Night blindness is prevalent during pregnancy and lactation in rural Nepal

Dietary vitamin A intake and its major food sources among rural pregnant women of South-West Bangladesh

The study aimed to estimate the dietary intake of vitamin A and its major food sources among rural pregnant women from the southwest region of Bangladesh. A multi-stage random cluster sampling method was used to select the respondents (N = 1012). A semi-structured questionnaire was used to collect the data, and statistical analysis was conducted using IBM SPSS 20.0. The mean age of the respondents was 23.27 ± 5.23 years, and the majority were in their second (48%) and third trimester (49%). The mean dietary intake of vitamin A was 392 ± 566 μg Retinol Activity Equivalent (RAE)/day (51% of Recommended Dietary Allowance). The contribution of β-carotene (plant source) and retinol (animal source) in vitamin A intake was about 60% and 40%, respectively. The major β-carotene contributing food groups were vegetables (dark and light) and tubers, and food items were colocasia, potato, beans, brinjal, and ripe tomatoes. On the other hand, the major retinol-contributing food groups were fish, eggs, and milk, and food items were small fish, Rui (carp) fish, and cow's milk. It was also observed that the consumption of food items from β-carotene and retinol-contributing food groups did not differ significantly among the three groups of respondents, but the variations in the amount of the different food items consumed were significant. Dietary vitamin A intake is low among pregnant women in the South-West region of Bangladesh. Hence, they are at a greater risk of adverse materno-fetal health outcomes associated with vitamin A deficiency.

Micronutrient levels and their effects on the prognosis of visceral leishmaniasis treatment, a prospective cohort study

BACKGROUND

Micronutrients are minerals and vitamins and they are essential for normal physiological activities. The objectives of the study were to describe the progress and determinants of micronutrient levels and to assess the effects of micronutrients in the treatment outcome of kalazar.

METHODS

A prospective cohort study design was used. The data were collected using patient interviews, measuring anthropometric indicators, and collecting laboratory samples. The blood samples were collected at five different periods during the leishmaniasis treatments: before starting anti-leishmaniasis treatments, in the first week, in the second week, in the third week, and in the 4th week of anti-leishmaniasis treatments. Descriptive statistics were used to describe the profile of patients and to compare the treatment success rate. The generalized estimating equation was used to identify the determinants of serum micronutrients.

RESULTS

The mean age of the patients were 32.88 years [SD (standard deviation) ±15.95]. Male constitute 62.3% of the patients and problematic alcohol use was present in 11.5% of the patients. The serum zinc level of visceral leishmaniasis patients was affected by alcohol (B - 2.7 [95% CI: - 4.01 - -1.5]), DDS (B 9.75 [95% CI: 7.71-11.79]), family size (B -1.63 [95% CI: - 2.68 - -0.58]), HIV (B -2.95 [95% CI: - 4.97 - -0.92]), and sex (B - 1.28 [95% CI: - 2.5 - -0.07]). The serum iron level of visceral leishmaniasis patients was affected by alcohol (B 7.6 [95% CI: 5.86-9.35]), family size (B -5.14 [95% CI: - 7.01 - -3.28]), malaria (B -12.69 [95% CI: - 14.53 - -10.87]), Hookworm (- 4.48 [- 6.82 - -2.14]), chronic diseases (B -7.44 [95% CI: - 9.75 - -5.13]), and HIV (B -5.51 [95% CI: - 8.23 - -2.78]). The serum selenium level of visceral leishmaniasis patient was affected by HIV (B -18.1 [95% CI: - 20.63 - -15.58]) and family size (B -11.36 [95% CI: - 13.02 - -9.7]). The iodine level of visceral leishmaniasis patient was affected by HIV (B -38.02 [95% CI: - 41.98 - -34.06]), DDS (B 25 .84 [95% CI: 22.57-29.1]), smoking (B -12.34 [95% CI: - 15.98 - -8.7]), chronic illness (B -5.14 [95% CI: - 7.82 - -2.46]), and regular physical exercise (B 5.82 [95% CI: 0.39-11.26]). The serum vitamin D level of visceral leishmaniasis patient was affected by HIV (B -9.43 [95% CI: - 10.92 - -7.94]), DDS (B 16.24 [95% CI: 14.89-17.58]), malaria (B -0.61 [95% CI: - 3.37 - -3.37]), and family size (B -1.15 [95% CI: - 2.03 - -0.28]). The serum vitamin A level of visceral leishmaniasis patient was affected by residence (B 0.81 [95% CI: 0.08-1.54]), BMI (B 1.52 [95% CI: 0.42-2.6]), DDS (B 1.62 [95% CI: 0.36-2.88]), family size (B -5.03 [95% CI: - 5.83 - -4.22]), HIV (B -2.89 [95% CI: - 4.44 - -1.34]),MUAC (B 0.86 [95% CI: 0.52-1.21]), and age (B 0.09 [95% CI: 0.07-0.12]).

CONCLUSION

The micronutrient levels of visceral leishmaniasis patients were significantly lower. The anti-leishmaniasis treatment did not increase the serum micronutrient level of the patients.

To see, hear, and live: 25 years of the vitamin A programme in Nepal

Nepal has a rich history of vitamin A research and a national, biannual preschool vitamin A supplementation (VAS) programme that has sustained high coverage for 25 years despite many challenges, including conflict. Key elements of programme success have included (a) evidence of a 26–30% reduction in child mortality from two, in‐country randomized trials; (b) strong political and donor support; (c) positioning local female community health volunteers as key operatives; (d) nationwide community mobilization and demand creation for the programme; and (e) gradual expansion of the programme over a period of several years, conducting and integrating delivery research, and monitoring to allow new approaches to be tested and adapted to available resources. The VAS network has served as a platform for delivering other services, including anthelmintic treatment and screening for acute malnutrition. We estimate that VAS has saved over 45,000 young lives over the past 15 years of attained national coverage. Consumption of vitamin A‐ and carotenoid‐rich foods by children and women nationally remains low, indicating that supplementation is still needed. Current challenges and opportunities to improving vitamin A status include lower VAS coverage among younger children (infants 6–11 months of age), finding ways to increase availability and access to dietary vitamin A sources, and ensuring local programme investments given the recent decentralization of the government.

Vitamin A Deficiency Disorders in Children and Women

Vitamin A deficiency is an endemic nutrition problem throughout much of the developing world, especially affecting the health and survival of infants, young children, and pregnant and lactating women. These age and life-stage groups represent periods when both nutrition stress is high and diet likely to be chronically deficient in vitamin A. Approximately 127 million preschool-aged children and 7 million pregnant women are vitamin A deficient. Health consequences of vitamin A deficiency include mild to severe systemic effects on innate and acquired mechanisms of host resistance to infection and growth, increased burden of infectious morbidity, mild to severe (blinding) stages of xerophthalmia, and increased risk of mortality. These consequences are defined as vitamin A deficiency disorders (VADD). Globally, 4.4 million preschool children have xerophthalmia and 6 million mothers suffer night blindness during pregnancy. Both conditions are associated with increased risk of morbidity and mortality. While reductions of child mortality of 19–54% following vitamin A treatment have been widely reported, more recent work suggests that dosing newborns with vitamin A may, in some settings, lower infant mortality. Among women, one large trial has so far reported a ≥ 40% reduction in mortality related to pregnancy with weekly, low-dose vitamin A supplementation. Epidemiologic data on vitamin A deficiency disorders can be useful in planning, designing, and targeting interventions.

Effect of Nutrition Education Based on Health Belief Model on Nutritional Knowledge and Dietary Practice of Pregnant Women in Dessie Town, Northeast Ethiopia: A Cluster Randomized Control Trial

BACKGROUND

In Ethiopia, poor dietary practice among pregnant women ranges from 39.3 to 66.1%. Limited nutritional knowledge and wrong perception towards dietary behaviours were underlying factors. Hence, this study was aimed to determine the effect of nutrition education based on Health Belief Model on nutritional knowledge and dietary practice of pregnant women in Dissie town, northeast Ethiopia, 2017 GC.

METHODS

Community-based cluster randomized control trial was employed. A total of 138 pregnant women participated. Nutrition education was given using Health Belief Model (HBM) theory and general nutrition education for intervention and control group, respectively. The baseline and endline nutrition knowledge and dietary practice was assessed using knowledge and dietary practice questions. HBM construct was assessed using five-point likert scale. Data were analyzed using SPSS version 20. Student's t-tests and chi-square tests were used. At 95% confidence level, P < 0.05 was considered statistically significant.

