sight and life€¦ · common agenda for micronutrients presentation highlights: vitamin a and the...

SIGHT AND LIFE

INCORPORATING THE XEROPHTHALMIA CLUB BULLETIN

NEWSLETTER 1/2005

Correspondents: Bruno de Benoist, William S. Blaner, George Britton, Omar Dary,Frances R. Davidson, Tracey Goodman, Philip Harvey, Rolf D. W. Klemm, Donald S.McLaren, José O. Mora, Christine Northrop-Clewes, Vinodini Reddy, Delia Rodriguez-Amaya, Ram Kumar Shrestha, Noel W. Solomons, Florentino S. Solon, Alfred Sommer,Andrew Tomkins, Frits van der Haar, G. Venkataswamy, Emorn Wasantwisut, KeithP. West Jr. Editor: Martin Frigg

Girls in Caserio Aviacion, Tarapoto, Peru; see article on page 19.

DBS – a simple and field-friendly method for vitamin A status; βββββ-carotene metabolismby AMS; Vitamin A and the common agenda for micronutrients (XXII IVACG meeting);Study Tours to Potato Center, Project HOPE and Buen Inicio; Poster presentations atthe XXII IVACG meeting 15–17 November 2004, Lima, Peru; INACG, IZiNCG sympo-sium; Reports and information from Cameroon, China, Democratic Republic of Congo,Indonesia, Nepal, Pakistan; SIGHT AND LIFE supported students.

SIGHT AND LIFE NEWSLETTER 1/20052

DSM is active worldwide in the fields of life sci-ence and nutritional products, performance ma-terials and industrial chemicals. The companycreates innovative products and services thathelp improve the quality of life. DSM’s productsare found in a wide range of end markets andapplications such as human and animal nutritionand health, cosmetics, pharmaceuticals, automo-tive and transport, coatings, housing and electrics& electronics (E&E). The group has annual sales

(pro forma including the recent acquisition - re-named DSM Nutritional Products) of approxi-mately EUR 8 billion and employs in the regionof 25,000 people around the world. DSM ranksamong the global leaders in many of its fields.DSM is headquartered in the Netherlands, withlocations in Europe, Asia and the Americas. Moreinformation about DSM can be found atwww.dsm.com

DSM Nutritional Products, the successor toRoche’s Vitamins and Fine Chemicals Division,is the world’s leading supplier of vitamins,carotenoids and other fine chemicals to the feed,food, pharmaceutical and cosmetic industries.The company will maintain its tradition as a pio-neer in the discovery of new products, new for-mulations and attractive applications for all sec-

tors of industry. For further company informationplease visit www.dsmnutritionalproducts.com

DSM Nutritional Products

ContentsLetter from the President 3

Use of dried blood spots (DBS) – A simple andfield-friendly method of collecting blood samplesfor the measurement of vitamin A status 4

β-carotene metabolism measured byaccelerator mass spectrometry 6

Presentation highlights: Vitamin A and thecommon agenda for micronutrients

Presentation highlights: Vitamin A and thecommon agenda for micronutrientsXXII IVACG meeting held15–17 November 2004, in Lima, Peru 9

Study Tour to the International Potato Center(CIP), Lima, Peru, 20 November 2004 18

Study tour of Project HOPE in Peru inconjunction with the XXII IVACG meeting 19

UNICEF supported project Buen Inicio(Good Initiatives) on early child growthand development 21

Poster presentations at the XXII IVACG meeting,15–17 November 2004, in Lima, Peru 27

2004 INACG symposium and IZiNCG symposium,18–19 November 2004, Lima, Peru 37

Prevention and control of vitamin Adeficiency in Cameroon 39

Report on activities linked to the battleagainst vitamin A deficiency 41

Measles, malnutrition and malabsorption(3-Ms) management in children 43

Report on the utilization of vitamin Acapsules 45

Training trainers for early detection ofxerophthalmia in West Java Province 47

Promoting eye health through educationalprograms in the community 48

Community Eye Health at the LondonSchool of Hygiene and Tropical Medicine:SIGHT AND LIFE supported students 51

A digest of recent literature 53

New MOST publications 63

Letter to the editor 65

SIGHT AND LIFE Annual Report 2004 66

SIGHT AND LIFE, back cover

NEWSLETTER 1/2005 SIGHT AND LIFE3

It gives me great pleasure to ad-dress the readers of the SIGHTAND LIFE Newsletter once moreon behalf of DSM. SIGHT ANDLIFE has been integrated intoDSM for over a year now, and itsreadership comprises many DSMemployees as well as scientists,health professionals, field work-ers, academics and numerousothers with an interest in the rela-tionship between nutrition andhealth. We are all proud to havea humanitarian initiative of thiscaliber within DSM, where DSMNutritional Products is its naturalhome.

The process of assuming respon-sibility for SIGHT AND LIFE is partof a wider undertaking to integrateDSM Nutritional Products fully intothe family of DSM. This of coursetakes a certain time. There can beno doubt, however, as to DSM’scommitment to this significant ini-tiative. Indeed, recent eventshave presented us with a (tragic)opportunity to demonstrate ouractive support for SIGHT ANDLIFE.

Through SIGHT AND LIFE, DSMNutritional Products will be help-

ing many organizations to providesupport to the survivors of the Tsu-nami Disaster in Southeast Asia.Special grants have been do-nated to the World Food Programas well as many other organiza-tions which have approachedSIGHT AND LIFE for help at thelocal level. These include HelenKeller International, MicronutrientInitiative, Vitamin Angel Allianceas well as local NGOs in AndhraPradesh and Tamil Nadu in India.SIGHT AND LIFE will continue, asusual, to provide assistance inthose areas that represent ourcore competencies. Our intentionis to help secure the nutritionalsituation of children and other vic-tims of the disaster. We are inte-grating our own input into the ef-forts of other organizations withthe aim of supporting all who aremaking such valuable contribu-tions in areas affected by this ter-rible catastrophe.

SIGHT AND LIFE will continue toact as a mediator, providing theeducational materials, expertiseand insights to support interven-tion at a local level. DSM wishesto build on this concept in the fu-ture. Whereas in the past SIGHTAND LIFE provided educationalmaterials on vitamin A along withmore general health information,DSM intends to expand this ap-proach to include information onall vitamins as well as on otherrelevant health issues.

Naturally, DSM is a commercialenterprise that must operate prof-itably. Our corporate policy isbased, however, on maintaininga sustainable balance betweenPeople, Planet and Profits, as ourannual ‘Triple P’ report demon-strates. As the world’s leadingnutritional products company,DSM Nutritional Products has adeep concern for the nutritional

situation of millions of people inthe world, and we take the obli-gations of our corporate citizen-ship very seriously.

To focus on merely one vitamin,however, would be to limit ourcapacity for exerting a positiveinfluence. Although vitamin A is akey health factor and provides anexcellent example when commu-nicating generally applicablehealth messages, we cannot limitour activity to this one vitamin.DSM has a significant body of in-stitutionalized knowledge con-cerning the entire range of vita-mins and their nutritional function.We wish to exploit this knowledgein order to improve the nutritionalsituation of millions of peopleworldwide. We also know that allaspects of nutrition, and notmerely vitamin intake, are impor-tant for maintaining good health.It is therefore our intention to sup-port organizations dedicated tothe general improvement of thenutritional intake of peoplethroughout the world.

I look forward to a prosperous andpositive year for SIGHT AND LIFEin its new constellation.

