Prevalence of Vitamin A Deficiency among Preschool Children in Ethiopia: A Systematic Review and Meta-Analysis

Overnutrition is a risk factor for iron, but not for zinc or vitamin A deficiency in children and young people: a systematic review and meta-analysis

INTRODUCTION

Traditionally associated with undernutrition, increasing evidence suggests micronutrient deficiencies can coexist with overnutrition. Therefore, this work aimed to systematically review the associations between iron, zinc and vitamin A (VA) status and weight status (both underweight and overweight) in children and young people.

METHODS

Ovid Medline, Ovid Embase, Scopus and Cochrane databases were systematically searched for observational studies assessing micronutrient status (blood, serum or plasma levels of iron, zinc or VA biomarkers) and weight status (body mass index or other anthropometric measurement) in humans under 25 years of any ethnicity and gender. Risk of bias assessment was conducted using the American Dietetic Association Quality Criteria Checklist. Where possible, random effects restricted maximum likelihood meta-analyses were performed.

RESULTS

After screening, 83 observational studies involving 190 443 participants from 44 countries were identified, with many studies having reported on more than one micronutrient and/or weight status indicator. Iron was the most investigated micronutrient, with 46, 28 and 27 studies reporting data for iron, zinc and VA status, respectively. Synthesising 16 records of OR from seven eligible studies, overnutrition (overweight and obesity) increased odds of iron deficiency (ID) (OR (95% CI): 1.51 (1.20 to 1.82), p<0.0001, I2=40.7%). Odds appeared to be higher for children living with obesity (1.88 (1.33 to 2.43), p<0.0001, I2=20.6%) in comparison to those with overweight (1.31 (0.98 to 1.64), p<0.0001, I2=40.5%), although between group differences were not significant (p=0.08).

CONCLUSIONS

Overnutrition is associated with increased risk of ID, but not zinc or VA deficiencies, with an inverted U-shaped relationship observed between iron status and bodyweight. Our results highlight significant heterogeneity in the reporting of micronutrient biomarkers and how deficiencies were defined. Inflammation status was rarely adequately accounted for, and the burden of ID may well be under-recognised, particularly in children and young people living with overnutrition.

PROSPERO REGISTRATION NUMBER

CRD42020221523.

Clinical vitamin A deficiency among preschool aged children in southwest Ethiopia

Background

The clinical manifestations of vitamin A deficiency (VAD) involve night blindness, bitot's spots, corneal xerosis, and corneal scars. It is the most important cause of preventable childhood blindness among children and causes morbidity and mortality. Even though Ethiopia implemented high-potency vitamin A supplements, the occurrence of VAD remains significant. This study was to identify determinants of clinical VAD among preschool-aged children (PSC) in southwest Ethiopia.

Method

A community-based survey was conducted among 411 randomly selected PSCs. A pretested and structured questionnaire coupled with clinical observation for signs of vitamin A deficiency by a trained ophthalmologist was used to collect the data. An anthropometric measurement of height was taken and analyzed using WHO Anthro to calculate Z-scores for each index. The public health significance of VAD was declared after comparison with international references. A bi-variable and multi-variable logistic analysis was done. We reported the adjusted odds ratio (AOR), 95% confidence interval, and p-value.

Result

A total of 411 children were screened for clinical VAD, and the overall prevalence was 2.2% (95% CI: 1.5-2.5). Of which, night blindness affects 1.2%, bitot's spots affects 0.7%, and corneal xerosis affects 0.2%, indicating a major public health problem compared to the international reference. The odds of clinical VAD were 81% lower among children who received vitamin A supplementation (VAS; AOR = 0.19, 95% CI: 0.04-0.92). On the other hand, PSC of mothers who had attended ANC visits were 89% less likely to develop clinical VAD (AOR = 0.11, 95% CI: 0.02-0.53). In addition, the study revealed that the odds of developing clinical VAD are 82% lower among PSC aged 36 to 47 months (AOR = 0.18; 95% CI: 0.03-0.97).

Conclusion

The prevalence of clinical VAD among PSC is a public health problem and is associated with ANC visits, VAS status, and the age of the child, which could be used to target interventions to further reduce existing VAD. Further studies using reliable dietary intake and biomarker data could further depict the burden of subclinical VAD.

