S de Pee

Effectiveness of weekly vitamin A (10 000 IU) and iron (60 mg) supplementation for adolescent boys and girls through schools in rural and urban East Java, Indonesia

Objective: High prevalences of vitamin A deficiency and anaemia among adolescents warrant interventions. This study evaluated the effectiveness of school-based supplementation to reduce anaemia and improve vitamin A status.Design: School-based, grade-randomized, intervention.Subjects and setting: In all, 1757 girls and 1859 boys, aged 12–15 y, in 24 Junior High Schools.Interventions: Weekly supplementation for 14 weeks with 60 mg iron and 250 μg folate (Fe group; n=978), 10 000 IU vitamin A (VA group; n=970) or both (VAFe group; n=1042) to subjects in 15 schools, compared to subjects in nine other schools not receiving supplements (control; n=626).Results: The baseline anaemia prevalence (Hb <120 g/l) in girls was 20% (prepubertal) and 26% (pubertal), and in boys 24% (pre-pubertal) and 11% (pubertal). Serum retinol concentrations were low (<1.05 μmol/l) in 41% of boys and 45% of girls. The interventions did not increase haemoglobin concentrations. Serum retinol concentration of boys, but not girls, in the VA group increased (0.33 vs 0.07 μmol/l in controls; P<0.01). The risk factors for low serum retinol concentration were lower baseline serum retinol concentration (OR 0.02–0.03) with, for girls, nightblindness at baseline (OR 5.88), and for boys, not receiving vitamin A (OR control: 1.00; VA: 0.37; Fe: 0.77; VAFe: 0.34) and maternal illiteracy (OR mother never attended school 1.00, mother received any formal education 0.17–0.33).Conclusions: Supplementation with vitamin A increased serum retinol concentration of boys. Iron supplementation did not change Hb. This appeared to be due to poor compliance, and partly related to side effects.Sponsorship: This study was funded by USAID through the OMNI Project.

The potential of various foods to serve as a carrier for micronutrient fortification, data from remote areas in Indonesia

Objective: To estimate the potential of various industrially produced foods, to serve as a carrier for micronutrient fortification based on the frequency of their consumption in different socio-economic strata; to determine the role of fortified instant noodles as a source of micronutrients; to assess the contribution of plant foods, animal foods and fortified foods to vitamin A intake.Setting: A survey was conducted in rural South Sulawesi and urban South Kalimantan between November 1996 and January 1997.Subjects: Households (1500 in South Sulawesi; 2112 in South Kalimantan) were selected randomly by multi-stage cluster sampling. From each household, data were collected from the mother and her youngest child (0–5 y).Data collection: Mothers were interviewed on various topics, including socio-economic status, food consumption, receipt of high-dose vitamin A capsules, health and nutritional status.Results: Monosodium glutamate and salt were consumed daily in almost all households in both areas, and consumption was not associated with socio-economic status. Instant noodles were consumed in nearly all households in both areas, but consumption of fortified noodles was related to socio-economic status; it was highest among households of government employees and private investors, and lowest among farmers and share-croppers. Vegetables were the most important source of vitamin A in rural South Sulawesi, while foods of animal origin were the most important source in urban South Kalimantan.Conclusions: The results support double or triple fortification of salt and/or monosodium glutamate with iodine, vitamin A and/or iron. Efforts to overcome associated technical and logistical difficulties are urgently needed.Sponsorship: Opportunities for Micronutrient Interventions (OMNI); United States Agency for International Development (USAID). European Journal of Clinical Nutrition (2000) 54, 822–827

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 ≤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; ≥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).

Who has a high vitamin A intake from plant foods, but a low serum retinol concentration? Data from women in Indonesia.