Letter from the President

Feike SijbesmaCEO of DSM Nutritional Productsand member of theManaging Board of DSM


Introduction

In determining vitamin A status themeasurement of retinol in bloodis still the most accepted methodof assessment. Since the retinollevel in blood is homeostaticallycontrolled and the liver stores haveto be depleted to see a decrease,serum retinol is not a perfect indi-cator for vitamin A status. Addition-ally, infection decreases the con-centration of vitamin A in blood.Currently the most frequently usedprocedure for measuring vitaminA status is to take venous bloodsamples, to centrifuge them and,after freezing and transporting tothe lab, to measure the retinol con-tent in serum by HPLC. It is obvi-ous that this is a tedious and ex-pensive procedure. The aim of thisSIGHT AND LIFE project wastherefore to improve and evaluatethe use of dried blood spots (DBS)for measuring the vitamin A status.The collection of DBS in the fieldis very simple. Only a small dropof blood from a finger prick has tobe applied to filter paper and canbe sent after drying by normal mailto the lab. Since retinol is protectedby the retinol binding protein (RBP)from oxidation we have alreadyshown (Erhardt 2002) that it is pos-sible to measure the retinol con-tent in this DBS by HPLC. A lessexpensive and more efficient wayis to measure RBP. This correlatesvery well with the retinol content,can be measured by an inexpen-sive sandwich ELISA techniqueand can also be easily combinedwith the measurement of C-reac-tive protein (CRP) and alpha-1glycoprotein (AGP) as indicatorsfor acute and chronic infections. It

also allows the correction of theretinol or RBP values in blood(Thurnham 2003).

Methods

Collection of DBS in the field:For the collection of DBS thestandard finger prick procedurewhich every diabetic patient usescan be applied. Since the ELISAtechnique is very sensitive, onlya small DBS, corresponding toapprox. 15–20 µl whole blood, isnecessary to perform all themeasurements. A drop of blood isput on the filter paper, dried over-night and then put for storage ina plastic bag. Under humid con-ditions a desiccant should beadded to fully dry the blood on thefilter paper. In dry form the DBSare very stable at normal tem-peratures for several months.Only at high humidity and tem-peratures above 25 oC does deg-radation seem to occur.

ELISA technique for measuringRBP, CRP and AGP in DBS:Figures 1and 2 show the proce-

dure for this technique. For extrac-tion of the proteins from the DBS,a 3-mm hole punch is taken fromthe DBS card and extracted over-night in the fridge in phosphatebuffered saline. This extract isthen put on the analysis plate ofa standard sandwich ELISA tech-nique. It uses a primary antibody(DAKO, Denmark) to capture theproteins, and a secondary anti-body, which is coupled to a per-oxidase, to perform a color reac-tion which is proportional to theamount of protein in the sample.Only different dilutions of the ex-tract and different antibodies areused for the three proteins. Thedetails of this procedure can befound in an article which was pub-lished recently in the Journal ofNutrition (Erhardt 2004). The onlyexpensive part of this techniqueare the antibodies. A pair of anti-bodies cost around USD 600 butthey are sufficient for more than10,000 measurements. If a largenumber of samples is measuredthe average cost of chemicals isreduced to 50 cents per samplefor all three measurements. This

Use of dried blood spots (DBS) – A simple andfield-friendly method of collecting blood samplesfor the measurement of vitamin A statusJuergen Erhardt, PhD, SEAMEO-TROPMED, Regional Center for Community Nutrition,University of Indonesia, P.O. Box 3852, Jakarta 10038, Indonesia, [email protected]

Figure1. Taking of blood by finger prick and collection of DBS in a storagebox with reusable dessiccant.


does not include the cost of run-ning a laboratory and salaries, butthe cost of chemicals is usuallythe most critical factor in decidingwhether to perform a biochemicalassessment or not. With a simplemultichannel pipette the measure-ment can also be done very effi-ciently. With some training, 80samples per day can be easilymeasured for all three param-eters.

Evaluation study in 27Indonesian children:

To evaluate this method, bloodsamples from 27 Indonesian chil-dren were analyzed, the plasmafraction of the blood and DBSbeing prepared in parallel. The

measurement was done 1 weekafter collection and 4 weeks later.

Results

Immunological measurementsare usually not as accurate as aHPLC measurement but the CVof this ELISA technique is below10% which is sufficient for a reli-able measurement. The figures 3,4, 5 for RBP, CRP and AGP showthe correlation plots of this evalu-ation study. This kind of evalua-tion is not the optimal way ofchecking a new method but itdoes show very easily how thenew method compares with astandard method. The results ofthe DBS and plasma measure-ments are very similar, with re-

gression coefficients around 0.9.This is a consistent observationconfirming results from previousstudies.

Conclusion

This study shows that it is possi-ble to measure vitamin A statusreliably via RBP in DBS, which iscurrently probably the most field-friendly method for getting bloodsamples. In the lab the measure-ment can also be done inexpen-sively and efficiently, and thesame method can be used tomeasure CRP and AGP as indi-cators for the infectious status.This allows for the correction ofthe RBP values in blood. Becauseof its slightly lower accuracy the

Figure 2. Procedure for DBS collection and measurement: Taking a 3 mm hole punch. Extraction of the DBS hole-punches in a 96 deep well plate. Transfer of extract with a multichannel pipette. Final plate for measurement.

Figures 3, 4, 5. Correlation plots comparing the new method with the standard method.


Introduction

We use accelerator massspectrometry (AMS) to traceminute amounts of radioactive β-carotene as it is absorbed andmetabolized in the human body(1–4). AMS is too expensive andthe apparatus too rare to be usedfor routine analysis, but it can pro-vide powerful insights into theabsorption and metabolism of vi-tamin A and β-carotene, the con-version of carotenoids to vitaminA, and the factors that influencethe extent of this conversion. Wecan then use the results from AMSstudies to plan and analyze stud-ies using less costly and moreconventional techniques.

AMS was developed in the 1970sfor radiocarbon dating and tomeasure trace environmentalcontaminants (5, 6). AMS sepa-rates and measures individual at-oms of 12C, 13C and 14C directly,unlike the older and more familiarmethod of liquid scintillationcounting (LSC) which measuresthe energy emitted from 14C dur-ing its decay (7, 8). With a half-life of 5760 years, only a few 14Catoms decay during reasonablecounting times which severely lim-

its the sensitivity of 14C LSC. AMSis millions of times more sensitivethan liquid scintillation countingbecause it measures every atomof 14C in the sample. This meansthat we can administer tiny dos-ages (100 to 200 nCuries; 100 to500 µg) of 14C-labelled carot-enoids and expose our volunteersto radiation levels that are lessthan the amount of radiation theywould receive in one trans-Atlan-tic flight.

AMS and other radioisotope-based methods share an impor-tant advantage over natural orstable isotope-based methods:radioisotope activity can becounted without separating, puri-

fying or identifying what is beingcounted. This means that we cancollect and measure all of themetabolites of β-carotene, knownand unknown. We can separate,identify and measure the concen-trations of previously unknownmetabolites. A second advantageis that AMS is more sensitive thanmost natural or stable isotope-based methods. This allows us touse very small dosages (0.5 to 1nmol β-carotene) that act as truemetabolic tracers. Detection lim-its for β-carotene and its metab-olites are less than 1 fmol 14C-metabolite/ml, about 1000 timesmore sensitive than commonHPLC methods, which allows usto collect smaller samples (30 µl

βββββ-carotene metabolism measured byaccelerator mass spectrometryBetty Jane Burri1,2 and Andrew J Clifford21Western Human Nutrition Research Center, USDA; 2ARS, PWA and Nutrition Department, University ofCalifornia, Davis, CA 95616, USA

Figure 1. Accelerator mass spectrometry diagram (8).

DBS method should not be themethod of choice if the collectionand transport of serum is easilypossible. If collection and trans-port are a problem then this newtechnique can make the assess-ment of the vitamin A status mucheasier.

ReferencesErhardt JG, Craft NE, Heinrich F,Biesalski HK (2002) Rapid and simplemeasurement of retinol in human driedwhole blood spots. J Nutr 2002;132(2):318–321

Thurnham DI, McCabe GP, Northrop-Clewes CA, Nestel P (2003) Effects ofsubclinical infection on plasma retinolconcentrations and assessment of preva-

lence of vitamin A deficiency: meta-analy-sis. Lancet 2003; 362 (9401):2052–8.