Prevalence of Vitamin A Deficiency in Children Aged 6 to 17 Years - Western and Central Rural Areas, China, 2012-2021

What is already known about this topic?

Vitamin A deficiency (VAD) is a leading global nutritional concern, ranking among the top four major nutritional deficiencies worldwide. The prevalence of VAD is unevenly distributed across various regions, both within China and globally.

What is added by this report?

The report adds valuable insights into the vitamin A nutritional status of rural students aged 6-17 years who participated in the Nutrition Improvement Programme for Rural Compulsory Education Students (NIPRCES). Over the decade from 2012 to 2021, there was a modest improvement in vitamin A status. The prevalence of VAD and sub-clinical VAD (SVAD) declined as the students aged. Throughout the majority of the survey years, the incidence of VAD was higher among males and western regions compared to females and central regions, respectively.

What are the implications for public health practice?

A comprehensive approach, incorporating dietary diversification, nutrition education, and food fortification, should be implemented to prevent VAD and SVAD especially in males, younger children and children in western areas.

Vitamin A deficiency among pregnant women in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Vitamin A deficiency (VAD) during pregnancy is a public health challenge in low-income countries. There are inconsistent findings that can affect policy in planning appropriate intervention. This systematic review and meta-analysis were conducted to summarize the evidence in order to identify existing gaps and propose strategies to reduce VAD during pregnancy in Ethiopia.

METHODS

This study included published and unpublished observational studies searched from different databases (PubMed, CINHAL [EBSCO], Embase, Google Scholar, Directory of Open Access Journals, Web of Sciences, MEDLINE, Cochrane Library, Scopus, Google Search and MedNar). Statistical analysis was conducted using Stata version 14 software. Heterogeneity and publication bias were assessed. Forest plots were used to present the pooled prevalence using the random effects model.

RESULTS

A total of 37 618 pregnant women from 15 studies were included. The overall pooled prevalence of VAD was 29% (95% confidence interval 21 to 36) with I2=99.67% and p<0.001. Socio-economic and sociodemographic factors were identified as affecting vitamin A deficiencies among pregnant women.

CONCLUSIONS

Nearly one-third of pregnant women in Ethiopia had VAD. Strengthening intervention modalities that aimed to increase the uptake of vitamin A-rich foods can avert VAD among pregnant women in Ethiopia.

Bioaccumulated provitamin A in black soldier fly larvae is bioavailable and capable of improving vitamin A status of gerbils

The aim was to study whether provitamin A (proVA), which can bioaccumulate in black soldier fly larvae (BSFL), is bioavailable and can restore VA status in mammals. A model for studying the metabolism of this vitamin, the gerbil, was either fed a standard diet (C+ group), a diet without VA (C-), a diet in which VA was provided by β-carotene (β-C) from sweet potatoes (SP), or a diet in which VA was provided by β-C from BSFL that had been fed sweet potatoes (BSFL). The animals were killed at the end of the supplementation period and β-C, retinol and retinyl esters were measured in plasma and liver. As expected β-C was not detected in plasma and liver of the C+ and C- groups. β-C concentrations were lower (p < 0.05) in plasma and liver of the BSFL group as compared to the SP group. Liver retinol and retinyl ester concentrations were lower in the C- group than in all the other groups (p < 0.05). These concentrations were not significantly different in the C+ and SP groups while they were lower in the BSFL group (p < 0.05 for retinyl oleate and retinyl linoleate). In total, the liver stock of retinol equivalent was almost twice lower in the BSFL group than in the SP group. Thus, β-C present in the BSFL matrix is bioavailable and capable of improving VA status, but this matrix decreases its effectiveness by a factor of around two compared to the sweet potato matrix.

