Sherry A. Tanumihardjo

Vitamin A: biomarkers of nutrition for development

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

Factors Influencing the Conversion of Carotenoids to Retinol: Bioavailability to Bioconversion to Bioefficacy

Vitamin A (retinol) is a necessary nutrient for vision, reproduction, growth, and immune function. Pro-vitamin A carotenoids are an important source, especially in developing countries. While preformed vitamin A is readily available from foods, carotenoids are much more difficult to assimilate. A number of factors have been identified that either enhance or hinder the bioavailability of carotenoids. These have been presented in the literature and given the mnemonic SLAMENGHI by some researchers. The following factors are summarized: Species of carotenoid, molecular Linkage, Amount in the meal, Matrix Properties, Effectors, Nutrient status, Genetics, Host specificity, and Interactions between factors. Identifying which of these are key issues for the general public, and promoting the increased consumption of fruits and vegetables with moderate and high levels of pro-vitamin A carotenoids, are important to vitamin A status and overall good health.

Biofortified orange maize is as efficacious as a vitamin A supplement in Zambian children even in the presence of high liver reserves of vitamin A: a community-based, randomized placebo-controlled trial

Background: Biofortification is a strategy to relieve vitamin A (VA) deficiency. Biofortified maize contains enhanced provitamin A concentrations and has been bioefficacious in animal and small human studies. Objective: The study sought to determine changes in total body reserves (TBRs) of vitamin A with consumption of biofortified maize. Design: A randomized, placebo-controlled biofortified maize efficacy trial was conducted in 140 rural Zambian children. The paired 13C-retinol isotope dilution test, a sensitive biomarker for VA status, was used to measure TBRs before and after a 90-d intervention. Treatments were white maize with placebo oil (VA−), orange maize with placebo (orange), and white maize with VA in oil [400 μg retinol activity equivalents (RAEs) in 214 μL daily] (VA+). Results: In total, 133 children completed the trial and were analyzed for TBRs (n = 44 or 45/group). Change in TBR residuals were not normally distributed (P < 0.0001); median changes (95% CI) were as follows: VA−, 13 (−19, 44) μmol; orange, 84 (21, 146) μmol; and VA+, 98 (24, 171) μmol. Nonparametric analysis showed no statistical difference between VA+ and orange (P = 0.34); both were higher than VA− (P = 0.0034). Median (95% CI) calculated liver reserves at baseline were 1.04 (0.97, 1.12) μmol/g liver, with 59% >1 μmol/g, the subtoxicity cutoff; none were <0.1 μmol/g, the deficiency cutoff. The calculated bioconversion factor was 10.4 μg β-carotene equivalents/1 μg retinol by using the middle 3 quintiles of change in TBRs from each group. Serum retinol did not change in response to intervention (P = 0.16) but was reduced with elevated C-reactive protein (P = 0.0029) and α-1-acid glycoprotein (P = 0.0023) at baseline. Conclusions: β-Carotene from maize was efficacious when consumed as a staple food in this population and could avoid the potential for hypervitaminosis A that was observed with the use of preformed VA from supplementation and fortification. Use of more sensitive methods other than serum retinol alone, such as isotope dilution, is required to accurately assess VA status, evaluate interventions, and investigate the interaction of VA status and infection. This trial was registered at clinicaltrials.gov as NCT01814891.

Serum Carotenoid Concentrations in Postmenopausal Women from the United States with and without Osteoporosis

Antioxidant defenses may be compromised in osteoporotic women. Little is known about fruit and vegetable or carotenoid consumption among postmenopausal women. The primary carotenoids in human serum are alpha- and beta-carotene, lycopene, beta-cryptoxanthin, lutein, and zeaxanthin. This study investigated the interrelationships among serum carotenoid concentrations, fruit and vegetable intake, and osteoporosis in postmenopausal women (n = 59, 62.7 +/- 8.8 y). Bone density was assessed by dual energy x-ray absorptiometry and osteoporosis diagnosis was based upon T-scores. Serum samples (n = 53) and three-day diet records (n = 49) were analyzed. Logistic regression analyzed differences between carotenoids after adjusting for serum retinol; supplement usage; milk, yogurt, fruit, and vegetable intake; and body mass index (BMI). Pearson statistics correlated carotenoids with specific fruit or vegetable intake. Serum lycopene concentrations were lower in the osteoporosis group than controls (p = 0.03). Beta-cryptoxanthin intake was higher in the osteoporosis group (p = 0.0046). Total fruit and vegetable intakes were correlated with serum lycopene and beta-cryptoxanthin (p = 0.03, 0.006, respectively). Serum alpha-carotene concentration was associated with carrot intake, and zeaxanthin and beta-cryptoxanthin with lettuce intake. Carotenoids that may have beneficial skeletal effects are lower in women with osteoporosis. Research is needed to identify potential protective mechanisms or utilization of carotenoids during osteoporosis.