Erhardt JG, Estes JE, Pfeiffer CM,Biesalski HK, Craft NE (2004) Combinedmeasurement of ferritin, soluble trans-ferrin receptor (sTfR), retinol binding pro-tein (RBP) and c-reactive protein (CRP)by an inexpensive, sensitive and simplesandwich ELISA technique. J Nutr 2004;134(11): 3127–32.


serum, 1 ml urine) than typicallyused for HPLC. This is an advan-tage because there are unre-solved questions about whetherhigh and low β-carotene and vita-min A dosages are absorbed andmetabolized similarly.

Basic AMS Method for 14C

AMS is technically difficult. First,biological samples are oxidized tocarbon dioxide in the presence ofcopper oxide at high temperature(900 oC). Then the carbon diox-ide is reduced to graphite in thepresence of titanium hydride andzinc powder at 500 oC, using co-balt as a catalyst. The graphitizedsamples are collected onto smallcathodes that are loaded into theAMS at high vacuum (7, 8). Aschematic of an AMS is shownin Figure 1, and a photo of theAMS we use is shown in Figure 2.

The graphitized samples arebombarded with cesium vaporthat causes them to form nega-tive ions that are extracted by aseries of highly positive plates.The negative ions enter an injec-tion magnet where the ions areseparated and selected by theirmass-to-charge ratio, so that most12C, 13C, and 14C ions pass sepa-rately into a tandem electrostaticVan de Graff particle accelerator

and flow toward a positive termi-nal held at millions of volts. As theions travel, they attain very highenergies, and these high-energyion beams are focused to collidewith argon gas molecules in acollision cell. This collision stripsthe outer valence electrons fromthe ions, so that their chargechanges from negative to positiveand all molecular species are con-verted to atoms. These positiveatomic ion beams are now re-pelled by the positive high termi-nal voltage used and exit the ac-celerator. The beams then passinto a high-energy analyzing mag-

net where the 12C, 13C, and 14Catoms are separated by theirmass moment charge state ratio.12C and 13C are measured withFaraday cups, while the lessabundant 14C beam is focused bya quadropole and electrostaticcylindrical analyzer and countedin a gas ionization detector.

Health and Safety issues

The amount of radioactivity thatcan be given to humans is se-verely restricted, especially in thecase of long-lived isotopes suchas 14C. In practice, at most a doseequivalent to about 1 µSievert(µSv) can be administered, whilea dose of 1µSv is considered neg-ligible and does not require spe-cial radioisotope approvals (4, 7).This has limited LSC to quicklydecaying isotopes. In practiceLSC methods are seldom used inhealthy adults, and studies in in-fants, children, adolescents, andpregnant and lactating women areespecially rare. Furthermore, thehazards of radioactive waste arewell understood, while the meth-ods for disposing of this wastehave not progressed. AMS hasthe great advantage of using verylow dosages of radioactive com-pounds, so that our radioisotopedosages are less than one µSv,

Figure 3. 14C in plasma after an oral dose of 14C-β-carotene1 (fractions ofthe carotenoid product of the 14C-dose/l plasma).

Figure 2. View of Lawrence Livermore National Laboratory10 MV accelerator mass spectrometer (8; www.llnl.gov).


and the samples collected are notconsidered radioactive and needno special radioisotope disposalprocedures. Table 1 compares ra-diation exposure from a typicalAMS dose (100 – 200 nCi) to typi-cal activities that expose peopleto radiation.

We have only used AMS to studyβ-carotene metabolism in adults,and so have not needed to de-velop sample collection andprocessing methods that takeadvantage of the exquisite sensi-tivity of AMS. For example, wetypically have collected one 7-mlblood sample per time point; firstby catheter and then by singleneedle stick. We have also col-lected 24-hour urines and fecalsamples by standard methods.Sample sizes could easily be de-creased if necessary. We actuallyonly use 30 µl plasma per AMSmeasurement, in triplicate, so thetotal amount of plasma needed isabout 100 µl. We use 1 ml urine,in triplicate.

βββββ-carotene and vitamin Ametabolism

We have just begun studies us-ing AMS, but have already gottenresults that should be of interestto other scientists and publichealth professionals working withvitamin A. Results from a well-fedadult female are shown in(Figure 3). Results are given asfractions of 14C-dose/l plasma

analytes. Circulating β-caroteneconcentrations peaked at about2,000 to 4,000 amol, and retinolat 5,000 to 10,000 amol. As canbe seen, many blood samples canbe collected in rapid successionand analyzed with this technique,generating a more complete pro-file of β-carotene metabolism thenpreviously seen in studies usingstable isotopes. These resultsprove conclusively what previousstudies have suggested: thatretinyl esters appear at the sametime as β-carotene in plasma, andbefore the appearance of retinol.A second major finding is that onlyabout 60% of the 14C in plasmawas associated with the labeledretinyl esters, retinol, and β-car-otene fractions. The remainder isassociated with yet-unidentifiedcarotenoid and retinoid meta-bolites, possibly epoxides, apo-carotenals, and retinoic acids.This suggests that β-carotenemight be metabolized by complexmechanisms than includeexcentric cleavage, and opensthe exciting possibility that someof the people classified as ‘non-’or ‘low-responders’ to singledoses of β-carotene may merelybe metabolizing β-carotene to un-expected products. We are nowusing this data to generate kineticmodels of β-carotene metabolismand conversion in humans.

Applications

AMS allows us to use radioactivetracer methods safely in humans.This means that we can use AMSto measure metabolites of vitaminA and β-carotene, whether or notthey have been identified. Thiscould let us measure the absorp-tion and excretion of β-caroteneand vitamin A directly, and to iden-tify or confirm new metabolic path-ways for them. The solution tosome of these problems has di-rect applications for programs thatattempt to end vitamin A defi-ciency through feeding β-carot-ene or vitamin A-rich foods. Forexample, AMS could be used to

determine directly how much β-carotene or vitamin A is absorbedby people of different ages, healthstatus, or who have differences intheir diet. AMS will always be adifficult and expensive technique,and this will limit its use. However,most AMS belong to national orinternational government labora-tories, so interested nations couldsponsor this important researchby providing AMS access at lowcost.

References1. Dueker SR, Lin Y, Buchholz BA, Sch-

neider PD, Lame MW, Segall HJ,Vogel JS, Clifford AJ (2000) Long-term kinetic study of β-carotene, us-ing accelerator mass spectrometry inan adult volunteer. J Lip Res41:1790–1800.

2. Hickenbottom SJ, Lemke SL, DuekerSR, Lin Y, Follett JR, Carkeet C,Buchholz BA, Vogel JS, Clifford AJ(2002) Dual isotope test for assess-ing β-carotene cleavage to vitamin Ain humans. Eur J Nutr 41:141–147.

3. Lemke SL, Dueker SR, Follett JR, LinY, Carkeet C, Buchholz BA, Vogel JS,Clifford AJ (2003) Absorption and reti-nol equivalence of β-carotene in hu-mans is influenced by dietary vitaminA intake. J Lip Res 44:1591–1600.

4. Burri BJ, Clifford AJ (2004) Caroten-oid and retinoid metabolism: Insightsfrom isotope research. Arch BiochemBiophys 430:110–119.

5. Nelson DE, Korteling RG, Stott WR(1977) Carbon-14 direct detection atnatural concentrations. Science 198:507–508.

6. Bennett CL, Beukens RP, Clover MR,Gove HE, Liebert RB, Litherland AE,Purser KH, Sondheim WE (1977)Radiocarbon dating with electrostaticaccelerators: Negative ions providethe key. Science 198: 508–510.

7. Lappin G, Garner RC (2004) Currentperspectives of 14C-isotope measure-ment in biomedical accelerator massspectrometry. Anal Biochem 378:356–364.