TFOS Lifestyle: Impact of nutrition on the ocular surface

Nutrients, required by human bodies to perform life-sustaining functions, are obtained from the diet. They are broadly classified into macronutrients (carbohydrates, lipids, and proteins), micronutrients (vitamins and minerals) and water. All nutrients serve as a source of energy, provide structural support to the body and/or regulate the chemical processes of the body. Food and drinks also consist of non-nutrients that may be beneficial (e.g., antioxidants) or harmful (e.g., dyes or preservatives added to processed foods) to the body and the ocular surface. There is also a complex interplay between systemic disorders and an individual's nutritional status. Changes in the gut microbiome may lead to alterations at the ocular surface. Poor nutrition may exacerbate select systemic conditions. Similarly, certain systemic conditions may affect the uptake, processing and distribution of nutrients by the body. These disorders may lead to deficiencies in micro- and macro-nutrients that are important in maintaining ocular surface health. Medications used to treat these conditions may also cause ocular surface changes. The prevalence of nutrition-related chronic diseases is climbing worldwide. This report sought to review the evidence supporting the impact of nutrition on the ocular surface, either directly or as a consequence of the chronic diseases that result. To address a key question, a systematic review investigated the effects of intentional food restriction on ocular surface health; of the 25 included studies, most investigated Ramadan fasting (56%), followed by bariatric surgery (16%), anorexia nervosa (16%), but none were judged to be of high quality, with no randomized-controlled trials.

Vitamin-A enriched yogurt through fortification of pumpkin (Cucurbita maxima): A potential alternative for preventing blindness in children

Vitamin-A deficiency associated with night blindness in children is a global health problem that could be prevented or reduced by promoting the intake of β-carotene in food. The fortification of β-carotene in yogurt using pumpkin flesh (PF) could be a very cost-effective public health intervention. The current study aimed to analyze the proximate, functional, microbial, textural, and sensory properties of yogurt fortified with PF to evaluate its suitability as a β-carotene enriched food. The research was conducted with three treatments, control set-type yogurt (CSY) with no PF, 15% PF-fortified set-type yogurt (15PFSY), and 20% PF-fortified set-type yogurts (20PFSY) followed by pumpkin pie spice and ground pumpkin seed to improve consumer acceptability. The fortified yogurt with 20PFSY and 15PFSY contained a higher amount of β-carotene, protein, fiber, and ash, and lower carbohydrate, fat, and energy in compression with CSY, which might attract health-conscious people. In addition, viable bacterial count, firmness, consistency, cohesiveness, and viscosity index were found better in fortified yogurt. Based on reports of sensory panellists, 15PFSY achieved a significantly (p < 0.01) highest overall acceptability than 20PFSY and CSY. These findings suggest that pumpkin-fortified yogurt could be used widely as a nutrient-enriched fermented food. In addition, as a β-carotene (vitamin-A) fortified yogurt, it could be a potential alternative to prevent or reduce blindness in children with minimal cost.

Vitamin A deficiency during the perinatal period induces changes in vitamin A metabolism in the offspring. The regulation of intestinal vitamin A metabolism via ISX occurs only in male rats severely vitamin A-deficient

PURPOSE

1) To test the hypothesis of the existence of a perinatal vitamin A (VA) programming of VA metabolism and to better understand the intestinal regulation of VA metabolism.

METHODS

Offspring from rats reared on a control (C) or a VA-deficient (D) diet from 6 weeks before mating until offspring weaning, i.e., 7 weeks after mating, were themselves reared on a C or D diet for 19 weeks, resulting in the following groups: C-C (parents fed C-offspring fed C), D-C, C-D and D-D. VA concentrations were measured in plasma and liver. β-Carotene bioavailability and its intestinal conversion rate to VA, as well as vitamin D and E bioavailability, were assessed after gavages with these vitamins. Expression of genes involved in VA metabolism and transport was measured in intestine and liver.

RESULTS

C-D and D-D had no detectable retinyl esters in their liver. Retinolemia, hepatic retinol concentrations and postprandial plasma retinol response to β-carotene gavage were higher in D-C than in C-C. Intestinal expression of Isx was abolished in C-D and D-D and this was concomitant with a higher expression of Bco1, Scarb1, Cd36 and Lrat in males receiving a D diet as compared to those receiving a C diet. β-Carotene, vitamin D and E bio-availabilities were lower in offspring receiving a D diet as compared to those receiving a C diet.