Lycopene and β-carotene are bioavailable from lycopene ‘red’ carrots in humans

Objective: The purpose of this study was to determine if lycopene and β-carotene are bioavailable from lycopene red carrots and if lycopene absorption is affected by carrot fiber.Design: Two crossover studies in humans attempted to compare the relative bioavailability of lycopene and β-carotene from tomato paste to a genetically selected lycopene red carrot during chronic feeding. Each study contained three treatment groups. The vehicle of administration was muffins.Intervention and methods: Study 1 (n=9) used white carrots (0 mg lycopene/day), red carrots (5 mg/day), and tomato paste (20 mg/day). Study 2 (n=10) used red carrots (2.6 mg/day), tomato paste (5 mg/day), and tomato paste plus white carrots (5 mg/day). Each intervention lasted 11 days with a 10-day washout period between treatments. Serum lycopene and β-carotene were measured by HPLC.Results: Statistical analysis indicated a significant effect of muffin type in study 1 (P<0.001), and a significant treatment by sequence interaction in study 2 (P=0.04). The response to increasing amounts of lycopene is linear at the levels fed in these studies (r=0.94). The data suggest that maintenance of serum lycopene concentrations at 0.3 μmol/l occurs at about 2 mg/day of lycopene from mixed dietary sources and a serum plateau occurs at ≥20 mg/day.Conclusions: These results show that lycopene and β-carotene are bioavailable from red carrots and lycopene absorption seems to be affected by carrot fiber. Making inferences from both studies, the lycopene in the red carrot is about 44% as bioavailable as that from tomato paste. Red carrots provide an alternative to tomato paste as a good dietary source of lycopene and also provide bioavailable β-carotene.

Biomarkers of Nutrition for Development (BOND)—Vitamin A Review

The Biomarkers of Nutrition for Development (BOND) project is designed to provide evidence-informed advice to anyone with an interest in the role of nutrition in health. The BOND program provides information with regard to selection, use, and interpretation of biomarkers of nutrient exposure, status, function, and effect, which will be especially useful for readers who want to assess nutrient status. To accomplish this objective, expert panels are recruited to evaluate the literature and to draft comprehensive reports on the current state of the art with regard to specific nutrient biology and available biomarkers for assessing nutritional status at the individual and population levels. Phase I of the BOND project includes the evaluation of biomarkers for 6 nutrients: iodine, folate, zinc, iron, vitamin A, and vitamin B-12. This review of vitamin A is the current article in this series. Although the vitamin was discovered >100 y ago, vitamin A status assessment is not trivial. Serum retinol concentrations are under homeostatic control due in part to vitamin A’s use in the body for growth and cellular differentiation and because of its toxic properties at high concentrations. Furthermore, serum retinol concentrations are depressed during infection and inflammation because retinol-binding protein (RBP) is a negative acute-phase reactant, which makes status assessment challenging. Thus, this review describes the clinical and functional indicators related to eye health and biochemical biomarkers of vitamin A status (i.e., serum retinol, RBP, breast-milk retinol, dose-response tests, isotope dilution methodology, and serum retinyl esters). These biomarkers are then related to liver vitamin A concentrations, which are usually considered the gold standard for vitamin A status. With regard to biomarkers, future research questions and gaps in our current understanding as well as limitations of the methods are described.

Stable isotope dilution techniques for assessing vitamin A status and bioefficacy of provitamin A carotenoids in humans

Vitamin A deficiency is a major global public health problem. Among the variety of techniques that are available for assessing human vitamin A status, evaluating the provitamin A nutritional values of foodstuffs and estimating human vitamin A requirements, isotope dilution provides the most accurate estimates. Although the relative expense of isotope dilution restricts its applications, it has an important function as the standard of reference for other techniques. Mathematical modelling plays an indispensable role in the interpretation of isotope dilution data. This review summarises recent applications of stable isotope methodology to determine human vitamin A status, estimate human vitamin A requirements, and calculate the bioconversion and bioefficacy of food carotenoids.

