VITAMIN A AND THE CONSEQUENCES

OF VITAMIN A DEFICIENCY (VAD)

Natalie Masis
November 23, 2010
NS 5000

BACKGROUND INFORMATION

What is Vitamin A?
Obtained from the diet
Animal
Preformed vitamin A
Retinol

Plant
Provitamin A carotenoids

Dietary sources

Major forms of vitamin A

(2)

Why flamingos are pink.

Beta-carotene
Found in fish, brine
shrimp, and wasps that
flamingos eat (bluealgae contains
carotenoid!)
Turns them pink!
The baby is not pink
because it cant eat
larger fish

(http://healthguide.howstuffworks.com/vitamin-a-benefit-picture-a.htm)

Importance of Vitamin A

Eye health
Bone growth
Reproduction
Cell division
Cell differentiation

(2)

Vitamin A and eye health

11-cis retinaldehyde (photoisomerization) to
all-trans retinaldehyde
Important for vision cycle
Inadequate intake of vitamin A leads to
impaired vision or blindness

(5)

Consequences

Vitamin A deficiency (VAD)

Night blindness
Bitots spots
Xerophthalmia

(3)

(Lookingfordiagnosis.com, 2010)

Vitamin A Deficiency
WHO states that it is the most important
cause of preventable childhood blindness
Morbidity
Mortality

Prevalent in children and pregnant women

Low and middle income countries

Improved vitamin A nutrition

Over a million childhood deaths per year could be
prevented
(8)

Vitamin A Deficiency

(Fao.org, 2010)

South-East Asian Region

Methods of intervention
Dietary diversification and modification
Fortification
Supplementation
Preschool-aged children

(4)

Vitamin A and child health

127 million preschool aged children under 5
are vitamin A deficient
4.4 million have xerophthalmia

Critical factor in child health/survival

Ability to fight infections
Corneal xerophthalmia
Anemia
Poor growth
Mortality
(4)

The prevalence of vitamin A deficiency in preschool aged children (6-71 months of age) in
urban and rural districts of Central Java,
Indonesia

Purpose
Determine the prevalence of vitamin A deficiency (VAD) in
preschool-aged children in both urban and rural districts in
Central Java, Indonesia
Determine the differences in dietary intake of vitamin A
sources in each setting
Determine available vitamin A sources
More information to determine where public health
interventions should provide focus

(12)

Hypothesis
Preschool-aged children attending school
from more urban settings will have a lower
prevalence of VAD compared to those
children from rural settings
Accessibility to more fruits and vegetables at local
markets
Nutrition education in school settings, higher
education in parents
Risk factors

Study design
Cross-sectional cohort study
Urban and rural areas in Central Java,
Indonesia in the month of June 2011
Population of Central Java may be above 35
million
Collaborate with the projects of Helen Keller
International

Study design
Children from ages of 6-71 months recruited
from schools
Caregivers will be given baseline
questionnaire
Subject testing and evaluation of VAD status
Interview
Testing

Subject demographic
The Semarang district in Central Java,
Indonesia with population of 1.5 million
inhabitants
Will cover urban and rural sections of
Semarang
Preschool-aged children involved will be of
ages 6-71 months
Minimum sample size of 1522 subjects per
community

Explanation of subject number

Calculated using an anticipated prevalence of
night blindness of 1.0%
Minimum sample size of 1522 subjects for
defining clinical VAD of public health
importance in a community of children under
6 years of age for each setting
To account for high attrition rate, sample size will
be increased by 20%

P<0.05 will be considered significant

(3)

Recruitment strategy
Children will be recruited from randomly
selected schools in both urban and rural subdistricts in Semarang district, Central Java,
Indonesia
Childrens caregivers will be notified and be
asked for approval for childs participation in
the study
Informed consent

Inclusion/Exclusion criteria
All eligible subjects, in participating schools,
from age 6 to 71 months will be included
Subjects unwilling to participate in testing for
specific indicators of VAD will be excluded

Methods: screening/testing
Interviews and testing will take place at the
school
Ophthalmologist, optometrist, trained social
workers and data entry clerks
Baseline questionnaire
Translated in official native language of Bahasa
Indonesia

Methods: testing
First portion of testing: Baseline questionnaire
Made using guidelines for nutrition baseline surveys
Demographics
Socio-economic condition
Risk factors
Questions about accessibility and availability of
potential sources of vitamin A
Street vendors/grocery stores

Methods: testing
Questions included in baseline questionnaire:
1. What type of community do you live in?
2. How many supermarkets/vendors are near your
home?
3. Is there a hospital near your home?

Methods: testing
Semi-quantitative food frequency questionnaire
(FFQ)
Foods consumed preceding 12 months
To approximate frequency of certain potential retinol
and carotenoid-containing food items
Usual pattern of food consumption (UPF) score will
be calculated for foods with low, moderate, and high
vitamin A scores
Low: <50 RE
Moderate: 50-250 RE
High: >250RE

Methods: testing
Validity
Focus groups will be used to determine if
questions are culturally acceptable and
understandable for population of Central Java,
Indonesia

Methods: testing
Second portion: interview for determination
of VAD status
Night blindness-related questions
Appropriate local terms

Questions (examples)
1. Does your child have any problem of seeing at
day time?
2. Does your child have any problem of seeing at
night time?
(3)

Methods: measurements
Anthropometric measurements of children
will be taken (height/length/weight)
Ophthalmologist will examine the eyes of
children using a torch and magnifying loupe
Blood by finger pricking
Serum retinol (<0.70mol/l cut off point)
HPLC

Statistical analyses
Data analyzed using the Statistical Package
for Social Studies (SPSS 11.5) software
Weight/length/height will be expressed as zscores and will be incorporated in Epi-Info
software
Epi-Info will also be used to explore the risk
factors evaluated using univariate analysis

Statistical analyses
Multivariate models will be created and will
include the risk factors of VAD with a p<0.05
to be considered significant
Cluster analysis will be used to separate the
findings among the urban and rural settings
for preschool-aged children and determine
prevalence of having VAD
ANOVA
Kruskal-Wallis test

Study timeline
Study will begin in June 2011
Study will last depending on how long it takes
to collected the needed data set for vitamin A
deficiency determination
Minimum prevalence and minimum sample size
for public health importance of VAD
As determined by WHO

Limitations or anticipated
problems
Many caregivers may not give consent for
indicator test
Finger-prick for infant

Inability to determine risk factors for VAD

Recall bias/response bias
Serum retinol
Obtaining adequate sample size
Available funding for testing

THANK YOU!

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