CONCLUSION

A VA-deficient diet during the perinatal period modifies the metabolism of this vitamin in the offspring. Isx-mediated regulation of Bco1 and Scarb1 expression exists only in males severely deficient in this vitamin. Severe VA deficiency impairs β-carotene and vitamin D and E bioavailability.

Determinants of good vitamin A consumption in the 12 East Africa Countries using recent Demographic and health survey

BACKGROUND

Vitamin A one of the important micronutrients that it cannot be made in the human body and must be taken from outside the body through the diet. Ensuring that vitamin A is available in any form in sufficient quantities remains a challenge, especially in regions where access to vitamin A-containing foods and healthcare interventions is limited. As a result, vitamin A deficiency (VAD) becomes a common form of micronutrient deficiency. To the best of our knowledge, there is limited evidence on determinants of good Vitamin A consumption in East African countries. Therefore, this study aimed to assess the magnitude and determinants of good vitamin A consumption in East African countries.

METHODS

A recent Demographic and Health Survey (DHS) of twelve East African countries were included to determine the magnitude and determinants of good vitamin A consumption. A total of 32,275 study participants were included in this study. A multilevel logistic regression model was used to estimate the association between the likelihood of good vitamin A-rich food consumption. Both community and individual levels were used as independent variables. Adjusted odds ratio and its 95% confidence interval were used to see the strength of the association.

RESULT

The pooled magnitude of good vitamin A consumption was 62.91% with a 95% CI of 62.3 to 63.43. The higher proportion of good vitamin A consumption 80.84% was recorded in Burundi and the smallest good vitamin A consumption 34.12% was recorded in Kenya. From the multilevel logistic regression model, women's age, marital status, maternal education, wealth index, maternal occupation, children's age in a month, media exposure, literacy rate, and parity were significantly associated with good vitamin A consumption in East Africa.

CONCLUSION

The magnitude of good vitamin A consumption in twelve East African countries is low. To increase good vitamin A consumption health education through the mass media and enhancing the economic status of women is recommended. Planners and implementers should give attention and priority to identified determinants to enhance good vitamin A consumption.

Global Burden of Vitamin A Deficiency in 204 Countries and Territories from 1990-2019

Vitamin A deficiency (VAD) is one of the important public health issues worldwide. However, a detailed understanding of the incidence and disability-adjusted life years (DALYs) due to VAD in recent years is lacking. We aimed to estimate the incidence and DALYs of VAD at global, regional, and national levels in terms of sex, age, and socio-demographic index (SDI). Using data from the 2019 Global Burden of Disease (GBD) study, the estimated annual percentage change (EAPC) was measured to assess trends in the age-standardized incidence and DALY rates from 1990 to 2019. The global age-standardized incidence and DALY rates of VAD decreased with an EAPC of −3.11% (95% confidence interval (CI): −3.24% to −2.94%) and −2.18% (95% CI: −2.38% to −1.93%), respectively. The age-standardized incidence and DALY rates decreased least in low-SDI regions, which had the highest age-standardized incidence and DALY rates of all SDI regions. Sub-Saharan Africa, especially central sub-Saharan Africa, had the highest age-standardized incidence and DALY rates in 2019. At the national level, Somalia and Niger had the highest age-standardized incidence and DALY rates. The age-standardized incidence and DALY rates were higher in males than in females. Younger children, especially those aged < 5 years in low-SDI regions, had a higher VAD burden than other age groups. Although the global burden of VAD has decreased, future work should aim to improve the prevention and treatment strategies for VAD, particularly in children aged < 5 years in countries and territories with low SDI values, such as sub-Saharan Africa.