RESULT

The mean pre- and postintervention nutritional knowledge was 6.9 and 13.4, and good dietary practice was 56.5% and 84.1% in intervention group, respectively. The increase in mean nutritional knowledge was statistically significant (P < 0.001). In control group, the pre- and postintervention mean nutritional knowledge was 7.4 and 9.8, and good dietary practice was 60.9% and 72.5%, respectively. There was significant difference (P < 0.05) in mean nutritional knowledge and proportion of good dietary practices between two groups at endline, but the difference was not significant (P > 0.05) at baseline. There was significant (P < 0.001) improvement in the scores of HBM constructs in intervention group.

CONCLUSION AND RECOMMENDATIONS

Providing nutrition education based on Health Belief Model improves nutritional knowledge and dietary practices of pregnant women. Hence, governmental, nongovernmental organization, health extension workers, and other health-care provider should include Health Belief Model construct into existing nutrition education programs. Moreover, government should incorporate HBM theory into national nutrition education guidelines.

The Case for Promoting Multiple Vitamin And Mineral Supplements for Women of Reproductive Age in Developing Countries

Women in developing countries often consume inadequate amounts of micronutrients because of their limited intake of animal products, fruits, vegetables, and fortified foods. Intakes of micronutrients less than the recommended values increase a woman's risk of having micronutrient deficiencies. the adverse effects of deficiencies in vitamin A, iron, and folic acid, including night-blindness in pregnant and lactating women and iron-deficiency anaemia, are well known. Low intakes of these and other nutrients, including zinc, calcium, riboflavin, vitamin B6, and vitamin B12, also have consequences for women's health, pregnancy outcome, and the health and nutritional status of breastfed children. Multiple deficiencies coexist, so the benefit of multiple micronutrient supplements is becoming increasingly apparent. Supplementation of women with multiple vitamins and minerals should be one component of a strategy to improve micronutrient status among women in developing countries. However, there are several issues for programme managers to consider before implementing programmes. Which reference standards will be used to determine nutrient levels to include in the supplements? Which nutrients will be included and in what quantities? Which factors need to be considered in purchasing supplements? These issues are discussed, and guidance is provided on the selection of appropriate supplements for pregnant women and women of reproductive age in developing countries.

Vitamin A in Pregnancy: Impact on Maternal and Neonatal Health

Vitamin A is an essential nutrient, for which there is a slightly increased requirement during the third trimester of pregnancy, with even greater requirements for lactating women. Serum retinol levels decline during pregnancy, especially during the third trimester, followed by a rapid increase postpartum. Hemodilution and inadequate nutritional status contribute to this pattern. Night-blindness is more common in the third trimester of pregnancy, and night-blind pregnant women have lower mean serum retinol concentrations. Increased morbidity is associated with night-blindness in women, especially during pregnancy. Vitamin A supplementation during pregnancy in deficient populations reduces night-blindness, low serum retinol levels, and nutritional anemia during pregnancy and substantially reduces maternal postpartum infections. A substantial reduction in maternal mortality has been observed in malnourished vitamin A–deficient women following vitamin A or β-carotene supplementation. Infant cord blood retinol and birthweight appear to be resistant to maternal supplementation with vitamin A during pregnancy. No studies have reported an impact of maternal vitamin A supplementation on neonatal morbidity or mortality.

Safety of Vitamin A Supplementation of Postpartum Women and Young Children

It is now known that the previous World Health Organization (WHO) recommendation for vitamin A supplementation of postpartum women (200,000 IU) is not sufficient and that larger doses are well tolerated. the new recommendation is to give women 400,000 IU during the first eight weeks postpartum, as two 200,000-IU doses separated by at least 24 hours. the most common side effect of large doses of vitamin A in young infants is bulging of the fontanelle. This side effect is rare (0%–8%), spontaneously resolves within 72 hours, and is not associated with significant short- or long-term clinical consequences. A 50,000-IU dose is safe for young infants, but doses greater than 50,000 IU may be harmful, especially for infants under four months of age. the revised WHO recommendation for infants zero to five months old is 150,000 IU as three doses of 50,000 IU with a one-month interval between doses.

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.

Vitamin A Requirements of Infants under Six Months of Age

Infants are born with negligible liver stores of vitamin A. to enable some storage of the vitamin, the infant needs to be predominantly breastfed with milk containing at least 30 μg/dl. Where vitamin A in breastmilk is low, maternal supplementation with a single postpartum high dose increases milk vitamin A for three to eight months. the current cutoff levels for serum retinol and the modified relative dose response (MRDR) ratio probably need to be revised for young infants. Kinetic analyses of infants’ retention of vitamin A from breastmilk and supplements indicate that the doses of vitamin A given with immunizations in the World Health Organization (WHO) multicenter trial were inadequate to maintain adequate normal stores for more than a few months. the recommendation to double the doses currently given to mothers and infants in the Expanded Program in Immunization should prevent the depletion of liver vitamin A stores for most of the first year of life.

Impact of Providing a Small Income on Women's Nutritional Status and Household Food Expenditures in Rural Nepal

This study evaluated the impact of providing a small income on the household food expenditures and nutritional status of women employed part-time in a health project. A prospective, nonrandomized, unmasked, controlled trial was conducted in Sarlahi District in rural southeastern Nepal. The study subjects were 870 women who applied for a job with a project distributing nutritional supplements in their villages. Of these women, 736 (85%) completed the two-year follow-up; 341 were hired for the job and 395 were not hired. The intervention consisted of part-time employment that provided a small income, and the outcome was the two-year change in mid-upper-arm circumference (MUAC) and household food expenditures after adjustment for baseline demographic and socioeconomic differences. The women who were hired were younger and better educated than those who were not hired, but in other respects the two groups of women were similar. After adjustment for these baseline differences, the change in MUAC was not significantly different between the two groups of women. The two groups of women also had similar two-year changes in total household food expenditures and in expenditures on meat, clarified butter, fish, eggs, milk, and vegetables. There was a decline in the proportion of households buying milk and ghee, and the decline was significantly smaller in the households of women who were hired. Although employment by the project did not appear to affect the nutritional status of the women or change their overall expenditure on food, households of women who were hired were more likely to be able to continue to buy certain higher-status foods that could have a nutritional benefit for other household members.

Vitamins A and E Deficiencies among Pregnant Women Attending Antenatal Care at General Hospital Dawakin Kudu, North-West Nigeria

Background:

Vitamins A and E deficiency is prevalent in developing countries, and plasma levels are low in pregnancy. This study was undertaken to determine the serum Vitamins A and E status among pregnant women attending antenatal care at a General Hospital in Dawakin Kudu, Kano and to provide the necessary information needed to suggest the supplementation of Vitamins A and E during pregnancy.

Methods:

The study was done in General Hospital Dawakin Kudu Local Government Area. Dawakin Kudu, a rural community in Kano State is about 12 km from Kano metropolis which is the most populous city in Nigeria and commercial nerve center of Northern Nigeria. Most of the women are housewives, however, some engage in subsistent farming and petty trading. This was a prospective study of 200 pregnant women at various maternal ages, gestational ages, and parities. Informed consent was obtained from the participants. Research structured questionnaire was administered to 200 respondents which showed age and parity distributions. Determination of Serum Vitamins A and E was done using methods of Bessey, et al. and Tsen. Ethical approval for the research was obtained from General Hospital, Dawakin Kudu, Kano. Statistical Analysis Used: Data obtained were analyzed using SPSS version 17 statistical software (SPSS Inc., IL, Chicago, USA). Descriptive statistics was done. Mean serum Vitamins A and E concentration between trimesters were compared using two-way ANOVA and P < 0.05 was considered statistically significant.

Results:

Majority of the women were aged 20–39 years with mean of 23.67 ± 6.11. Most were in the 1–4 parity range. Mean birth weight was 2.42 ± 0.74 kg. Above 65% were deficient while 34.5% had normal levels of Vitamin A and 51% were deficient of serum Vitamin E. Serum Vitamins A and E levels showed a marked reduction from first through third trimester. The differences were statistically significant (P < 0.05).

Conclusions:

There is a significant reduction in the serum Vitamins A and E concentration throughout the period of pregnancy with the highest levels in the first trimester. Therefore, further studies should evaluate the value of Vitamins A and E supplementation during pregnancy especially for those whose fruit and vegetable consumption is inadequate.

Determinants of gestational night blindness in pregnant women from Rio de Janeiro, Brazil

OBJECTIVE

To describe the prevalence and determinants of gestational night blindness in pregnant women receiving care in a hospital in Rio de Janeiro, Brazil.