8. Vogel JS, Turteltaub KW, Finkel R,Nelson DE (1995) Accelerator massspectrometry. Anal Chem 67:353A–359A.

Table 1. Activity leading to radia-tion exposure (µSv)

AMS dose 10–20Coast to coast (USA) flight 30Natural background (USA) 1,500–3,000Chest X-ray 150–650Risk of cancer increased 0.09% 10,000CAT scan (20 views) 30,000-60,000


This IVACG meeting was the larg-est ever. It was attended by morethan 660 policy makers, programmanagers, planners, and scien-tists from 79 countries. Its scien-tific program on ways to improvedelivery of vitamin A and othermicronutrients to infants, youngchildren and women of childbear-ing age in developing countriesincluded a number of themes onvitamin A rich foods, aspects ofbioavailability and biofortification,vitamin A status assessment, therole of vitamin A in infection andother clinical outcomes as well ascountry experiences on supple-mentation, policy and deliverysystems.

In the opening ceremony, Dr Pi-lar Mazzetti Soler, Minister forHealth for Peru, paid tribute to theIVACG Meeting for providing anopportunity to share the latestscientific findings on ways to re-duce “hidden hunger” in womenand children worldwide. VitaminA deficiency, which is only onecomponent of “hidden hunger”,affects approximately 127 millionpreschool children worldwide.Other guests of honor (Dr LEPedesta, Ministry of Health, Peru;Dr A Sommer, USA; Dr A Franco,

UNICEF, Peru; Dr L Castello,FAO, Peru; Dr M Pena, PAHO,Peru; and Dr R Martin, USAID,Peru) emphasized that reductionin the prevalence of vitamin A de-ficiency constituted an excellentinvestment for developing coun-tries, and called for better politi-cal will which is indispensable toprotecting the life and develop-ment of children. The reduction inthe prevalence of vitamin A defi-ciency should also be seen as anintegral part of the MillenniumDevelopment Goals as well aswithin the greater context of mi-cronutrient deficiencies, poverty,inequity and hunger.

The meeting also paid tribute tothe late Clive West, who will beremembered as a man who “chal-lenged dogma, went where evi-dence led him and forced us tofollow him”.

Introduction and keynoteaddress

The focus of the meeting was setby Dr Alfred Sommer’s plea that,at a time when 12 million childrendie annually from preventable dis-eases, an important part of thevitamin A agenda must be the

creation of effective delivery sys-tems not only for vitamin A butalso for all micronutrients. Deliv-ery, or the lack of it, for whateverreasons, was globalized by thethought-provoking keynote ad-dress of Dr Gerald Keusch, Direc-tor of the Global Health Initiativeat Boston University. He identifiedintegrity and action as being the

Presentation highlights: Vitamin A and thecommon agenda for micronutrientsXXII IVACG meeting held 15–17 November 2004, in Lima, PeruDemetre Labadarios, University of Stellenbosch and Tygerberg Academic Hospital,Faculty of Health Sciences, Dept. of Human Nutrition, Tygerberg 7505, South AfricaPhilipp Randall, Silverton, Pretoria 127, South Africa


keywords for achieving globalhealth in a globalized world. In thepresent world one sixth of thepopulation is chronically hungry.Two billion people live on less thanUSD 1 per day, and 2.8 billion peo-ple live on less than USD 2 per day.The HIV/AIDS pandemic remainsout of control with the people of fiveAfrican countries having a life ex-pectancy of less than 40 years. En-vironmental degradation is on theincrease and wars are common.Against this background, it can beconsidered anomalous that morethan 90% of health research ex-penditure is spent on diseasesthat affect less than 10% of theworld’s population. This inequal-ity needs to be addressed sincehealth in an essential prerequisitefor economic development, politi-cal stability, social structures andpersonal development, and is ofcourse a human right. Addition-ally, investment at the developingworld level is likely to be associ-ated with the greatest returns be-cause of the known relationshipbetween income and life expect-ancy.

The unfinished agenda on com-municable diseases (HIV/AIDS,malaria and respiratory infections)accounts for 43% of the globalburden of disease. There shouldtherefore be better efforts in trans-ferring technology (new diagnos-tics) and making access tovaccines and antimicrobials/antivirals easier to the developingworld. This aim could only beachieved by better integration ofefforts and strengthening public-private partnerships which havebeen successful in other spheresof public health. Such an ap-proach would be of crucial impor-tance to nutrition, since poor nu-trition is well documented to in-crease morbidity and mortalityfrom infectious diseases.

In relation to nutrition itself, theplea was made that health profes-sionals should be more preparedto accept the very significant and

extensive benefits to be derivedfrom nutritional interventions. Thelag period in accepting the largereduction of all cause mortalityfrom high dose vitamin A supple-ments was presented as a goodcase in point. This exampleunderscored the importance notonly of the need to have clinicalresearch more closely related tofield studies, but also of the ab-solute requirement to pay greaterattention to the underlying me-chanism(s) of a given association.Dr Sommer also highlighted theneed to apply modern cell biologytechniques more extensively, andto have an integrated approach,particularly since single nutrientdeficiencies do not occur com-monly and the interaction of nu-trition, the environment and ge-netic background is known to beintimately linked.

Importantly, it was pointed out thatfuture progress will not only de-pend on increasing the publichealth budget. If the 21st centuryis to become the century for pub-lic health, reliance on good andinformed leadership, the ability tochallenge dogma and rely on evi-dence rather than ideology as wellas the ability to see the global pic-ture and meet global responsibili-ties together with the integrationof research and delivery will be ofthe utmost importance.

Food-based approachesfor controlling vitamin AdeficiencyIn line with the plea for effectiveand integrated delivery systemsto address vitamin A deficiency,the opening session of the meet-ing was devoted to vitamin A richfoods (indigenous, natural orbioengineered) within the greatercontext of micronutrient status aswell as household food and nutri-tion security. An innovative ap-proach, the Helen Keller Interna-tional Homestead Food Produc-tion (HFP) program, in rural Bang-ladesh (G Stallkamp et al.) com-

bined home gardening (fruits andvegetables) with animal hus-bandry (chicken, cows and fish).The aim of this approach was notonly to improve vitamin A statusbut also to achieve food diversifi-cation. Over a period of one year,the HFP program significantly im-proved animal food consumption(liver, eggs) and the medianearned income from selling HFPproduce among the target house-holds. The extra income wasspent on additional foods, thuscontributing to improved house-hold food and nutrition security.Also presented in collaborationwith the Asian Vegetable Re-search and Development Center– Regional Center for Africa(AVRVD-RCA) was the commu-nity nutrition program to promotethe production and consumptionof vegetables (African indigenousvegetables including African egg-plant, African nightshade amar-anthus, Ethiopian kale, okra, andhigh β-carotene tomatoes) in fourdistricts in Tanzania (D Ash et al.).Importantly, nutrient analysis ofthese indigenous vegetables in-dicated that they have a highervitamin and mineral content thanthe introduced varieties, a findingwhich, theoretically at least, couldmake a greater contribution to thedietary intake of these micro-nutrients especially among im-poverished populations.

Bioavailability,biofortification andfortificationImportant as the increase in thedietary intake of provitamin Acarotenoids may be in address-ing vitamin A deficiency in thelonger term, significant debatewas devoted to the conversionfactors of β-carotene to vitamin A.Indeed the world’s food vitamin Asupply might prove to be inad-equate if the new proposed fac-tors (12:1 for fruit and 24:1 forvegetables) were to be finalizedand adopted. This debate should,however, be seen in the context


of the findings presented by NWongsiriroj et al., who concludedthat “the conversion of provitaminA carotenoids to vitamin A is regu-lated differently and involves dif-ferent enzymes in the intestine ascompared to other tissues. Thisprovides an important basis forregulating β-carotene conversionto vitamin A in a tissue specificmanner. Conversion in the smallintestine is geared towards con-tinuously allowing for optimalrates of conversion whereas withconversion in other tissues carot-ene cleavage enzyme (CCE) ac-tivity is regulated through a sens-ing mechanism that assesses vi-tamin A status”. Clearly, the de-bate will continue until our under-standing of the mechanism(s) ofprovitamin A carotenoid conver-sion to vitamin A is further clari-fied. Other presentations indi-cated that continued carotenoidbiosynthesis does occur up tonine weeks after harvesting inboth in-ground and room storagein the β-carotene-rich orange-fleshed sweet potato, with benefi-cial effects on vitamin A status (PJvan Jaarsveld et al.), and that thevitamin A content of eggs can beincreased twofold by incorporat-ing spirulina in a chicken ration(WG Piliang et al.).