Residential Food Environment, Household Wealth and Maternal Education Association to Preschoolers' Consumption of Plant-Based Vitamin A-Rich Foods: The EAT Addis Survey in Addis Ababa

Vitamin A deficiency is common among preschoolers in low-income settings and a serious public health concern due to its association to increased morbidity and mortality. The limited consumption of vitamin A-rich food is contributing to the problem. Many factors may influence children's diet, including residential food environment, household wealth, and maternal education. However, very few studies in low-income settings have examined the relationship of these factors to children's diet together. This study aimed to assess the importance of residential food availability of three plant-based groups of vitamin A-rich foods, household wealth, and maternal education for preschoolers' consumption of plant-based vitamin A-rich foods in Addis Ababa. A multistage sampling procedure was used to enroll 5467 households with under-five children and 233 residential food environments with 2568 vendors. Data were analyzed using a multilevel binary logistic regression model. Overall, 36% (95% CI: 34.26, 36.95) of the study children reportedly consumed at least one plant-based vitamin A-rich food group in the 24-h dietary recall period. The odds of consuming any plant-based vitamin A-rich food were significantly higher among children whose mothers had a higher education level (AOR: 2.55; 95% CI: 2.01, 3.25), those living in the highest wealth quintile households (AOR: 2.37; 95% CI: 1.92, 2.93), and in residentials where vitamin A-rich fruits were available (AOR: 1.20; 95% CI: 1.02, 1.41). Further research in residential food environment is necessary to understand the purchasing habits, affordability, and desirability of plant-based vitamin A-rich foods to widen strategic options to improve its consumption among preschoolers in low-income and low-education communities.

Does socio-economic inequality exist in micro-nutrients supplementation among children aged 6-59 months in India? Evidence from National Family Health Survey 2005-06 and 2015-16

Background

Globally, about 25% of children suffer from subclinical vitamin A deficiency (VAD), and approximately 300 million children globally had anemia as per 2011 estimates. Micronutrient deficiencies are generally referred to as “hidden hunger” because these deficiencies developed gradually. The present study determines the socio-economic inequalities in vitamin A supplementation (VAS) and Iron supplementation (IS) among children aged 6–59 months in India and to estimate the change in the percent contribution of different socio-economic correlates for such inequality from 2005 to 06 to 2015–16.

Methods

Data from National Family Health Survey (NFHS) 2005–06 and 2015–16 was used for the analysis. Bivariate analysis and logistic regression analysis was used to carve out the results. Moreover, Wagstaff decomposition analysis was used to find the factors which contributed to explain socio-economic status-related inequality among children in India.

Results

It was revealed that the percentage of children who do not receive vitamin A supplementation was reduced from 85.5% to 42.1%, whereas in the case of IS, the percentage reduced from 95.3% to 73.9% from 2005-06 to 2015–16 respectively. The child’s age, mother’s educational status, birth order, breastfeeding status, place of residence and empowered action group (EAG) status of states were the factors that were significantly associated with vitamin A supplementation and iron supplementation among children in India. Moreover, it was found the children who do not receive vitamin A supplementation and iron supplementation got more concentrated among lower socio-economic strata. A major contribution for explaining the gap for socio-economic status (SES) related inequality was explained by mother’s educational status, household wealth status, and empowered action group status of states for both vitamin A supplementation and iron supplementation among children aged 6–59 months in India.

Conclusion

Schemes like the Integrated Child Development Scheme (ICDS) would play a significant role in reducing the socio-economic status-related gap for micro-nutrient supplementation among children in India. Proper implementation of ICDS will be enough for reducing the gap between rich and poor children regarding micro-nutrient supplementation.

Vitamin A deficiency after prolonged intake of an unbalanced diet in a Japanese hemodialysis patient

BACKGROUND

In industrialized countries, vitamin A deficiency (VAD) is extremely rare, except association with bariatric surgeries and hepatobiliary disorders. It is unusual that VAD develops during hemodialysis due to reduced glomerular filtration of vitamin A-binding protein. We reported the case of a 58-year-old Japanese male hemodialysis patient diagnosed with VAD.

CASE PRESENTATION

The patient undergoing hemodialysis for more than 15 years presented with progressive photophobia and night blindness and was ophthalmologically examined. He denied a history of cancer or hepatobiliary disease and reported that he loved eating prepackaged noodle bowls and foods, with prolonged low intake of fruits/vegetables. He had good visual acuity. Fundus images showed numerous white dots in the midperipheral retinae, but no degenerative changes. In baseline full-field electroretinography (ERG), b-wave responses were extremely reduced in rod ERG, a-wave amplitudes in standard-flash/strong-flash ERG were reduced to 20-25% of our controls, a- and b-wave amplitudes in cone ERG were reduced to 40-50% of the controls. Whole-exome sequencing identified no pathogenic variant for any inherited retinal disorder. He was diagnosed with VAD because of reduced serum vitamin A levels and treated with retinol palmitate. Two months after treatment commencement, the serum vitamin A level was within the normal range. Full-field ERG showed that the scotopic ERG responses markedly improved compared with baseline.