DESIGN

Cross-sectional study of pregnant and postpartum women receiving care in a public hospital in Rio de Janeiro from 1999 to 2001 (group I; n 225) or from 2005 to 2008 (group II; n 381). Night blindness was identified through a standardized and validated interview (WHO, 1996). The determinants of gestational night blindness were identified through a hierarchical logistic regression model.

SETTING

Public maternity hospital in Rio de Janeiro, RJ, Brazil.

SUBJECTS

Adult pregnant and postpartum women (n 606), aged ≥20 years.

RESULTS

The prevalence of gestational night blindness was 9·9 %. The final model revealed that not living in the South Zone of Rio de Janeiro (distal level: adjusted OR=1·846; 95 % CI 1·002, 3·401), belonging to group I (intermediate level: adjusted OR=2·183; 95 % CI 1·066, 4·471) and for the proximal level, having a history of abortion (adjusted OR=2·840; 95 % CI 1·134, 7·115) and having anaemia during the first and second trimesters of pregnancy (adjusted OR=3·776; 95 % CI 1·579, 9·029) were determinants of gestational night blindness.

CONCLUSION

Gestational night blindness should be assessed for during the prenatal care of all pregnant women, especially those living in deprived areas of the city and/or who have a history of abortion or anaemia. Nutritional monitoring is recommended during pregnancy to control gestational night blindness.

Vitamin A status in pregnant women in Iran in 2001 and its relationship with province and gestational age

BACKGROUND

Vitamin A deficiency is considered as one of the public health problems among pregnant women worldwide. Population representative data on vitamin A status in pregnancy have not previously been published from Iran.

OBJECTIVES

The aim of this study was to publish data on vitamin A status in pregnant women in all the provinces of Iran in 2001, including urban and rural areas, and to describe the association of vitamin A status with maternal age, gestational age, and parity.

DESIGN

This descriptive cross-sectional study was conducted on 3,270 healthy pregnant women from the entire country, 2,631 with gestational age ≤36 weeks, and 639 with gestational age >36 weeks. Vitamin A status was determined in serum using high-performance liquid chromatography.

RESULT

Retinol levels corresponding to deficiency were detected in 6.6% (<0.36 µmol/L) and 18% had insufficient vitamin A levels (≥0.36-<0.7 µmol/L). Suboptimal level of serum retinol was observed in 55.3% of the pregnant women (0.7-1.4 µmol/L). Only about 20% of the women had optimal values (>1.4 µmol/L). The level of serum retinol was lower in older pregnant women (p=0.008), and at higher gestational age (p=0.009). High vitamin A levels were observed in pregnant women in the central areas of Iran and the lowest values in those in the southern areas of Iran.

CONCLUSIONS

The vitamin A status was good in 2001 but should be closely monitored also in the future. About 25% of pregnant women had a vitamin A status diagnosed as insufficient or deficient (<0.7 µmol/L). The mean serum retinol decreased as the gestational age increased. The clinical significance of this finding should be further investigated, followed by a careful risk group approach to supplementation during pregnancy.

Maternal supplementation with vitamin A or β-carotene and cardiovascular risk factors among pre-adolescent children in rural Nepal

Vitamin A plays an important role in fetal renal and cardiovascular development, yet there has been little research on its effects on cardiovascular risk factors later in childhood. To examine this question, we followed the children of women who had been participants in a cluster-randomized, double blind, placebo-controlled trial of weekly supplementation with 7000 μg retinol equivalents of preformed vitamin A or 42 mg of β-carotene from 1994 to 1997 in rural Nepal. Women received their assigned supplements before, during and after pregnancy. Over a study period of 3 years, 17,531 infants were born to women enrolled in the trial. In 2006-2008, we revisited and assessed 13,118 children aged 9-13 years to examine the impact of maternal supplementation on early biomarkers of chronic disease. Blood pressure was measured in the entire sample of children. In a subsample of 1390 children, venous blood was collected for plasma glucose, Hb1Ac and lipids and a morning urine specimen was collected to measure the ratio of microalbumin/creatinine. Detailed anthropometry was also conducted in the subsample. The mean ± s.d. systolic and diastolic blood pressure was 97.2 ± 8.2 and 64.6 ± 8.5 mm Hg, respectively, and about 5.0% had high-blood pressure (⩾120/80 mm Hg). The prevalence of microalbuminuria (⩾30 mg/g creatinine) was also low at 4.8%. There were no differences in blood pressure or the risk of microalbuminuria between supplement groups. There were also no group differences in fasting glucose, glycated hemoglobin, triglycerides or cholesterol. Maternal supplementation with vitamin A or β-carotene had no overall impact on cardiovascular risk factors in this population at pre-adolescent age in rural Nepal.

Vitamin A deficiency during pregnancy of HIV infected and non-infected women in tropical settings of Northwest Ethiopia

BACKGROUND

Vitamin A deficiency (VAD) is known to be a major public health problem among women of reproductive age in South East Asia and Africa. In Ethiopia, there are no studies conducted on serum vitamin A status of HIV-infected pregnant women. Therefore, the present study was aimed at determining the level of serum vitamin A and VAD among pregnant women with and without HIV infection in tropical settings of Northwest Ethiopia.

METHODS

In this cross-sectional study, blood samples were collected from 423 pregnant women and from 55 healthy volunteers who visited the University of Gondar Hospital. Serum concentration of vitamin A was measured by high performance liquid chromatography.

RESULTS

After controlling for total serum protein, albumin and demographic variables, the mean ± SD serum vitamin A in HIV seropositive pregnant women (0.96 ± 0.42 μmol/L) was significantly lower than that in pregnant women without HIV infection (1.10 ± 0.45 μmol/L, P < 0.05). Likewise, the level of serum vitamin A in HIV seropositive non-pregnant women (0.74 ± 0.39) was significantly lower than that in HIV negative non-pregnant women (1.18 ± 0.59 μmol/L, P < 0.004). VAD (serum retinol < 0.7 μmol/L) was observed in 18.4% and 17.7% of HIV infected and uninfected pregnant women, respectively. Forty six percent of non-pregnant women with HIV infection had VAD while only 28% controls were deficient for vitamin A (P = 0.002).

CONCLUSION

The present study shows that VAD is a major public health problem among pregnant women in the tropical settings of Northwest Ethiopia. Considering the possible implications of VAD during pregnancy, we recommend multivitamin (which has a lower level of vitamin A) supplementation in the care and management of pregnant women with or without HIV infection.

Vitamin A dynamics in breastmilk and liver stores: a life history perspective

OBJECTIVES

Newborns are dependent on breastmilk vitamin A for building hepatic stores of vitamin A that will become critical for survival after weaning. It has been documented that vitamin A concentrations in breastmilk decline across the first year postpartum in both well-nourished and malnourished populations. The reason for this decline has been assumed to be a sign of concurrently depleting maternal hepatic stores. This study investigates this assumption to clarify why the decline occurs, drawing on life history theory.

METHODS

A cross sectional survey was conducted among lactating mothers in Kenya in 2006. Data were used to examine (1) the relationship between liver vitamin A and time, (2) if the relationship between milk and liver vitamin A varies by time, and (3) by maternal parity.

RESULTS

The relationship between liver vitamin A and time fits the quadratic pattern with marginal significance (P = 0.071, n = 192); the liver vitamin A declined during early postpartum then recovered in late postpartum time, controlling covariates. The milk-liver vitamin A relationship varied by postpartum time periods (P = 0.03) and by maternal parity (P = 0.005). Mothers in earlier postpartum or higher parity had a stronger positive relationship between milk and liver vitamin A than mothers in later postpartum or lower parity.

CONCLUSIONS

Our observations are consistent with life history tradeoffs and negate the assumption that maternal hepatic and milk vitamin A decline together. Rather, maternal liver vitamin A has a dynamic relationship with milk vitamin A, particularly depending on postpartum time and maternal parity.

Optimal vitamin A and suboptimal vitamin D status are common in Iranian infants

AIM

Investigation of serum concentrations of vitamins A and D in Iranian infants.

METHODS

A descriptive cross-sectional study, investigating 7112 infants (15-23 months of age) from all regions of Iran, who attended health care centres from May 25 to June 2, 2001. Unequal clusters with unequal household sizes were sampled. Vitamin A and D levels were analysed with high-performance liquid chromatography.

RESULTS

The mean (SD) concentration of vitamin A was 2.09 (0.83) μmol/L. At a national level, 0.7% of the infants had a level indicating deficiency, and 0.5% of the infants had insufficient concentrations of vitamin A, defined as serum concentrations <0.35 and <0.7 μmol/L retinol, respectively. A total of 88% of infants had optimal concentrations (>1.4 μmol/L). The mean (SD) concentration of vitamin D was 61.3 (31.4) nmol/L. Deficiency was found in 2.8% of infants (<25 nmol/L), and insufficiency in 32.9% (<50 nmol/L). Suboptimal and optimal concentrations were found in 44% and 20%, representing 50-75 and >75 nmol/L, respectively. Girls had lower vitamin D concentrations than boys (p = 0.006).