A glimpse of the future and itspromises was afforded to themeeting by the presentation onbioengineered provitamin A-en-riched tropical rice (K Datta et al.)as a means of addressing themajor vitamin A problem in SouthAsia. In Asian countries rice,which has a very minimal amountof carotenoid in the grain, is thestaple food and provides 40–60%of the total energy intake of thepopulation. Bioengineered riceproduces and accumulates beta-carotene in the endosperm tis-sues, an attractive achievementwhich would contribute signifi-cantly to the alleviation of the se-verity of vitamin deficiency in theregion. Transgenic indica GoldenRice, which has been developed

at the International Rice ResearchInstitute in the Philippines, con-tains the genes involved in theactivation of β-carotene synthesis.The intensity of the yellow coloris an indication of its beta-carot-ene content. The agronomic per-formance and gene stability of thisnovel strain of rice is being stud-ied using homozygous lines andwill undoubtedly define its futurepotential.

Excitement for the future was alsoprovided by the presentation onthe triple (iodine, iron and vitaminA) fortification of salt (M Zimmer-mann et al.). The efficacy of triplefortified salt [25 mg iodine (aspotassium iodate), 2 mg iron (asmicronized ferric pyrophosphate;mean particle size=2.5µm), and60 µg vitamin A (as retinyl palmi-tate)] was tested in children inMorocco in a randomized, double-blind trial. All three micronutrientswere microencapsulated togetherin hydrogenated palm oil.Microencapsulation did not onlyimprove the stability of vitamin Aand iodine when added with ironinto salt, but it was also associ-ated with significant increases inserum retinol concentration,mean hemoglobin concentrationand body iron stores. Micro-encapsulation also led to a signifi-cant improvement in urinary io-dine excretion and thyroid vol-ume. One might therefore argue

that such a technological devel-opment brings us nearer to thesought after “magic bullet” whichcould help the current efforts onalleviating multiple micronutrientdeficiencies. For the present, twopresentations reminded the del-egates of the efficacy, cost effec-tiveness and challenges of thecurrent successful food fortifica-tion efforts. One of them, from ru-ral Bangladesh (AS Rahman etal.) concluded that although mul-tiple micronutrient fortification ofchapatti improved the vitamin Astatus of school-aged children,iron status did not improve in allchildren, indicating that therewere other causes of anemia inthe population studied. The sec-ond presentation (V Abraham etal.) indicated that the type of pack-aging (tin packaging would ap-pear to be the best) and storageconditions rather than duration ofcooking were important factors invitamin A retention from fortifiedoils. The authors considered oilfortification as the method ofchoice in developing countries. Itshould however be borne in mindthat the success of any food forti-fication program depends not onlyon technical considerations butalso on other aspects beyondnutritional efficacy (O Dary), suchas economic factors of the foodvehicle chosen for fortification andenforcement as well as industrycompliance.

Frances Davidson and Alfred Sommer received well-merited recognitionfor their outstanding contributions to the IVACG meeting.


Vitamin A statusassessment techniques

The improvement of vitamin A sta-tus assessment methodology, to-gether with the expanded appli-cation of such methodology(ies)in all possible settings, continuesto enjoy a high priority for obvi-ous reasons. In this regard, asummary of the state-of-the-artvitamin A assessment methodolo-gies based on the 2004 report ofa joint International Atomic EnergyAuthority and USAID expert con-sultancy was presented (SATanumihardjo et al.). Data waspresented to substantiate the suc-cessful application of the modifiedrelative dose response (MRDR)test in the determination of thebioefficacy of sweet potatoes asa source of vitamin A. Thedeuterated retinol dilution (DRD)test was also deemed to be a verysensitive indicator of vitamin A sta-tus which can be used to give aquantitative estimate of total bodyreserves of vitamin A. The authorsconcluded that “one needs tokeep in mind the advantages andconstraints of the methods asapplied to the population of inter-est. The method chosen, whetherstable isotopes, MRDR test orfunctional indicators, will be dic-tated by resources available andaccess to appropriate collabora-tions”.

Serum retinol would appear toremain the method of choice forassessing vitamin A status in mostrelevant settings. With regard tothe latter, significant technologicaldevelopments were presented onthe assessment of vitamin A sta-tus in dried blood spots (DBS).The most remarkable was thecombined measurement of retinolbinding protein (RBP), serumtransferrin receptors (sTfR) andC-reactive protein (CRP) in oneDBS for the evaluation of vitaminA, iron and infectious status re-spectively (JG Erhardt et al.). It isto be noted however, that in theseapparently attractive alternative

methodologies the sTfR and CRPrecovery in DBS was not 100%and the variation in the measure-ments was slightly higher thanthose in plasma. Therefore appro-priate corrections needed to bemade, apart from the expertiserequired for the ELISA techniqueemployed. Although the DBStechnique would appear to be“field friendly”, the authors pointedout that the technique “should notbe the method of choice if it is nota big problem to collect and trans-port plasma samples” probablybecause of the higher variabilityencountered.

Data was also presented on thevalidation of the use of DBS in vi-tamin A status assessment inpregnant women in Nepal (RKlemm et al.). Although a goodcorrelation was obtained betweenserum retinol and the DBS retinolconcentration, the technique re-mains in need of further validationin vitamin A deficient populations.More experimental and in need offurther validation was theimmunochromatographic strip(ICS) test for the analysis of RBPin DBS (J Hix et al.). RBP isknown to be only a surrogate in-dicator of serum retinol and doesnot provide absolute vitamin Aconcentration values.

Infectionand inflammation

Serum vitamin A concentration isnow well known to be affected bythe presence of infection and in-flammation as measured mostlyby CRP in the host. This often in-sufficiently appreciated relation-ship was again highlighted by thedata presented from Zambia onthe apparent impact CRP canhave on serum retinol concentra-tion (CA Northrop-Clewes et al.).In this national random clustersurvey, correcting for the pres-ence of infection using CRP alone“raised” the mean plasma retinolconcentrations in children by ap-proximately 10% overall. Thestudy rather elegantly under-scored the difficulties in interpret-ing serum retinol concentration ifinflammatory markers are notmeasured concurrently when as-sessing vitamin A status by serumretinol. A similar study (MADiikhuizen et al.) documented thatpregnancy affects plasma retinoland acute phase proteins concen-trations differentially, thus makingthe determination of vitamin A sta-tus and acute phase responseduring pregnancy difficult.

Infection does not only influencethe concentration of vitamin A inthe blood but it would appear that


it can also modify the outcome(s)of intervention programs. A col-laborative study (H Hadi et al.)highlighted the complex interac-tions of infection and diet. It wouldappear that such interactions maywell explain differential seasonalgrowth responses to vitamin Asupplementation in preschool chil-dren. The study showed that ineach season, the highest effect ofvitamin A supplementation wasfound in children with a low bur-den of respiratory infections andlow vitamin A dietary intakes. Chil-dren with a high burden of respi-ratory infections or high vitamin Aintakes benefited less from vita-min A supplementation in termsof linear growth. Indeed, therewas no beneficial effect on lineargrowth from vitamin A supplemen-tation in children with both a highburden of respiratory infectionsand high vitamin A intakes regard-less of the season. Thus, respira-tory infections and vitamin A in-takes were shown to be importantdeterminants underlying the sea-sonal effect of vitamin A supple-mentation on growth. A similarstudy in Zimbabwe (MF Miller etal.) investigated the potential ofvitamin A supplementation (VAS;randomized placebo control trial;400,000 IU and 50,000 IU formother and infant respectively) toreduce anemia among infantsborn to HIV-positive and HIV-negative mothers. The authorsconcluded that although VAS mayplay an important role in infantileanemia, the efficacious supple-mental vitamin A dose needs tobe better defined. The authorsalso pointed out that any preven-tive strategies to address infan-tile anemia should include meas-

ures to increase the birth endow-ment of iron, prevention of HIVinfection and promotion ofbreastfeeding.