Retinol to Retinol-Binding Protein (RBP) Is Low in Obese Adults due to Elevated apo-RBP

Elevated serum retinol-binding protein (RBP) concentration has been associated with obesity and insulin resistance, but accompanying retinol values have not been reported. Assessment of retinol is required to discriminate between apo-RBP, which may act as an adipokine, and holo-RBP, which transports vitamin A. The relations between serum RBP, retinol, retinyl esters, BMI, and measures of insulin resistance were determined in obese adults. Fasting blood (≥8 h) was collected from obese men and women (n = 76) and blood chemistries were obtained. Retinol and retinyl esters were quantified by HPLC and RBP by ELISA. RBP and retinol were determined in age and sex-matched, nonobese individuals (n = 41) for comparison. Serum apo-RBP was two-fold higher in obese (0.90 ± 0.62 μM) than nonobese subjects (0.44 ± 0.56 μM) (P < 0.001). The retinol to RBP ratio (retinol:RBP) was significantly lower in obese (0.73 ± 0.13) than nonobese subjects (0.90 ± 0.22) (P < 0.001) and RBP was strongly associated with retinol in both groups (r = 0.71 and 0.90, respectively, P < 0.0001). In obese subjects, RBP was associated with insulin (r = 0.26, P < 0.05), homeostatic model assessment of insulin resistance (r = 0.29, P < 0.05), and quantitative insulin sensitivity check index (r = −0.27, P < 0.05). RBP was associated with BMI only when obese and nonobese subjects were combined (r = 0.25, P < 0.01). Elevated serum RBP, derived in part from apo-RBP, was more strongly associated with retinol than with BMI or measures of insulin resistance in obese adults. Investigations into the role of RBP in obesity and insulin resistance should include retinol to facilitate the measurement of apo-RBP and retinol:RBP. When evaluating the therapeutic potential of lowering serum RBP, consideration

Undernutrition, the Acute Phase Response to Infection, and Its Effects on Micronutrient Status Indicators

Infection and undernutrition are prevalent in developing countries and demonstrate a synergistic relation. Undernutrition increases infection-related morbidity and mortality. The acute phase response (APR) is an innate, systemic inflammatory reaction to a wide array of disruptions in a hosts homeostasis, including infection. Released from immune cells in response to deleterious stimuli, proinflammatory cytokines act on distant tissues to induce behavioral (e.g., anorexia, weakness, and fatigue) and systemic effects of the APR. Cytokines act to increase energy and protein requirements to manifest fever and support hepatic acute phase protein (APP) production. Blood concentrations of glucose and lipid are augmented to provide energy to immune cells in response to cytokines. Additionally, infection decreases intestinal absorption of nutrients and can cause direct loss of micronutrients. Traditional indicators of iron, zinc, and vitamin A status are altered during the APR, leading to inaccurate estimations of deficiency in populations with a high or unknown prevalence of infection. Blood concentrations of APPs can be measured in nutrition interventions to assess the time stage and severity of infection and correct for the APR; however, standardized cutoffs for nutrition applications are needed. Protein-energy malnutrition leads to increased gut permeability to pathogens, abnormal immune cell populations, and impaired APP response. Micronutrient deficiencies cause specific immune impairments that affect both innate and adaptive responses. This review describes the antagonistic interaction between the APR and nutritional status and emphasizes the need for integrated interventions to address undernutrition and to reduce disease burden in developing countries.

Sweet Potato β-Carotene Bioefficacy Is Enhanced by Dietary Fat and Not Reduced by Soluble Fiber Intake in Mongolian Gerbils

Orange-fleshed sweet potato (OFSP) is an important source of beta-carotene (betaC). Provitamin A bioefficacy from plant foods is influenced by dietary fat and fiber. We fed 3% OFSP powder diets with varying amounts of fat and soluble fiber to vitamin A (VA)-depleted Mongolian gerbils (n = 85) for 3 wk (8 groups, n = 10/group; control, n = 9) following a baseline kill (n = 6). OFSP diets differing in fat (3, 6, and 12%) contained 0.24% soluble fiber. Two additional 3% OFSP diets contained 6% fat and 3 or 9% white-fleshed sweet potato (WFSP) powder with soluble fiber contents of 0.42 and 0.80%, respectively. Control, VA-, and betaC-supplemented groups were included. Simulated digestion experiments compared the bioaccessibility of betaC from boiled vs. oil stir-fried OFSP. All OFSP diets maintained VA status and 12% fat and WFSP-added diets improved VA status above baseline (P < 0.05). Bioefficacy, as bioconversion factors, in gerbils fed 12% fat (3.5 +/- 1.4 microg betaC:1 microg VA) was improved over the 3% fat and betaC groups (6.5 +/- 3.7 and 6.7 +/- 3.7 microg betaC:1 microg VA, respectively) (P < 0.05) but did not differ from WFSP-added groups or the 6% fat group with no WFSP. Stir-frying doubled the efficiency of betaC incorporation into micelles during small intestinal digestion in support of the stimulatory effect of dietary fat on bioefficacy in vivo. Soluble fiber intake derived from WFSP did not influence bioefficacy. Replacing WFSP with OFSP will affect VA status if adopted by target groups.