CONCLUSION

As in developed countries, vitamin A deficiency was rare in Iranian infants. Vitamin D deficiency was also rare, but 33% of infants had insufficient levels; this was more common in girls than boys.

[Association between Vitamin A deficiency and socioeconomic, nutritional and obstetric variables]

This study verified the night blindness prevalence, the first manifestation of this deficiency, and its association with socioeconomic, nutritionals and obstetric variables of 92 pregnant who were assisted on a health municipal center in Diamantina, Vale do Jequitinhonha. Data was collected through a model interview recommended by WHO (1996) to diagnose night blindness. The statistic analysis used Fisher exact test and Wilcoxon test. The results showed a higher prevalence of night blindness at Diamantina districts and neighbor cities (13.04%). No significant association was found between night blindness and socioeconomic and obstetric variables (p>0.05). It was observed a low vitamin A levels by pregnant with night blindness (4.4). This found shows the necessity of more investigations on vitamin A deficiency in order to help prevent, diagnose and combat this issue.

Coping with a Nutrient Deficiency: Cultural Models of Vitamin A Deficiency in Northern Niger

Cultural explanations and management strategies for specific signs and symptoms of vitamin A deficiency are explored in a Hausa-speaking community in northern Niger. Their interpretations of the etiology of nightblindness in young children and pregnant women focus on food-related causes, in which "lack of good food" is central. In parallel with the significance of food in the etiology of nightblindness, the recommended treatments are home food remedies, primarily involving liver, meat, or green leaves. The locally attributed etiology for the more severe manifestation of vitamin A deficiency, xerophthalmia, stands in sharp contrast to this. People believe the primary cause is "heat" produced by acute infectious disease (particularly measles). A trip to the medical dispensary or a reliance upon home remedies are the preferred treatment options for this condition. We explore the striking correspondence between local interpretations of nightblindness and contemporary medical knowledge and treatment in relation to the very different explanations and curative measures offered for more serious manifestations of vitamin A deficiency.

The post-partum mid-upper arm circumference of adolescents is reduced by pregnancy in rural Nepal

The purpose of this study was to examine whether changes in the mid-upper arm circumference (MUAC) in pregnancy and early post-partum varied by maternal age. The MUAC of 3359 nulliparous pregnant women ≤25 years of age in rural Nepal was measured in early pregnancy and at 3 months post-delivery of a live-born infant. Regression was used to model the change in MUAC and prevalence of MUAC < 20 cm by maternal age, adjusted for confounders. A total of 5.2% of the pregnant women were under 16 years of age. The prevalence of MUAC measurements <20 cm was 11.3% in early pregnancy and did not differ by maternal age. The prevalence of low MUAC was 17.7% at post-partum, but those <16 years of age had a significantly higher prevalence of low post-partum MUAC [odds ratio: 2.47, 95% confidence interval (CI) 1.49, 4.10] compared with women 20-25 years of age, adjusted for maternal literacy, caste, meat consumption in early pregnancy and timing of measurements. All women reduced their MUAC from early pregnancy through post-partum. The adjusted loss of the MUAC among those under 16 years of age was 0.97 cm (95% CI: -1.33, -0.60), compared with 0.40 cm (95% CI: -0.70, -0.10) among women 20-25 years of age. In an energy-restricted environment, girls under 16 years contributed to a half centimetre more loss of MUAC than older women of the same parity. Such a loss of fat, muscle or both may put younger women and their breastfed offspring at greater risk of other adverse health and nutritional outcomes.

Prevalence and determinants of malnutrition among reproductive aged women of rural Bangladesh

Malnutrition among the rural Bangladeshi women of reproductive age is still very high. This high prevalence attributes to a range of adverse health consequences on the women and their offspring. A total of 2341 women aged between 20 and 45 years residing in the study area were interviewed in this cross-sectional study. Information on socioeconomic variables, nutritional status, and pregnancy-related history was obtained using interviewer administered questionnaire. A total of 34% of the reproductive aged rural women suffer from malnutrition. A multivariate analysis shows association between malnutrition and monthly household income, history of taking oral contraceptive, current pregnancy status, and history of breastfeeding. The final regression model shows a statistically significant decreasing trend in malnutrition status with increasing income (P for trend <.001). The economic and health consequences of malnutrition in this group of women are enormous. National nutritional program should target this women group for any intervention with a special priority.

Risk factors for maternal night blindness in rural South India

PURPOSE

This study aimed to identify risk factors associated with maternal night blindness in rural South India.

METHODS

At delivery, women enrolled in a population-based trial of newborn vitamin A supplementation were asked whether they were night blind at any time during the pregnancy. Multivariate logistic regression was used to identify socioeconomic, demographic, and pregnancy-related factors associated with maternal night blindness.

RESULTS

Women reported night blindness in 687 (5.2%) of 13,171 pregnancies. In a multivariate model, having a concrete roof (Odds Ratio (OR): 0.60, 95% Confidence Interval (CI): 0.47, 0.78), religion other than Hindu (OR: 0.46, 95% CI: 0.27, 0.76), maternal literacy (OR: 0.58, 95% CI: 0.49, 0.69), and maternal age from 25 to 29 years (OR: 0.68, 95% CI: 0.50, 0.93) were associated with a lower risk of night blindness in pregnancy. The odds of night blindness were higher for those leasing rather than owning land (OR: 1.78, 95%CI: 1.08, 2.93), parity 6 or more compared to 0 (OR: 2.11, 95% CI: 1.09, 4.08), and with twin pregnancies (OR: 3.23, 95% CI: 1.93, 5.41). Factors not associated with night blindness in the multivariate model were other markers of socioeconomic status such as electricity in the house, radio and television ownership, type of cooking fuel and household transportation, and number of children under 5 years of age in the household.

CONCLUSIONS

Maternal night blindness was prevalent in this population. Being pregnant with twins and of higher parity put women at higher risk. Maternal literacy and higher socioeconomic status lowered the risk.

Extent of vitamin A deficiency among rural pregnant women in Bangladesh

OBJECTIVE

To investigate the prevalence of vitamin A deficiency (VAD) among pregnant women in rural Bangladesh, and examine the relationship between various factors and vitamin A status.

SETTING

Community Nutrition Promoter (CNP) centres in Kapasia sub-district of Gazipur district, Bangladesh.

DESIGN

A cross-sectional study.

SUBJECTS AND METHODS

Two hundred women, aged 18-39 years, in their second or third trimester of pregnancy were selected from seventeen CNP centres in four unions of Kapasia sub-district where they usually visit for antenatal care. Various socio-economic, personal and pregnancy-related information, dietary intake of vitamin A and mid-upper arm circumference (MUAC) data were collected. Serum retinol (vitamin A) concentration was determined.

RESULTS

More than half (51 %) of the pregnant women had low vitamin A status (serum retinol <1.05 micromol/l) with 18.5 % having VAD (serum retinol <0.70 micromol/l). Fifty-three per cent of the women's vitamin A intake was less than the recommended dietary allowance. By multiple regression analysis, MUAC, per-capita expenditure on food and wealth index were found to have significant independent positive relationship with serum retinol concentration, while gestational age of the pregnant women had a negative relationship. The overall F-ratio (10.3) was highly significant (P = 0.0001), the adjusted R2 was 0.18 (multiple R = 0.45).

CONCLUSION

VAD is highly prevalent among rural pregnant women in Bangladesh. Gestational age, nutritional status, per-capita expenditure on food and wealth index appear to be important in influencing the vitamin A status of these women. An appropriate intervention is warranted in order to improve the vitamin A status.