In preliminary data presentedfrom another study from Zimbab-we (J Humphrey et al.), singledose maternal and infant vitaminA supplementation (2X2 factorialdesign trial; infants 50,000 IU;mothers 400,000 IU immediatelypostpartum; or both) had no im-pact on mortality. VAS amongHIV-positive women during 6weeks following supplementation,however, was associated with a21% reduction in sick clinic visitsand a 40% reduction in the needfor hospitalization.

Clinical outcomes

In relation to the role ofmicronutrients in reproductivehealth, data from a randomizedcontrolled trial in Nepal (P Chris-tian et al.) examined the efficacyof 4 combinations of supplemen-tal antenatal micronutrients onbirth outcomes such as labor anddelivery complications. The sup-plements contained folic acid(400ug), folic acid+iron (60 mg),folic acid+iron+zinc (30 mg) anda “multiple micronutrient” (MM)supplement with all 3 plus 11 oth-ers micronutrients. The authorsreported that symptoms of prema-ture rupture of membranes werelower in women who receivedMM. Folic acid supplementationalone was associated with fewerreports of convulsions, and pla-cental retention and breakage. Inthe 9 days following the day ofbirth, symptoms of poor appetiteand diarrhoea/dysentery were

lower in all micronutrient supple-mented groups when comparedwith controls (vitamin A 1000 RE).Fever, as reported in the preced-ing 24 h and measured (≥100degrees F) at the time of the homevisit, and sepsis (defined as foulsmelling vaginal discharge andfever) were lower in groups thatreceived folic acid+iron, folicacid+iron+zinc and the MM sup-plement, when compared withcontrols. It would therefore appearthat the micronutrient combina-tions employed in this trial mayreduce the risk of some obstetriccomplications. MM supplementa-tion, however, was also associ-ated with an increased risk of ob-structed and prolonged labor (>15h), and forceps/vacuum/Caesar-ian section-assisted deliveries. Itwas proposed that the increasedrisk for obstructed and prolongedlabor may have been due to anincrease in the birth size of theinfants. With regard to the latter,previously published data fromrural Nepal have reported thatantenatal micronutrient supple-mentation was associated with amean birth weight increase of 40-70 g. Further analysis of this dataindicated that intrauterine growthmay be altered by micronutrientsupplements since somemicronutrients, such as iron, mayconfer a benefit among the mostvulnerable infants, whereas othermicronutrients may have a moreconstant effect across the spec-trum of birth weight (J Katz et al.).

The session was concluded by aplea from Indonesia (S Sukotio etal.) that if the dissemination ofhealth messages of maternal andchild survival communication pro-


grams including those aimed atimproving the daily dietary intakeof vitamin A-rich foods are to suc-ceed, program planners need tounderstand the varying circum-stances in different interventionareas and utilize existing commu-nication channels and local socialsystems.

Multiple micronutrientsupplementation

Although micronutrients haveunique functions on their own,their interaction in metabolic path-ways is well described. Iron andriboflavin deficiency has been re-ported to be common amongpregnant Nepali women. Iron isthought to enhance vitamin A uti-lization and riboflavin plays animportant role in photoreceptorfunction. Vitamin A (VA) treatmentfailed to cure night blindness inapproximately 30% of pregnantNepali women. On this basis, arandomized food-based trial (LAllen et al.) compared the com-bined effect of VA, iron and ribo-flavin supplements on eye health.The effect of VA, in the form offortified Ultra RiceTM (0.85 mgRE=2839 IU/d), supplemental iron(30 mg Fe) and riboflavin (6 mg)daily for 6 weeks on pupillary re-sponse threshold (PRT) andplasma retinol was compared withthat of VA alone in a population ofpregnant (2–7 month gestation)night-blind (XN, present in 8.4%of those screened) women. Thekey finding of the trial was thatPRT improvement was greatest inwomen with iron deficiency at

baseline, indicating that poor ironand possibly riboflavin status mayimpair dark adaptation.

Another double-blind placebo-controlled, multi-centre trial with4 study sites in Indonesia, Thai-land and Vietnam investigated theeffects of iron (10 mg) and/or zinc(10 mg) and vitamin A supplemen-tation daily for 6 months in infantson indicators of iron and zinc sta-tus (E Wasantwisut et al.). Thestudy documented that combinedsupplementation of iron and zincwas less effective than either ironor zinc alone. There was no inter-action between zinc and iron onhemoglobin concentration. How-ever, zinc supplementation had anegative and independent effecton hemoglobin concentration.There was also a strong interac-tion between zinc and iron onplasma zinc concentration. Vita-min A capsule distribution (VAC)at baseline also affected iron sup-plementation. VAC was related tolower hemoglobin concentrationin infants not receiving iron sup-plements. The authors concludedthat iron supplements on theirown appeared to be safe. Zincsupplements should however bepreferably given with iron supple-ments and VAC may increaseanemia prevalence in the ab-sence of iron supplementation.

The known experimental associa-tion of vitamin A deficiency andabnormal thyroid function formedthe basis for a double-blind,randomized, placebo-controlled10-month duration trial in children

in Morocco (M Zimmermann etal.). Children with severe iodinedeficiency and poor vitamin A sta-tus were given iodized salt (20 µgiodine/g salt) and either vitamin A(200,000 IU as retinyl palmitate)or placebo. The findings of thestudy indicated that moderate vi-tamin A deficiency in iodine defi-cient children increased the riskfor goiter but decreased the riskfor hypothyroidism. In iodine andvitamin A deficient children whoreceive iodized salt, concurrentvitamin A supplementation im-proved the efficacy of the iodizedsalt to control goiter.

Supplementation safety,strategies and program:Alternative size supple-ments

This session of the meeting ad-dressed the potential risks of highdose vitamin A supplements es-pecially when such supplementswere administered at the time ofimmunization. A multi-centre,randomized controlled trial ofpostpartum plus immunization-linked supplementation was con-ducted in India, Ghana and Peru(ME Penny et al.). Infants re-ceived either retinyl palmitate orplacebo (vitamin E) orally with in-fant vaccines. Mothers who wererandomized to supplementationreceived 200,000 IU postpartum.The children’s fontanels were ex-amined before each immuniza-tion-vitamin A/placebo dose and24 and 48 hours after the admin-istration of the supplement. The


highest prevalence of bulging wasreported in Ghana (1.9% in thesupplemented group at the thirddose). Within-country increasedrates of bulging were only signifi-cantly more common at the sec-ond dose in Ghana, at the thirddose in Ghana and India and atthe fourth dose in India. Bulgingwas associated with fever (oddsratio 3.44, 95% CI 2.13–5.55) butcaused little maternal concern. Itusually appeared within 24 hoursand had resolved by 48 hours. Itwould therefore appear that al-though there is an increased riskof bulging fontanel when vitaminA is given with childhood immuni-zations, the risk is small and theeffect mild and transient.

