a tool for the assessment of vitamin A status in the community.

DESIGN

A prospective transverse study in which blood samples were obtained from 188 preschool children for the determination of serum retinol concentrations and the children were submitted to ocular inspection and anthropometric measurements. Information about the presence of diarrhea and/or fever during the 15 days preceding the study was also obtained. The children received an oral dose of 200,000 IU vitamin A immediately after the first blood collection. A second blood sample was obtained 30-45 days after supplementation in order to determine the +S30DR.

RESULTS

In all, 74.5% (140/188; 95% confidence interval: 68.3-80.7%) of the children presented +S30DR values indicative of low hepatic reserves. The mean serum retinol concentration was significantly lower before supplementation (0.92 and 1.65 micromol/l, respectively; P < 0.0001). No child presented xerophthalmia; 3.7% (7/188) of the children were malnourished. The presence of fever and/or diarrhea during the 15 days preceding the first blood collection did not affect the +S30DR value.

CONCLUSIONS

The prevalence of VAD in the study group was elevated. +S30DR proved to be a good indicator of subclinical VAD in children from an underdeveloped country.

The effect of retinyl palmitate added to iron-fortified maize porridge on erythrocyte incorporation of iron in African children with vitamin A deficiency

Retinyl palmitate added to Fe-fortified maize bread has been reported to enhance Fe absorption in adult Venezuelan subjects but not in Western Europeans. It is not known to what extent these results were influenced by differences in vitamin A status of the study subjects. The objective of the present study was to evaluate the influence of retinyl palmitate added to Fe-fortified maize porridge on erythrocyte incorporation of Fe in children with vitamin A deficiency, before and after vitamin A supplementation. Erythrocyte incorporation of Fe-stable isotopes was measured 14 d after intake of maize porridge (2.0 mg Fe added as ferrous sulfate) with and without added retinyl palmitate (3.5 micromol; 3300 IU). The study was repeated 3 weeks after vitamin A supplementation (intake of a single dose of 210 micromol retinyl palmitate; 'vitamin A capsule'). Vitamin A status was evaluated by the modified relative dose-response (MRDR) technique. Retinyl palmitate added to the test meal reduced the geometric mean erythrocyte incorporation of Fe at baseline from 4.0 to 2.6 % (P=0.008, n 13; paired t test). At 3 weeks after vitamin A supplementation, geometric mean erythrocyte incorporation was 1.9 and 2.3 % respectively from the test meal with and without added retinyl palmitate (P=0.283). Mean dehydroretinol:retinol molar ratios were 0.156 and 0.125 before and after intake of the single dose of 210 micromol retinyl palmitate; 'vitamin A capsule' (P=0.15). In conclusion, retinyl palmitate added to the labelled test meals significantly decreased erythrocyte incorporation of Fe in children with vitamin A deficiency at baseline but had no statistically significant effect 3 weeks after vitamin A supplementation. The difference in response to retinyl palmitate added to Fe-fortified maize porridge on erythrocyte incorporation of Fe before and after intake of the vitamin A capsule indicates, indirectly, changes in vitamin A status not measurable by the MRDR technique. The lack of conclusive data on the effect of retinyl palmitate on Fe absorption indicates the complexity of the interactions between vitamin A status, dietary vitamin A and Fe metabolism.

Vitamin A supplementation of women postpartum and of their infants at immunization alters breast milk retinol and infant vitamin A status

Vitamin A supplementation of lactating mothers and of infants at the time of diphtheria-pertussis-tetanus (DPT) and oral polio vaccine (OPV) immunizations have both been suggested as measures to prevent deficiency among infants. This multicenter randomized, double-blind, placebo-controlled trial was conducted in Ghana, India and Peru to determine the effect of maternal vitamin A supplementation on breast milk retinol and of maternal and infant supplementation on infant vitamin A status. Mothers in the intervention group received 60 mg vitamin A (as retinol palmitate) at 18-42 d postpartum; their infants were given 7.5 mg three times, i.e., at 6, 10 and 14 wk of age with DPT and OPV immunizations. Mothers and infants in the comparison group received a placebo. Maternal supplementation resulted in higher breast milk retinol at 2 mo postpartum [difference in means 7.1, 95% confidence interval (CI), 3.4, 10.8 nmol/g fat] and lower proportion of mothers with breast milk retinol < or = 28 nmol/g fat (15.2 vs. 26.6%, 95% CI of difference -16.6, -4.1%). At 6 and 9 mo, maternal supplementation did not affect breast milk retinol or the proportion of mothers with low breast milk retinol. Vitamin A supplementation of the mothers and their infants reduced the proportion of infants with serum retinol < or = 0.7 micro mol/L (30.4 vs. 37%, 95% CI of difference -13.7, 0.6%) and that with low vitamin A stores as indicated by the modified relative dose response (MRDR) > 0.06 (44.2 vs. 52.9%, 95% CI of difference -16.6, -0.9%) at 6 mo. Supplementation had no effect at 9 mo. The beneficial effect of supplementation on breast milk retinol and infants' vitamin A status varied by site. It was greatest in India followed by Ghana and Peru. At the doses used, maternal supplementation improved breast milk retinol status at 2 mo (P < 0.001) and maternal and infant supplementation modestly increased (P = 0.03) infant vitamin A status at 6 mo of age. Additional strategies to improve vitamin A status of 6- to 9-mo-old infants must be considered.