Maternal night blindness during pregnancy is associated with low birthweight, morbidity, and poor growth in South India

Maternal night blindness is common during pregnancy in many developing countries. Previous studies have demonstrated important consequences of maternal night blindness during pregnancy on the health of the mother and newborn infant. We compared birthweight, 6-mo infant mortality, morbidity, and growth among infants of women who did and did not report a history of night blindness from a community-based, randomized trial of newborn vitamin A supplementation in south India. Birthweight was measured within 72 h of delivery. Infants were followed until 6 mo of age for mortality and morbidity was assessed at household visits every 2 wk. Anthropometry was assessed at 6 mo of age. A total of 12,829 live-born infants were included, 680 of whom were infants of mothers with night blindness during the index pregnancy. Maternal night blindness was associated with an increased risk of low birthweight in a dose-dependent fashion based on birthweight cut-offs: <2500 g, adjusted relative risk (RR) = 1.13 (95% CI = 1.01, 1.26); <2000 g, adjusted RR = 1.70 (95% CI = 1.27, 2.26); <1500 g, adjusted RR = 3.38 (95% CI = 1.18, 6.33); with an increased risk of diarrhea (adjusted RR = 1.16, 95% CI = 1.03, 1.30), dysentery (adjusted RR = 1.25, 95% CI = 1.03, 1.53), acute respiratory illness (adjusted RR = 1.32, 95% CI = 1.21, 1.44), and poor growth at 6 mo; underweight (adjusted RR = 1.14, 95% CI = 1.02, 1.26), stunting (adjusted RR = 1.19, 95% CI = 1.05, 1.34). Maternal night blindness was not associated with 6-mo infant mortality or wasting at 6 mo. This study demonstrates that there are important consequences to the infant of maternal vitamin A deficiency during pregnancy.

Risk factors for pregnancy-related mortality: a prospective study in rural Nepal

OBJECTIVES

This study examined the risk factors of mortality related to pregnancy for the first year post partum in a cohort of 25,580 pregnancies.

STUDY DESIGN

Longitudinal cohort follow-up.

METHODS

Details of socio-economic status, mid-upper arm circumference (MUAC), diet, illness, work, substance use and previous pregnancy history were collected during early to mid-gestation, and these women were followed for 1 year post partum. All-cause mortality rates per 100,000 pregnancies were calculated for deaths during pregnancy or up to 42 days post partum (early period) and 43-364 days post partum (late period). Odds ratios (OR) of mortality were estimated using five groups of risk factors: biological; morbidity; dietary; lifestyle; and socio-economic. Significant factors within each group were included in a single risk model for each time period.

RESULTS

Early and late pregnancy-related mortality rates were 469 [95% confidence interval (CI) 385-553] and 254 (95% CI 192-316), respectively. Maternal age > or = 35 years was associated with a three- to four-fold increase in mortality, whereas increasing parity conferred increasing protection. In the final model, a larger MUAC and consumption of dark green leaves were associated with decreased risk of death in the early period (OR 0.76, 95% CI 0.67-0.87 and 0.64, 95% CI 0.41-0.99, respectively). A larger MUAC was also associated with a lower risk of death in the late period. Diarrhoea/dysentery and pre-eclampsia were associated with increased risk of death in the early period (OR 2.78, 95% CI 1.40-5.51 and 2.95, 95% CI 1.48-5.90, respectively). Factors weakly associated (P<0.1) with mortality in both periods included night blindness, strenuous work activity and cigarette smoking. No socio-economic factors were significant in the models.

CONCLUSIONS

Maternal age, parity, MUAC, diet and illness in early to mid-gestation were associated with risk of death during pregnancy and the first year post partum in rural Nepal.

Micronutrientes na gestação e lactação

Vitamina A, ferro e zinco são micronutrientes essenciais ao pleno funcionamento do organismo humano. Durante o período gestacional, seus requerimentos encontram-se aumentados devido ao intenso crescimento e proliferação celular e, durante a lactação, o leite materno constitui a mais importante fonte destes nutrientes para o recém-nascido e lactente. O atendimento às necessidades nutricionais do grupo materno-infantil, considerado como grupo de risco, para o desenvolvimento de carências nutricionais, deve ser uma preocupação dos profissionais de saúde, e a prevenção e o diagnóstico precoce da deficiência de micronutrientes reveste-se de extrema importância. Este trabalho objetiva revisar informações disponíveis na literatura acerca do papel da vitamina A, do ferro e do zinco na gestação e lactação, enfatizando os agravos à saúde decorrentes de sua deficiência e o papel da suplementação no combate ao estado carencial desses micronutrientes. Foram pesquisadas as bases de dados MEDLINE e LILACS, utilizando os decritores: "vitamin A", "iron", "zinc", "deficiency", "pregnancy", "lactation", "newborn", "anemia" e "micronutrient", no período 1966 a 2004. Sugerem-se medidas que concorram para a modificação das práticas alimentares e da qualidade da dieta como estratégia de combate à deficiência de micronutrientes e incluídas no elenco de ações universais da atenção pré-natal. Tais ações podem produzir benefícios para a saúde materno-infantil e contribuir para a redução dos níveis de morbi-mortalidade no binômio mãe-filho.

Breast-feeding, dietary intakes and their associations with subclinical vitamin A deficiency in children in Anhui Province, China

Objective

This study aimed to explore the associations between breast-feeding, dietary intakes and other related factors and subclinical vitamin A deficiency (SVAD) in children aged 0–5 years in an area in China where mild vitamin A deficiency (VAD) is found.

Methods

Data were from a population-based cross-sectional study with 1052 children aged 0–5 years. SVAD cases were identified by the indicator of serum retinol ≤ 20 μg dl− 1. Breast-feeding status, dietary intakes and other factors were collected through a pre-designed questionnaire.

Results

The prevalence of SVAD in children aged 0–5 years was 6.9%. Logistic regression analysis showed that the odds ratio of SVAD for breastfeeding was 3.56 (95% confidence limits (95% CL) 2.17–5.82). After adjustment for sex, age in categories, residence, mother's education, mother's occupation, vitamin A preparation supplements, rank in siblings and diarrhoea, the odds ratio for breast-feeding fell to 2.38 (95% CL 1.13–4.95). The odds ratios for breast-feeding within children aged 1 year were 5.46 (95% CL 2.07–15.03) and 4.6 (95% CL 1.72–12.82) before and after adjustment of other confounders, respectively. The odds ratios for breast-feeding did not show statistical significance within children aged 0 or 2 years. The odds ratios decreased, but remained statically significant after further adjustments for individual dietary factor or all dietary factors.

Conclusion

Breast-feeding was a risk factor of SVAD for children, especially for those aged 1 year. The differences in dietary intakes and other established risk factors could not fully explain the increased risk. This finding implies that prolonged breast-feeding alone may not ensure protection of children from VAD in an area with mild SVAD.

Moderate maternal vitamin A deficiency affects perinatal organ growth and development in rats

Vitamin A deficiency during pregnancy is associated with detrimental effects in the offspring. We have developed a rat model to examine specific effects of maternal vitamin A status on perinatal growth and development. A total of 54 female rats were fed a vitamin A-free (VAF), -marginal (VAM) or -sufficient (VAS) diet from weaning until mating (at 7 weeks) and throughout pregnancy. Half of the rats in each group were injected with a single large dose of vitamin A on day 10 of pregnancy. Fetal and neonatal samples were taken on day 20 of pregnancy and the day of birth respectively. Maternal plasma retinol concentrations on day 20 and at birth were 50 % and 30 % lower in the VAF and VAM when compared to the VAS group. Fetal weight and survival did not differ between groups although placental: fetal ratio was higher in the VAF group than in the VAS group (0·195 (SE 0·005) V. 0·175 (se 0·004), P < 0·05). Rats fed the VAF diet gave birth at 23·5 d, an average of 1 d later than the other groups, and had lower number of live neonates at birth. Fetal liver, heart and lung weights relative to total body weight were lower in the VAF group and had altered growth trajectories. In neonates, only the relative lung weight was reduced. In addition, an increased protein: DNA ratio indicated hypertrophy in fetal kidneys. Vitamin A injection had no additional effect on length of gestation and fetal or neonatal number. However, injection increased relative fetal organ weights in the VAF group but did not alter the effects of vitamin A deficiency in the neonate. These data suggest that chronic vitamin A deficiency during pregnancy compromises liver, heart and kidney and impairs lung growth and development during the last few days of gestation and reduces number of live neonates at birth.

A investigação da cegueira noturna no grupo materno-infantil: uma revisão histórica

Objetivou-se neste estudo apresentar uma revisão histórica sobre a cegueira noturna, um indicador funcional da deficiência de vitamina A. Realizou-se uma revisão da literatura científica publicada no período de 1929 a 2005, nas bases de dados Medline, Lilacs, SciELO e dos comitês nacionais e internacionais de saúde e de micronutrientes, utilizando-se os termos night blindness, xerophthalmia, pregnancy, post partum women, newborn, children, vitamin A deficiency, micronutrient, deficiência de vitamina A, micronutriente, cegueira noturna, gestação, xeroftalmia. O reconhecimento da importância do indicador funcional da deficiência de vitamina A foi consagrado em 1996 pela Organização Mundial de Saúde, a partir da recomendação de uma entrevista padronizada para investigação da cegueira noturna. O método se caracteriza por apresentar facilidades operacionais, ser de baixo custo, além de permitir a sua aplicação tanto para o monitoramento do estado nutricional de pessoas e comunidades, quanto para a avaliação da eficácia de programas de intervenção. Entre gestantes e nutrizes, estudos recentes sugerem a utilidade deste indicador no diagnóstico dos casos de deficiência de vitamina A ainda no estágio subclínico da deficiência, sendo grande a sua concordância com indicadores bioquímicos. Ao longo dos anos, verifica-se também o reconhecimento deste indicador como um instrumento importante para a predição do risco de morbimortalidade no grupo materno-infantil.