Another randomized double-blindclinical trial compared the safetyand efficacy of two regimens of vi-tamin A supplementation adminis-tered together with EPI vaccinesduring the first 6 months of life insouthern Tanzania (B Idindili et al.).Mothers in the lower supplemen-tation dose group of the trial re-ceived 200,000 IU of vitamin Awithin 24 hours of delivery and theirinfants received three doses of25,000 IU at the time of routineDPT/polio vaccinations at approxi-mately 1, 2 and 3 months of age.Mothers randomized to the higherdose regimen received a second200,000 IU dose of vitamin A whenthey brought their child for routinevaccination at 1 month of age, andtheir infants received three dosesof 50,000 IU at 1, 2 and 3 monthsof age. The higher dose regimenwas well tolerated by mothers and

infants. However, the higher dosesupplement was not found to bemore efficacious in terms of vita-min A deficiency prevention. Vita-min A deficiency was still presentin more than 40% of infants at 6months in both the lower andhigher supplementation regimens.Since the higher supplemental vi-tamin A doses do not appear tosustain an improved vitamin A sta-tus at 6 months of age, the thirdclinical trial presented (S Newtonet al.) investigated the safety andefficacy of doubling the supple-mental dose (400,000 IU postpar-tum mothers and 50,000 IU infantsat the same EPI contacts). Al-though the results presentedwould appear to support the safetyof this even higher supplementaldose regimen, its impact on vita-min A status appeared unremark-able on the basis of the parametersmeasured (MRDR and breast milkvitamin A at 6 and 9 months). Thepreliminary results presented withhigher doses of vitamin A (200,000IU on days 1 and 5 postpartum)also appeared to be unremarkablein terms of breast milk oligosac-charide composition in Gambianwomen (DI Thurnham et al.).

Supplementation:Post-NIDs

In the post-NID days, a numberof innovative approaches for sus-taining the gains of vitamin A sup-plementation were presented inthis session of the last day of themeeting. In Ghana for instance (EAmoaful et al.) a new strategy in-volves using Child Health Promo-

tion Weeks as one-stop opportu-nities for providing twice yearlyvitamin A supplementation to atleast 80% of children aged 6–59months. This activity is supportedby key services and facts on pre-ventive health care. A number ofsub-district activities have beendesigned to improve efficiencyand quality of service delivery, uti-lization by caregivers and cover-age of several key child healthservices. The package of servicesincluded vitamin A supplementa-tion, immunization, re-treatmentof insecticide-treated materials,growth monitoring and promotion;adequate supply of child healthrecord cards and birth registra-tion, staff retraining, provision ofrevised tools as well as caregivereducation. A monitoring frame-work had also been designed tocapture data on the provision andutilization of services including theproportion of trained personnel,quantities of commodities and in-formation provided. A similar ap-proach has been adopted in Mali(F Ouattara et al.) where vitaminsupplementation in the form ofvitamin A capsules is deliveredthrough National Nutrition Weeks(SIAN) to children aged 6–59months and postpartum womenwith the aim of achieving at least80% coverage. A mix of distribu-tion strategies has been usedwhich is appropriate to the re-gional needs and circumstances.The supplementation programalso includes Regional Micronu-trient Days (RMD), which appearto have achieved coverage of>90% in some regions. The Min-


istry of Health plans to institution-alize SIAN in the National Strate-gic Food and Nutrition Plan (2004-2008).

In Rwanda (A Ndagiyimfura et al.)the goal set is to eliminate VADby 2010 and maintain its elimina-tion after 2010. The main strate-gies include supplementation ofpregnant women, lactatingwomen after delivery, and infantsand children 0–5 years; advocacyand social mobilization againstVAD; promotion of exclusivebreastfeeding to six months, im-provement of management ofchildhood illnesses, improvementof availability, accessibility andconsumption of foods rich in vita-min A as well as vitamin A foodfortification. These activities areintegrated in the World HealthWeek and the National HealthWorker Day. The first campaignwhich began in November 2003yielded a very high coverage levelof about 93% for infants, 103%,for children and 48% for lactatingwomen six weeks after delivery.

Country Experiencesand Policy Implications

Country experiences and suc-cesses with vitamin A supplemen-tation were shared. They high-lighted the achievements whichcan be attained with carefullyplanned, integrated and sustainedpolicies. The host country (CNaquira) reported a significantincrease in vitamin A intake whichwas associated with a tendencyfor a lower prevalence of vitaminA deficiency in women and chil-dren. In Nicaragua (J Mora et al.)the prevalence of vitamin A defi-ciency has decreased from 31%in 1993 to <9% in 2000 to <2% in2003. This remarkable progresswas achieved by a combinationof supplementation and sugar for-tification as well as immuniza-tions, iron supplementation,deworming, health education andoral rehydration packages. Theauthors cautioned that the long-

term sustainability of this achieve-ment will very much depend oncontinued food fortification andtargeted supplementation ofyoung children.

Remarkable achievements havealso been attained in Nepal (RShrestha et al.) since the introduc-tion of the National Vitamin A Pro-gram (NVAP) in 1993. The pro-gram uses a community-baseddistribution system, with FemaleCommunity Health Volunteers(FCHV), to supplement vitamin Acapsules in each village. By Oc-tober 2002 it had expanded to all75 districts. NVAP has maintainedcoverage rates above 85% sinceits introduction and reduced theprevalence of Bitot’s spots to0.33% (WHO cut-off level <0.5%).NVAP was also reported to be amajor factor in the reported de-crease in child mortality during thepast decade. This cost effectiveprogram, at just US$ 0.74 perchild each year, has also contrib-uted significantly to the implemen-tation of deworming for childrenaged 2–5 years at almost no ad-ditional implementation cost.

By contrast, such successes re-main to be achieved in the Africancontinent and Indian subcontinent.Irrespective of the reasons andrealizing the urgent need for bet-ter delivery, Uganda introducednew initiatives in 2003 in thehealth, agriculture, and food indus-try sectors to help achieve ad-equate vitamin A intake in thepopulation (L Sserunioai et al.).These initiatives include bi-annualvitamin A supplementationmonths, integration of vitamin Asupplementation with NIDs formeasles and polio campaigns tosupplement more children. Theinitiative also includes the success-ful launch of an improved varietyof orange-fleshed sweet potato inone district and its adoption by alocal women’s group, and the in-tensive promotion of this cropthrough women’s groups in morethan 30 districts by the Ministry of

Agriculture. Private food indus-tries have also embraced an ini-tiative to fortify oil with vitamin Aand maize meal with multiplemicronutrients.

Tanzania is also reassessing theassociated constraints of the ap-parently low coverage (normally<62% but decreased to <30% in2004) vitamin A supplementationprogram of women postpartum(JKL Mugyabuso et al.). The iden-tified constraints, despitefavorable policy environmentsand standardized monitoring sys-tems, were reported to includeinadequate adherence to policyguidelines by health workers, lowrate of facility deliveries, slowpace of incorporating vitamin Asupplementation in comprehen-sive council health plans, inad-equacies in the training of healthworkers and community-ownedresource persons, shortage ofhealth workers and inadequaciesin data management and report-ing. Similar initiatives are beingintroduced in Jharkhand State inIndia, where government effortsat vitamin A supplementation inroutine immunization reachedonly 8% of the population (GVerma et al.). The results of theseinitiatives are being awaited andit is imperative that they succeed.

Supplementationprograms

In view of the enviable progressachieved by the Nicaraguan Gov-ernment, the Nicaraguan Minis-try of Health with the assistanceof a multi-member partnership[USAID/ MOST, CDC, MI,UNICEF and the Institute of Nu-trition of Central America andPanama (INCAP)], has developedand is in the process of establish-ing a centralized, modular, Inte-grated National Nutrition Monitor-ing and Evaluation (M&E) System(SIVIN) for periodic program M&Eand decision-making. In the firstyear (2002-2003) of its operation,SIVIN compiled key information,


including relevant micronutrientdata which document for exam-ple continued control of vitamin Aand iodine deficiencies, high cov-erage rates of vitamin A supple-mentation in children (>85%) butvery low coverage in postpartumwomen (13%). Iron supplementa-tion in pregnant women has in-creased to >80% and in childrento >60%, and sugar, wheat flourand salt fortification are properlyimplemented. These findings arenow used for nutrition policy/pro-gram decision-making in Nicara-gua (J Bonilla et al.).