The vitamin A spectrum: from deficiency to toxicity

Dark adaptation has been used as a tool for identifying patients with subclinical vitamin A deficiency. With this functional test it was shown that tissue vitamin A deficiency occurs over a wide range of serum vitamin A concentrations. However, serum vitamin A concentrations >1.4 micromol/L predict normal dark adaptation 95% of the time. Other causes of abnormal dark adaptation include zinc and protein deficiencies. Stable isotopes of vitamin A and isotope-dilution techniques were used recently to evaluate body stores of vitamin A and the efficacy of vitamin A intervention programs in field settings and are being used to determine the vitamin A equivalences of dietary carotenoids. Vitamin A toxicity was described in patients taking large doses of vitamin A and in patients with type I hyperlipidemias and alcoholic liver disease. Conversely, tissue retinoic acid deficiency was described in alcoholic rats as a result of hepatic vitamin A mobilization, impaired oxidation of retinaldehyde, and increased destruction of retinoic acid by P450 enzymes. Abnormal oxidation products of carotenoids can cause toxicity in animal models and may have caused the increased incidence of lung cancer seen in 2 epidemiologic studies of the effects of high-dose beta-carotene supplementation. Major issues that remain to be studied include the efficiency of conversion of carotenoids in whole foods to vitamin A by using a variety of foods in various field settings and whether intraluminal factors (eg, parasitism) and vitamin A status affect this conversion. In addition, the biological activity of carotenoid metabolites should be better understood, particularly their effects on retinoid signaling.

Serum trace elements and fat-soluble vitamins A and E in healthy pre-school children from a Venezuelan rural community

Zn (SZn), Cu (SCu), Fe (SFe), vitamin A (SVA) and vitamin E (SVE) were measured in blood serum samples of 85 healthy pre-school children aged 2-6 yr. from the rural community of Canaguá, Mérida State, Venezuela. The relationship between these biochemical indexes was also investigated. The mean serum concentrations of zinc, copper, iron, vitamin A and vitamin E were 0.74 +/- 0.25, 1.18 +/- 0.30, 0.76 +/- 0.20, 0.30 +/- 0.15 and 5.87 +/- 0.43 mg/L, respectively. There was a tendency for SZn to increase with age, whereas SCu and SVA decreased. There was no significant difference in serum trace elements and fat-soluble vitamin concentration between males and females in the different age groups. SFe tended to be lower than that reported in the literature. However, the age groups studied showed no statistically significant sex- and age-related differences. The present study shows that there is a complex interaction between SZn, SCu, SFe, SVA, SVE and age of the children. Multiple regression analysis showed serum zinc was strongly related to serum copper, and serum iron. Serum vitamin A was strongly related to serum zinc and serum vitamin E, whereas serum vitamin E was strongly related to serum zinc, serum copper, and serum vitamin A. On the other hand, our observations also suggest that more detailed studies of these metals and fat-soluble vitamins should be carried out, and that the study should include nutritional surveys, metabolic balances and associations between SZn, SCu, SFe, SVA and SVE and anthropometric variables (height, weight, body mass index and skinfold thickness).

Serum retinol and HIV-1 RNA viral load in rapid and slow progressors

Few studies have addressed the relation between serum vitamin A levels and HIV disease progression. Thirty HIV-infected women in Rwanda were studied over a time span of 26 to 99 months. Fourteen subjects seroconverted and died of HIV-related disease at a mean of 44 months (range, 26-69 months) after their first HIV-positive test and were termed "rapid progressors," (RPs). A comparison group of 16 "slow progressors" (SPs) were HIV-positive at the time of their first HIV serology and had asymptomatic HIV infections at a mean of 96 months (range, 93-99 months) after their first HIV serology. Baseline mean serum retinol values were the same in RPs and SPs: 0.65 + 0.08 micromol/L versus 0.67 + 0.09 micromol/L (p = .7). Lower serum retinol levels were observed in RPs compared with SPs for the second and third measurements, obtained at a median of 12 and 24 months past baseline: 0.51 + 0.07 micromol/L versus 0.76 + 0.14 micromol/L (p = .3) and 0.44 + 0.09 micromol/L versus 0.64 + 0.08 micromol/L (p = .08), respectively. Median retinol levels for the third sample measurement were similar in RPs with lower viral load (LVL) and SPs (0.49 micromol/L and 0.52 micromol/L, respectively) compared with only 0.19 micromol/L in RPs with higher viral load (HVL; p = .02). A trend toward decreasing serum retinol levels and increasing HIV-1 RNA viral load was observed at the third sample measurement (p = .04). Subjects with LVL, higher serum retinol levels (> or =0.70 micromol/L), or both had more favorable rates of survival than subjects with HVL, low serum retinol levels (<0.70 micromol/L), or both. Although sample size does not permit definitive conclusions, this study demonstrates an association of high HIV load, rapid progression, and low serum retinol late but not early in disease progression.