Lipid-soluble antioxidants status and some of its socio-economic determinants among pregnant Ethiopians at the third trimester

Objective

To determine the serum levels of three lipid-soluble antioxidants (retinol, β-carotene and α-tocopherol) in pregnant women attending an antenatal clinic (ANC) in Gondar, Ethiopia.

Design

A cross-sectional study involving laboratory determination of serum levels of retinol, α-tocopherol and β-carotene using high-performance liquid chromatography and questionnaire-based assessment of socio-economic status.

Setting

ANC of a university teaching hospital.

Subjects

Three hundred and twenty-two healthy pregnant women in their third trimester, who attended the ANC.

Results

Mean serum levels of retinol, α-tocopherol and β-carotene were found to be 1.23±0.5, 25.5±0.9 and 0.21±0.09 μmol l−1, respectively. The prevalence of vitamin A deficiency (<1.05 μmol l−1) among pregnant women was 38.5%. Women having low retinol (vitamin A) levels were highly likely to live in earth-floored and mud-walled houses, and less likely to own a house and to have a latrine.

Conclusion

The study shows that serum levels of lipid-soluble antioxidants were low among ANC attendees in northern Ethiopia. It also indicates that some socio-economic factors (such as poor housing standard) are associated with vitamin A deficiency.

Vitamin A deficiency disorders in children and women

Vitamin A deficiency is an endemic nutrition problem throughout much of the developing world, especially affecting the health and survival of infants, young children, and pregnant and lactating women. These age and life-stage groups represent periods when both nutrition stress is high and diet likely to be chronically deficient in vitamin A. Approximately 127 million preschool-aged children and 7 million pregnant women are vitamin A deficient. Health consequences of vitamin A deficiency include mild to severe systemic effects on innate and acquired mechanisms of host resistance to infection and growth, increased burden of infectious morbidity, mild to severe (blinding) stages of xerophthalmia, and increased risk of mortality. These consequences are defined as vitamin A deficiency disorders (VADD). Globally, 4.4 million preschool children have xerophthalmia and 6 million mothers suffer night blindness during pregnancy. Both conditions are associated with increased risk of morbidity and mortality. While reductions of child mortality of 19-54% following vitamin A treatment have been widely reported, more recent work suggests that dosing newborns with vitamin A may, in some settings, lower infant mortality. Among women, one large trial has so far reported a > or = 40% reduction in mortality related to pregnancy with weekly, low-dose vitamin A supplementation. Epidemiologic data on vitamin A deficiency disorders can be useful in planning, designing, and targeting interventions.

Association between gestational night blindness and serum retinol in mother/newborn pairs in the city of Rio de Janeiro, Brazil

OBJECTIVE

Gestational night blindness (XN) is associated with increased risk of reproductive morbidity and mortality. This study investigated the prevalence of gestational XN among postpartum women treated in a public maternity hospital in the city of Rio de Janeiro, Brazil and evaluated its association with maternal and neonatal (cord blood) serum retinol concentrations.

METHODS

XN was evaluated retrospectively, using an interview according to guidelines of the World Health Organization, in 222 postpartum women (< or = 6 h after delivery) after singleton births who had low obstetric risk. Serum retinol concentrations were measured according to the modified Bessey method, with a cutoff point lower than 1.05 micromol/L for inadequate serum retinol concentration.

RESULTS

Prevalence of gestational XN was 18%, and inadequate maternal and cord blood serum retinol concentrations were found in 24.4% and 45.5% of samples, respectively. The results associated gestational XN with inadequate maternal serum retinol concentration (P = 0.000), and an association was observed between maternal and neonatal serum retinol concentrations (P = 0.000). A poor association was observed between maternal XN and serum levels of retinol in newborn children (P = 0.06).

CONCLUSIONS

The results suggest that prevalence of gestational XN and inadequate serum retinol concentration among postpartum women and newborns is a concern, calling attention to the need for studies in other parts of Brazil. In addition, the risk of inadequate serum retinol in newborns was significantly higher among infants of postpartum women with serum retinol levels below 1.05 micromol/L. Gestational XN was associated with inadequate levels of maternal serum retinol, and the results suggest a poor relation between maternal XN and vitamin A nutritional status of newborns.

Effects of antenatal multiple micronutrient supplementation on birthweight and gestational duration in Nepal: double-blind, randomised controlled trial

BACKGROUND

Neonatal mortality is the biggest contributor to global mortality of children younger than 5 years, and low birthweight is a crucial underlying factor. We tested the hypotheses that antenatal multiple micronutrient supplementation would increase infant birthweight and gestational duration.

METHODS

We did a double-blind, randomised controlled trial in Dhanusha district, Nepal. Women attending for antenatal care with singleton pregnancies at up to 20 weeks' gestation were invited to participate. Participants were randomly allocated either routine iron and folic acid supplements (control; n=600) or a multiple micronutrient supplement providing a recommended daily allowance of 15 vitamins and minerals (intervention; n=600). Supplementation began at a minimum of 12 weeks' gestation and continued until delivery. Primary outcome measures were birthweight and gestational duration. Analysis was by intention to treat. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN88625934.

FINDINGS

Birthweight was available for 523/600 infants in the control group and 529/600 in the intervention group. Mean birthweight was 2733 g (SD 422) in the control group and 2810 g (453) in the intervention group, representing a mean difference of 77 g (95% CI 24-130; p=0.004) and a relative fall in the proportion of low birthweight by 25%. No difference was recorded in the duration of gestation (0.2 weeks [-0.1 to 0.4]; p=0.12), infant length (0.3 cm [-0.1 to 0.6]; p=0.16), or head circumference (0.2 cm [-0.1 to 0.4]; p=0.18).

INTERPRETATION

In a poor community in Nepal, consumption of a daily supplement containing a recommended daily allowance of 15 micronutrients in the second and third trimesters of pregnancy was associated with increased birthweight when compared with a standard iron and folic acid preparation. The effects on perinatal morbidity and mortality need further comparisons between studies. Published online March 3, 2005 http://image.thelancet.com/extras/04art11045web.pdf.

Recovery from impaired dark adaptation in nightblind pregnant Nepali women who receive small daily doses of vitamin A as amaranth leaves, carrots, goat liver, vitamin A-fortified rice, or retinyl palmitate

BACKGROUND

It is not known whether daily consumption of vitamin A-containing foods is efficacious for treating nightblindness.

OBJECTIVE

We assessed the effect of supplementation with vitamin A from food or synthetic sources on dark adaptation and plasma retinol concentrations in nightblind pregnant Nepali women.

DESIGN

Nightblind pregnant women were randomly assigned to 1 of 6 treatment groups to receive 6 d/wk for 6 wk either 850 microg retinol equivalents/d as retinyl palmitate, vitamin A-fortified rice, goat liver, amaranth leaves, or carrots or 2000 microg retinol equivalents/d as retinyl palmitate. Dark adaptation was assessed weekly by using the pupillary threshold (PT) test; plasma retinol concentrations were measured before and after the intervention. These outcomes were also assessed in a comparison group of nonnightblind pregnant women.

RESULTS

In the nightblind women, the mean PT improved significantly (P<0.0001) from -0.71+/-0.04 to -1.42+/-0.02 log cd/m2, and the final mean PT did not differ significantly from that in the nonnightblind women (-1.43+/-0.04; P=0.55). Improvement in dark adaptation was greater in the liver group than in the vitamin A-fortified rice group (P<0.02). Plasma retinol concentrations increased significantly (P<0.0001) from 0.95+/-0.05 to 1.07+/-0.05 micromol/L. The plasma retinol response was greater in the higher-dose capsule and liver groups than in the vegetable groups and significantly greater in the liver group than in the vitamin A-fortified rice group (both: P<0.05).

CONCLUSION

Improvement in dark adaptation did not differ significantly between women who received vitamin A as liver, amaranth leaves, carrots, or retinyl palmitate.

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

OBJECTIVE

To determine provisional estimates of the extent of vitamin A (VA) deficiency and xerophthalmia among school-aged children.