Objective: To examine whether the relationship between vitamin A intake, from plant and animal foods, and vitamin A status is the same throughout a population.Design: Analysis of cross-sectional data on vitamin A intake, vitamin A status, physiological condition and socio-economic status.Setting: Central Java, Indonesia.Subjects: Women with a child ≤24 months old (n=600).Results: Mean serum retinol concentration of women with animal vitamin A intake below or above the median (50 RE/d) was 1.28 and 1.38 μmol/L, respectively (P<0.05). For those with intake above the median the distribution curve for serum retinol concentration was shifted towards the right, to higher concentrations. Serum retinol concentration of women with plant vitamin A intake below or above the median (279 RE/d) was 1.30 and 1.36 μmol/L, respectively (P<0.05). Again, the distribution curve for serum retinol was shifted towards higher concentrations for women with an intake above the median, except for the subgroup of 25% with the lowest serum retinol concentration (<1.10 μmol/L). These women did not seem to benefit from their relatively high vegetable intake. They also had the lowest socio-economic status.Conclusions: The subgroup that was most in need of vitamin A could not obtain it from plant foods. It may well be that, because of their lower socio-economic status, their hygiene conditions were worse and therefore host-related factors that affect carotene bioavailability, such as parasitic infestation, were less favourable in this group. They depended on supplements and, if affordable, on animal foods, fruits and/or fortified products.Sponsorship: This study was carried out as part of the contract between UNICEF Indonesia and Helen Keller International Indonesia for the implementation and evaluation of the project: Social marketing of vitamin A rich foods in Central Java, which is funded by a grant of the Micronutrient Initiative Canada to UNICEF Indonesia.

Conclusions about differences in linear growth between Bangladeshi boys and girls depend on the growth reference used.

Objective: To examine sex differences in height-for-age z-scores and the percentage stunting among Bangladeshi children estimated using three growth references.Design, setting and subjects: Data collected between 1990 and 1999 by Helen Keller Internationals nutritional surveillance system in rural Bangladesh were analyzed for 504 358 children aged 6–59 months. Height-for-age z-scores were estimated using the 1977 NCHS, 2000 CDC and 1990 British growth references.Results: The shape of the growth curves for Bangladeshi boys and girls, and their positions relative to one another, depend on which of the three growth references is used. At 6 months of age the British reference showed no sex difference whereas the NCHS and CDC showed girls to have higher average z-scores than boys by 0.14 and 0.28 s.d., respectively. While all references showed a faster deterioration of girls’ z-scores from 6 to 24 months, the magnitude and direction of the sex differences, and how they changed with age, were different. There was greater disagreement about girls’ z-scores than boys. Discontinuities at 24 months in the NCHS and CDC produced jagged curves whereas the British curves were smooth.Conclusions: The assessment of sex differences in linear growth depends on the growth reference used. Reasons for the different results need to be determined and may aid the final development of the new WHO international growth reference and the guidelines for its use. The findings suggest that anthropometry as a tool to explore the effects of societal gender inequality must be used with caution.

Malnutrition and morbidity among children not reached by the national vitamin A capsule programme in urban slum areas of Indonesia

OBJECTIVE To determine whether vitamin A capsule programmes fail to reach children who are at higher risk of malnutrition and morbidity. Although it has been suggested that there are health disparities between children who are reached or not reached by these programmes, little quantitative work has been undertaken to characterize this relationship. STUDY DESIGN As part of a national surveillance system, nutritional status and other factors were compared in 138,956 children, aged 12-59 months, who had and had not received vitamin A supplementation in urban slum areas in Indonesia. RESULTS In total, 63.1% of children had received a vitamin A capsule within the previous 6 months. Among children who had and had not received vitamin A supplementation, respectively, the proportion with weight-for-age and height-for-age Z scores <-3 were 7.8% vs 8.6% (P<0.0001) and 9.4% vs 10.7% (P<0.0001), and with a history of diarrhoea in the previous week was 8.1% vs 10.7% (P<0.0001). In families where a child had or had not received vitamin A supplementation, the proportion with a history of infant death <12 months was 5.2% vs 7.2% (P<0.0001) and child death <5 years was 6.7% vs 9.2%, respectively (P<0.0001). Children who had not received vitamin A supplementation were also significantly more likely to be anaemic and have diarrhoea or fever on the survey day compared with children who had received supplementation. CONCLUSIONS In the urban slums of Indonesia, children who do not receive vitamin A supplementation tend to be slightly more malnourished and ill, and are more likely to come from families with higher child mortality than children who receive vitamin A. Higher rates of child mortality in non-participating households suggest that reaching preschoolers could yield a disproportionate survival benefit. Importantly, children who are not reached by the vitamin A programme are also unlikely to be reached by vaccination and other services, emphasizing the need to identify and extend efforts to reach non-participants.