CONCLUSIONS

This is the first report of VAD associated with undernutrition in the Japanese hemodialysis population.

Vitamin A supplementation and estimated number of averted child deaths in Ethiopia: 15 years in practice (2005-2019)

Vitamin A supplementation (VAS), started as a short‐term strategy pending dietary improvements, has been implemented in Ethiopia for the last 15 years. We aimed to describe the trends in VAS coverage and estimated the associated reductions in child mortality. VAS coverage data obtained from the District Health Information System and the Demographic and Health Surveys were linked to child mortality data from the United Nations Interagency Group for Child Mortality Estimation (UN IGME). The number of child deaths averted was modelled assuming 12% and 24% reductions in all‐cause mortality. From 2006 to 2011, VAS was delivered through campaigns, and coverage was above 85%. However, from 2011 onwards, VAS delivery was integrated to the routine health system, and the coverage declined to <60% with significant disparities by wealth quintile and rural–urban residence. VAS has saved between 167,563 to 376,030 child lives (2005–2019), but additional lives (>42,000) could have been saved with a universal coverage (95%). Inconsistent supply of vitamin A capsules, but more importantly, low access to health care, and the limited contact opportunities for children after 24 months may have contributed to the declining VAS coverage. Any changes in target or scale‐up should thus consider these spatial and socioeconomic variations. Increasing the coverage of VAS and closing the equity gap in access to nutrition services is critical. However, with alternative programmes like vitamin A fortification being set‐up, the benefits and safety of VAS need to be closely monitored, particularly in areas where there will be overlap.

Prevalence and Associated Factors of Clinical Vitamin A Deficiency Among Pre-School Children 1-5 Years of Age in Rural Kebeles in Farta District, South Gondar Zone, Ethiopia: A Mixed Methods Study

Background

Globally, pre-school children are the most at-risk population groups for vitamin A deficiency (VAD). The 2009 World Health Organization (WHO) report stated that one-third (190 million) of pre-school children worldwide are deficient in vitamin A. Both clinical and subclinical VAD have been a long-standing problem in developing countries. In Ethiopia, VAD was recognized as a public health problem 4–5 decades before. Since then, researches conducted in other parts of the country still showed varied and high prevalence, which is 2–8 times higher than WHO cut-off points. This community-based study was therefore conducted on pre-school children of rural kebeles in Farta district to determine the prevalence of clinical VAD (Bitot’s spot and night blindness) and associated factors.

Methods

A community-based cross-sectional mixed quantitative and qualitative study was conducted. Randomly selected 588 pre-school children participated in the study. The clinical aspect of the study investigated the presence of Bitot’s spots on the children’s eye with the aid of a magnifying loop and torch. Data on the history of night blindness were obtained from mothers/caregivers by using WHO standard questions. The qualitative study data were obtained via a key informant interview with the mothers/caregivers whose child has clinical VAD. Quantitative data were entered using Epi Data statistical software and analysed by using SPSS version 20 statistical software package. A bivariable logistic regression was employed, and variables that showed significant association with clinical VAD (P < 0.2) were entered a multivariable logistic regression model to identify independent predictors of clinical VAD.

Results

The prevalence of Bitot’s spot and night blindness was 0.8% and 1.2%, respectively. Pre-school children who were from highland (AOR: 3.71; 95% CI: 1.01–13.68), a mother having antenatal care (ANC) visit during pregnancy of a child (AOR: 8.63; 95% CI: 2.58–28.79), family monthly income (AOR: 8.63; 95% CI: 2.58–28.79) and handwashing frequency were found to be determinants of VAD (p < 0.05).

Conclusion

Clinical vitamin A deficiency in the study area is of public health concern because the prevalence of Bitot’s and night blindness was above the WHO threshold level. Accordingly, effective preventive measures should be designed to reduce VAD prevalence.