DESIGN

Literature search of published, unpublished and website-based population survey and study reports, with country-specific imputation of prevalence rates and numbers of children affected by: (1) VA deficiency based on measured or imputed distributions of serum retinol concentration < 0.70 micromol/l (equivalent to < 20 microg/dl) and (2) xerophthalmia, by country.

SETTING

Countries within the WHO South-East Asian Region.

SUBJECTS

The target group for estimation was children 5-15 y of age.

INTERVENTIONS

None.

RESULTS

The estimated prevalence of VA deficiency is 23.4%, suggesting that there are approximately 83 million VA-deficient school-aged children in the region, of whom 10.9% (9 million, at an overall prevalence of 2.6%) have mild xerophthalmia (night blindness or Bitot's spot). Potentially blinding corneal xerophthalmia appears to be negligible at this age.

CONCLUSIONS

VA deficiency, including mild xerophthalmia, appears to affect large numbers of school-aged children in South-East Asia. However, nationally representative data on the prevalence, risk factors and health consequences of VA deficiency among school-aged children are lacking within the region and globally, representing a future public health research priority.

Validation of night blindness reports among children and women in a vitamin A deficient population in rural Tanzania

OBJECTIVE

This study validates different definitions of reported night blindness (XN) in a vitamin A deficient African population with no local term for XN.

DESIGN

Case-control study with follow-up after treatment.

SETTING

Eight primary schools and health centres in rural Tanzania.

SUBJECTS

A total of 1214 participants were screened for reported XN and other eye signs of xerophthalmia: 461 children aged 24-71 months, 562 primary school-age children and 191 pregnant or breast-feeding women. All 152 cases of reported XN were selected for the validation study and group matched with 321 controls who did not complain of XN. XN reports were validated against serum retinol concentrations and pupillary dark adaptation measurements in cases and controls.

INTERVENTION

All children and women who reported XN or had other signs of active xerophthalmia were treated with vitamin A and followed up 3-4 weeks later. Half of the untreated control group who had their serum retinol examined in the baseline examination were also followed up.

RESULTS

The overall prevalence of reported XN was 12.5%. At baseline, mean pupillary threshold (-1.52 vs -1.55 log cd/m(2), P=0.501) and median serum retinol concentrations (0.95 vs 0.93 micromol/l, P=0.734) were not significantly different in cases and controls either overall or in each population group. More restricted case definitions reduced the prevalence of reported XN to 5.5% (P<0.001), but there was still no significant difference between cases and controls although the results were in the expected direction. After treatment, the median serum retinol concentration improved significantly only in the most deficient group, the young children. Dark adaptation improved in all the subgroups but the difference was only significant for young children and primary school-age children when the restricted case definitions were used.

CONCLUSIONS

XN reports are a poor indicator of vitamin A deficiency in this population.

SPONSORSHIP

Task Force Sight and Life, Basel, Switzerland.

Vitamin A status of pregnant Nigerian women: relationship to dietary habits and morbidity

Vitamin A status of pregnant Nigerian women has been determined by measurement of retinol concentration in plasma samples obtained from pregnant subjects, using a spectrophotometric method. The relationship between vitamin A status, dietary habits and morbidity pattern was also examined. Two hundred (200) consecutive pregnant women registered for antenatal clinic at the Obafemi Awolowo University Teaching Hospitals Complex within a period of eight (8) weeks were recruited as subjects. The subjects were aged 15-43 years (mean 27.2 years), and were at different stages of pregnancy. Semi-structured questionnaires were administered on the subjects to obtain data on dietary habits, present health status and obstetric history. Vitamin A deficiency (plasma retinol concentration < 0.35 micromol/L) is found in 17.5% of the subjects, while 37% and 45.5% have borderline (plasma retinol concentration 0.35-0.70 micromol/L) and normal (plasma retinol concentration > 0.70 micromol/L) vitamin A status respectively. There is a significant relationship between frequent micturition and vitamin A status (chi-square = 0.39: P < 0.05). There is no relationship between maternal age and vitamin A status. Although about 80% of the subjects consumed red palm oil daily, about 64% would heat the oil to smoking for at least 10 minutes, before adding to stew during cooking. Green vegetables were also boiled in hot water before adding to sauce, while liver is consumed on just about three days per month. The findings reported in this study have further strengthened the claim that vitamin A deficiency is fairly prevalent in pregnant Nigerian women, underlining the need for prompt and effective intervention.

Risk factors for nightblindness among women of childbearing age in Cambodia

OBJECTIVE

To characterize risk factors for nightblindness among nonpregnant women of childbearing age, a group recently recognized to be at high risk of vitamin A deficiency in some developing countries.

DESIGN

Case-control study.

SETTING

The study included >15 000 households in National Micronutrient Survey of Cambodia conducted in 2000.

SUBJECTS

The prevalence of nightblindness among 13 358 nonpregnant women was 2.0%. A total of 328 nonpregnant women with nightblindness were matched by province with 1009 nonpregnant women without nightblindness.

METHODS

Univariate and multivariate logistic regression models were used to estimate odds ratios (ORs) as estimates of the relative risk of factors associated with nightblindness.

RESULTS

In a final model, materials in the wall of the house (OR 1.4, 95% confidence interval (CI) 0.9-2.0), land ownership < or =0.5 hectares (OR 1.4, 95% CI 1.0-1.9), nightblindness in last pregnancy (OR 44.5, 95% CI 29.2-67.8), parity >3 (OR 1.5, 95% CI 1.0-2.1), diarrhea within the last 2 weeks (OR 1.9, 95% CI 1.3-2.8), maternal body mass index <18.5 (OR 1.8, 95% CI 1.2-2.7), and lack of consumption of vitamin A-rich animal foods in the last 24 h (1-60 retinol equivalents (RE) OR 1.1, 95% CI 0.7-1.6; > or =60 RE, OR 0.7, 95% CI 0.4-1.0) were associated with nightblindness among nonpregnant women.

CONCLUSIONS

Women of childbearing age in Cambodia with low socioeconomic status, low consumption of vitamin A-rich animal foods, a history of nightblindness during the previous pregnancy, parity >3, malnutrition, and diarrhea have a higher risk of nightblindness.

SPONSORSHIP

United States Agency for International Development (442-G-00-95-00515-00).

Vitamin A deficiency in poor, urban, lactating women in Bangladesh: factors influencing vitamin A status

AIMS

To investigate the prevalence of vitamin A deficiency among lactating women in a poor urban population of Bangladesh, and to examine the relationship between various factors and vitamin A status.

DESIGN

Cross-sectional study.

SETTING

Maternal and child health clinic in Dhaka City, Bangladesh.

SUBJECTS AND METHODS

A total of 120 lactating women aged 17-37 years were randomly selected from women who attended a local maternal and child health clinic in Dhaka City for immunisation of their children. Various socio-economic, personal characteristics, dietary intakes of vitamin A and anthropometric data were collected. Serum retinol (vitamin A) concentration was determined as a measure of vitamin A status.

RESULTS

Of the subjects, 37% had low serum vitamin A levels (<30 microg x dl-1), with 13.3% having sub-clinical vitamin A deficiency (<20 microg x dl-1). Eighty-seven per cent had vitamin A intakes below the recommended dietary allowance. The lactating women who were either illiterate or received only informal education had significantly lower serum vitamin A levels compared with those who received formal education. The women whose husbands received formal education had significantly higher serum vitamin A levels than those whose husbands were either illiterate or received only informal education. The serum vitamin A levels of women in households with poor sanitation/latrine practice were significantly lower than those of women in households with good sanitation/latrine practice. The women with one child had significantly lower serum vitamin A levels than those with two or more children. Women with a lactation period of 6 months or more had significantly lower serum vitamin A levels than women with a lactation period of less than 6 months. The women who consumed less than the median vitamin A intake (274.8 microg day-1) had significantly lower serum vitamin A levels than those who consumed more than the median vitamin A intake. By multiple regression analysis, education level of the women, number of living children, duration of lactation and dietary intake of vitamin A were found to have significant independent relationships with serum vitamin A. The overall F-ratio (6.8) was highly significant the adjusted R2 was 0.16 (multiple ).

CONCLUSION

A significant proportion of poor, urban, lactating women in Bangladesh have vitamin A deficiency. Among the various factors, education level of the women, number of living children, duration of lactation and dietary intake of vitamin A appear to be important in influencing the vitamin A status of these women.