Serum retinol and HIV-1 RNA viral load in rapid and slow progressors

Few studies have addressed the relation between serum vitamin A level and HIV disease progression. Thirty HIV-infected women in Rwanda were studied over a time span of 26 to 99 months. Fourteen subjects seroconverted and died of HIV-related disease at a mean of 44 months (range, 26-69 months) after their first HIV-positive test and were termed "rapid progressors," (RPs). A comparison group of 16 "slow progressors" (SPs) were HIV-positive at the time of their first HIV serology and had asymptomatic HIV infections at a mean of 96 months (range, 93-99 months) after their first HIV serology. Baseline mean serum retinol values were the same in RPs and SPs: 0.65 + 0.08 mmol/L versus 0.67 + 0.09 micromol/L (p = .7). Lower serum retinol levels were observed in RPs compared with SPs for the second and third measurements, obtained at a median of 12 and 24 months past baseline: 0.51 + 0.07 mmol/L versus 0.76 + 0.14 mmol/L (p = .3) and 0.44 + 0.09 mmol/L versus 0.64 + 0.08 mmol/L (p = .08), respectively. Median retinol levels for the third sample measurement were similar in RPs with lower viral load (LVL) and SPs (0.49 mmol/L and 0.52 mmol/L, respectively) compared with only 0.19 mmol/L in RPs with higher viral load (HVL; p = .02). A trend toward decreasing serum retinol levels and increasing HIV-1 RNA viral load was observed at the third sample measurement (p = .04). Subjects with LVL, higher serum retinol levels (> or =0.70 mmol/L), or both had more favorable rates of survival than subjects with HVL, low serum retinol levels (<0.70 mmol/L), or both. Although sample size does not permit definitive conclusions, this study demonstrates an association of high HIV load, rapid progression, and low serum retinol late but not early in disease progression.

Red palm oil as a source of beta-carotene for combating vitamin A deficiency

Twenty four school children of 7-9 years of age were divided into two groups of six boys and six girls each. One group was given a daily supplement of 'Suji halwa', a sweet snack made with semolina and red palm oil, supplying 2400 mu g of beta-carotene and the second group was the control group which was given 600 mu g of oral vitamin A palmitate, for 60 days. Vitamin A status before and after supplementation was assessed by the Modified Relative Dose Response Assay (MRDR). Results indicated that serum vitamin A levels increased from the basal level of 0.86 +/- 0.13 mu m mol/l to 1.891 +/- 0.23 mu mol/l in the Red Palmoil (RPO) group and from 0.74 +/- 0.09 to 1.94 +/- 0.21 mu mol/l in the control vitamin A group. Dehydroretinol/Retinol (DR/R) ratio decreased from 0.073 +/- 0.025 to 0.023 +/- 0.004 in the RPO group and from 0.090 +/- 0.023 to 0.023 +/- 0.004 in the vitamin A group, indicating liver saturation with vitamin A after feeding RPO snacks, comparable to synthetic vitamin A. This study indicates that RPO is an efficient source of beta-carotene which is found to be bioavailable in all the subjects tested, hence it can be used for supplementary feeding programmes to combat vitamin A deficiency in target population.

Differences in cord serum retinol concentrations by ethnic origin in the Negev (southern Israel)

Subclinical vitamin A deficiency is related to increased morbidity and mortality in infants and children. Previous studies indicate that the traditional diet of Moslem Bedouins, an important ethnic group in Southern Israel, is low in vitamin A content. Cord serum retinol (vitamin A) concentration was measured by HPLC in samples from 251 apparently healthy (birth weight > 2500 g, gestational age > 37 weeks) neonates with no abnormal perinatal events, 138 Jews and 113 Bedouins. Retinol < 15 micrograms/dl was measured in a total of 14% of infants: in 7% of Jewish and 26% of Bedouin newborns (P < 0.001). However, mean cord serum retinol was only slightly lower in Bedouins than in Jews (30 +/- 26 vs. 37 +/- 27 micrograms/dl mean +/- S.D., n.s.). Cord serum retinol was not related to socioeconomic indices. Cord serum retinol < 15 micrograms/dl was measured in 25% and in 12% of infants with birth weight less than and equal or greater than 3000 g, respectively (P = 0.01), and in 28% and 13% of infants with gestational age 37-38 weeks and 39-41 weeks, respectively (P = 0.03). Low cord serum retinol was found to be prevalent in Southern Israel, particularly in Bedouin infants. In the population of healthy neonates studied, very low cord serum retinol concentrations were found more frequently in infants born with a lower weight and/or after a shorter gestation.