Nutritional interventions during pregnancy for the prevention or treatment of maternal morbidity and preterm delivery: an overview of randomized controlled trials

This overview assesses the effectiveness of nutritional interventions to prevent or treat maternal morbidity, mortality and preterm delivery. Cochrane systematic reviews and other up-to-date systematic reviews and individual randomized controlled trials were sought. Searches were carried out up to July 2002. Iron and folate supplements reduce anemia and should be included in antenatal care programs. Calcium supplementation to women at high risk of hypertension during pregnancy or low calcium intake reduced the incidence of both preeclampsia and hypertension. Fish oil and vitamins E and C are promising for preventing preeclampsia and preterm delivery and need further testing. Vitamin A and beta-carotene reduced maternal mortality in a large trial; ongoing trials should provide further evaluation. No specific nutrient supplementation was identified for reducing preterm delivery. Nutritional advice, magnesium, fish oil and zinc supplementation appear promising and should be tested alone or together in methodologically sound randomized controlled trials. Anema in pregnancy can be prevented and treated effectively. Considering the multifactorial etiology of the other conditions evaluated, it is unlikely that any specific nutrient on its own, blanket interventions or magic bullets will prevent or treat preeclampsia, hemorrhage, obstructed labor, infections, preterm delivery or death during pregnancy. The few promising interventions for specific outcomes should be tested or reconsidered when results of ongoing trials become available. Until then, women and their families should receive support to improve their diets as a general health rule, which is a basic human right.

Prevalence of iron, vitamin A, and iodine deficiencies amongst adolescent pregnant mothers

OBJECTIVE

The present study was undertaken to assess the prevalence of iron, vitamin A and iodine deficiencies amongst rural Adolescent Pregnant Mothers (APM).

METHODS

Survey was conducted amongst APM in a rural block; district Udham Singh Nagar, Uttaranchal State. In the district, all blocks were enlisted and one block was randomly selected. Further, villages in the block were listed (n = 64) and five villages were randomly selected for the detailed study. All APM residing in the selected villages were included for the detailed study. The data on socio demographic parameters was collected utilizing a pre-tested semi-structured questionnaire. Anaemia was assessed by hemoglobin estimation with the help of the HemoCue instrument. Vitamin-A deficiency (VAD) was assessed by presence of night blindness utilizing a pre-tested semi structured proforma. Iodine Deficiency was assessed by the clinical examination of the thyroid gland and estimating the Urinary Iodine Excretion (UIE) levels of each subject. Nutrient intake was assessed by the 24-hr dietary recall method.

RESULTS

One hundred and fifty one APM, belonging to low socio economic group, were selected for the study. The occupation of the families was farming, but the APM were housewives. The mean age of the APM was 17.8 +/- 1.5 yr. Eighty nine percent of the APM were in the age group 16-19 yr. Sixty percent of the APM were in the gestational age of 24 weeks and more. It was found that 46.0% of the APM were anaemic (Hb < 11.0 gm/dl). Sixteen percent of the study subjects had presence of night blindness. Fifteen percent of the subjects had Goiter. Median UIE level in the subjects studied was 95.0 micrograms/l. Concomitant prevalence of the three deficiencies was amongst 2.0% of the population. The 24-hour dietary intake revealed that the mean consumption of retinol and iron was only 13 and 28% of the recommended dietary allowance, respectively.

CONCLUSION

The findings of the present study indicated that Anaemia, Vitamin A, and Iodine deficiency existed as public health problems in the APM of the study area.

Recommendations for vitamin A supplementation

In all populations where vitamin A deficiency is an important public health problem, prophylactic vitamin A supplements should be given to all infants and young children (0-59 mo), pregnant women and postpartum women within 6 wk after delivery. The efficacy of vitamin A supplementation of young children is one of the best-proven, safest and most cost-effective interventions in international public health. The International Vitamin A Consultative Group (IVACG) also recommends that three 50,000-international unit (IU) doses of vitamin A should be given at the same time as infant vaccines during the first 6 mo of life. Recent kinetic studies have indicated that this regimen will be safe and is necessary to maintain the infant's vitamin A stores, even when the mother is also given 400,000 IU within the first 6 wk after delivery. IVACG will make a decision on whether to recommend prophylactic supplementation of all women of childbearing age when the results of two large trials in Ghana and Bangladesh are available. Active corneal xerophthalmia is always a medical emergency that should be treated with immediate high-dose vitamin A. High-dose vitamin A treatment is also recommended for infants and young children with xerophthalmia, severe malnutrition or measles. Low-dose vitamin A treatment is recommended for women with night blindness and/or Bitot's spots. Given the evidence of the cost-effectiveness of vitamin A supplementation, it is essential that effective vitamin A supplementation programs are made universally available to all populations where vitamin A deficiency is an important public health problem.

Recommendations for indicators: night blindness during pregnancy--a simple tool to assess vitamin A deficiency in a population

Night blindness during pregnancy caused by vitamin A deficiency is associated with an increased risk of morbidity and mortality among women. Because a history of maternal night blindness is simple and reliable to use, it is recommended as a population-based indicator of vitamin A deficiency. Furthermore, a maternal night blindness prevalence of >/=5% is recommended as a cut-off at which vitamin A deficiency may be considered to be a problem of public health significance within the community. This paper provides the justification for these recommendations. Night blindness during pregnancy is strongly associated with low serum and breast milk vitamin A concentration, abnormal conjunctival impression cytology and impaired dark adaptation, which suggests that it is a valid indicator of vitamin A deficiency. The prevalence of night blindness during pregnancy tends to be high in countries where the prevalence of xerophthalmia in children is high and in countries where interventions are in place to reduce childhood vitamin A deficiency. Existing data suggest that misclassification of self-reported maternal night blindness may account for a prevalence of up to 3%. The suggested cut-off, 5%, is set higher than this potential level of false-positive prevalence (3%). Illustrative data from India and Cambodia on childhood xerophthalmia and maternal night blindness rates are used to demonstrate the validity of using a 5% prevalence of maternal night blindness as indicative of a community vitamin A deficiency problem. Finally, it is recommended that night blindness history be elicited for a previous pregnancy that ended in a live birth in the past 3 y, using the local term for night blindness whenever possible.

High vitamin A content in some small indigenous fish species in Bangladesh: perspectives for food-based strategies to reduce vitamin A deficiency

Recognising the importance of fish in the Bangladeshi diet, the objective of the present study was to screen commonly consumed fish species for vitamin A content to evaluate the potential of fish as a vitamin A source in food-based strategies to combat vitamin A deficiency. Samples of 26 commonly consumed fish species and one crustacean were collected in Kishoreganj and Mymensingh, Bangladesh. To obtain edible parts, the fish were cleaned by Bangladeshi women according to traditional practices. Distribution of vitamin A in parts of the fish and the effect of the cleaning practices on the vitamin A content in#10; edible parts were assessed. The content of vitamin A compounds was analysed by high-performance liquid chromatography. The vitamin A content in small fish ranged from 2680 retinol equivalents (RE)/100 g raw edible parts in mola (Amblypharyngodon mola) to 20 RE/100 g raw edible parts in chata (Colisa lalia; an alternative scientific name is Colisa lalius). The vitamin A content in cultured species, silver carp (Hypophthalmichthys molitrix), rui (Labeo rohita), mrigal (Cirrhinus mrigala) and tilapia (Oreochromis niloticus) was low, <30 RE/100 g raw edible parts. In mola, 90% of the vitamin A was found in the eyes and viscera. The vitamin A content in the screened fish species was highly variable, by more than a factor of 100. The existence of commonly consumed fish in Bangladesh belonging to the categories of very high and high vitamin A content offers a great unexploited potential for food-based strategies to improve the vitamin A intake by promoting the production and consumption of these species.

Recommendations for monitoring and evaluating vitamin A programs: outcome indicators

Monitoring and evaluation are essential components of vitamin A intervention programs. They enable program managers to track progress in achieving their goals. Recommendations for outcome indicators are based on suggestions from the International Vitamin A Consultative Group Meeting (IVACG) workshop in late October 2000 in Annecy, France, followed by a pre-XX IVACG meeting in Hanoi, Vietnam. In areas with detectable xerophthalmia or eye signs, a fall in the prevalence of Bitot's spots to <0.5% and a decrease in night blindness during pregnancy to <5% indicates that vitamin A deficiency (VAD) is no longer a public health problem, although it still may be responsible for excess morbidity and mortality. Pupillary dark adaptation has been proposed as an objective indicator of vitamin A status. A program is considered to have made progress when the mean pupillary threshold improves to better than -1.24 log cd/m(2). For biochemical indices, the shift of mean or median values or the frequency distribution of preschool children with serum retinol concentration below 0.70 micromol (20 microg/dL), lactating mothers with breast milk retinol values below 0.70 micromol (6 microg per g of milk fat) or below 1.05 micromol (8 microg per g of milk fat) are useful to monitor program progress.