Also on the topic of M&E and inless well resourced environments,a retrospective study from north-ern Ghana (P David et al.) col-lected and compared existing pre-intervention data from householdsurveys, health service and pro-gram statistics with available dataon program implementation fromthe Ministry of Health, on severemorbidity and mortality. The studyalso attempted to identify poten-tial confounding factors fromhousehold surveys at two timeperiods post-implementation. Itwould appear that currently thecoverage of the national supple-mentation program is close to80% in the 3 northern regions,and other indicators suggestedthat it was being implemented ef-fectively. Although the mortalitydata so obtained could be ques-tioned, they do nevertheless indi-cate that there has been a sharper

decline in mortality in childrenaged 1 and 4 years than amonginfants since the program began.The authors acknowledged that“a more elaborate and costlystudy design would be necessaryto provide more definitive state-ments of impact, and rule out themany other factors that can affectchild survival”.

Another study (H Gardner et al.)compared vitamin A coverageusing administrative data follow-ing mass distribution campaignsand cross-sectional survey datafrom 17 countries (1995-2002).Coverage estimates based onadministrative data were reportedto be systematically higher thancross-sectional survey estimates(69 vs. 45% on average). Ofcourse both data sets may besubject to bias since administra-tive data are reliant on the accu-racy of the census data used andcross-sectional data rely on theaccuracy of maternal recall.Clearly, far greater experiencewould be necessary before themethod of choice for coverageestimates in resource poor envi-ronments can be agreed upon.

An interesting approach to deter-mining coverage estimates ad-dressed the appropriateness orotherwise of UNICEF’s vitamin Acapsule coverage rates data (JMateer et al.). For this purpose,cross-sectional surveys deter-mined VAC coverage and clinical

signs of VAD among children un-der five years of age in World Vi-sion intervention areas (Afghani-stan, Chad, Tanzania, Zambiaand India). It would appear thatWV data indicated a lower VACcoverage in 4 of the 5 countriesat a regional level when comparedwith UNICEF national statistics.The authors concluded that fur-ther efforts are needed to increaseVAC coverage to > 80% of chil-dren in these regions in all 5 coun-tries on the basis of WV data,since the latter is based on a sur-vey of children receiving vitaminA capsules in the previous 6months in the intervention areas,whereas UNICEF’s statistics maybe based on national surveysevaluating the number of childrenwho have received a VAC withinthe previous 6 months.

In conclusion

The XXII IVACG meeting updateddelegates on many aspects of theprogress so far achieved in ad-dressing multimicronutrient defi-ciencies and vitamin A deficiencyin particular. Promising as thedevelopment of enriched cultivarsof staple foods through traditionalbreeding and genetically engi-neered techniques may be, fur-ther real progress will only beachieved (G Keusch) by compe-tent and visionary leadership ingovernment, academia and civilsociety.


CIP was founded in 1971 with theaim of preserving, studying anddisseminating the great range ofgenetic varieties of the potato, aswell as other important tubercrops in the Andean Region.

The tour was led by CIP staff whoguided the participants throughthe various installations at thecenter, which included a visit tothe laboratories, and to see nu-merous varieties of roots and tu-bers currently under study at thecenter. Inaugurated in 2001, theCIP genebank is home to morethan 5,000 different types of sweetpotato, the world’s largest collec-tion of its kind.

The participants learned about theVitamin A for Africa partnership(VITAA). VITAA’s goal is to reducevitamin A malnutrition in Africa byproviding farmers with the optionto substitute white-fleshed sweetpotato with new high β-carotenecultivars. The new varieties, manyof which have been officially re-leased in Eastern Africa, weredesigned to meet local marketstandards and are particularly at-tractive to young children. A recent

impact case study by economistsworking at Michigan State Univer-sity and the International PotatoCenter suggests that 50 millionchildren under age 6 currently atrisk from diseases associated withvitamin A deficiency could benefitfrom the new VITAA varieties.

The final portion of the tour in-cluded the presentation of a videoabout CIP where the participantscould see the global applicationand impact of the center’s work.

Study Tour to the International Potato Center(CIP), Lima, Peru, 20 November 2004Faviola Jimenez from the Peruvian Food and Nutrition Network (translated by VeronicaTriana)

CIP has signed different interna-tional agreements permitting thetransfer of science and technol-ogy with the aim of contributingto the reduction of nutritional de-ficiencies worldwide.

The participants expressed theirthanks to the hosts for welcom-ing them and showing them thisinteresting and important work.For more information about CIPand the VITAA partnership, visithttp://www.cipotato.org


Study tour of Project HOPE in Peru in conjunc-tion with the XXII IVACG meetingRebecca L Surles, PhD graduate student at the University of Wisconsin-Madison in thelaboratory of Sherry Tanumihardjo.

Project HOPE is a humanitarianorganization focusing on the im-provement of global health. As thename implies, Health Opportuni-ties for People Everywhere(HOPE) has the mission to“achieve sustainable advances inhealth care around the world byimplementing health educationprograms and providing humani-tarian assistance in areas ofneed”. After the IVACG meetingthis year, a few of us experiencedProject HOPE’s Child SurvivalProject in the community ofCaserio Aviacion in the San Mar-tin province, Peru. Partnering withthe Ministry of Health, the pro-gram has been improving thehealth of 26,500 women of child-bearing age and 13,000 childrenunder 5 since it started in 1997.Promoting a nutritious diet andencouraging exclusive breast-feeding during the infant’s first 6months of life are two of the mainobjectives.

Located in the upper Amazon ba-sin, Caserio Aviacion is one of 162rural communities the Child Sur-vival Project has been workingwith since 1996. The trek toCaserio Aviacion was around onehour on a windy, bumpy dirt roadhigh up in the mountains. Our tourguide and local Health Coordina-tor, Karem Delgado Coloma, ex-plained that the road was onlyrecently constructed and she pre-viously walked five hours to reachthe village.

Caserio Aviacion was the last vil-lage on the road. It consisted ofapproximately 15 families whogreeted us with welcome musicand dancing. After the celebration,the community enlightened us

with a few of their nutrition edu-cation games. The first consistedof the trainer laying out a green,yellow and red cloth with the re-spective meanings of protection,strength, and growth. The womenwere divided into two groups andgiven various pictures of localfoods. They then placed the pic-

tures on top of the cloth corre-sponding to the food’s nutritionalvalue. For example, mangos wereplaced on the green cloth. Thetrainer asked what was in themango for them to choose thatoption. In synchronized voices thewomen responded “vitamin A”.


The next game consisted of pre-paring three meals. The teamswere to plan meals consisting offoods that provide protection,strength, and growth. An exam-ple may include tomatoes andonions over a bowl of beans andrice. An alternative might begroundnut soup served withchicken, rice, and plantains. Asour appetites increased, we weredelighted to find out the soup wasfor lunch.

After lunch we were given a shorttour of the village and completedour visit at the local health post.The trainer discussed theprogress made with the help ofProject HOPE’s Child Survivalprogram. Located on the wall inthe health post, a community mapindicated homes with pregnant/

lactating women, and childrenwho were either under 5, haddiarrhea, or were malnourished.Also indicated were homes withlatrines. Instruments to measurechildren’s height and weight werealso there to provide further docu-mentation of child developmentevery 5 months.

Another mission of Project HOPEis the promotion of breastfeeding.The trainer explained that thewomen introduce ripe plantain(maduro) as early as the first hourafter birth. Project HOPE providedthe village with education mate-rial and started a mothers’ groupto encourage the delay of thispractice and promote the use ofexclusive breastfeeding until theinfants are 6 months. Both moth-ers and pregnant women meet on

a regular basis to learn and shareknowledge related to breast-feeding while at the same timereinforcing the importance of ex-clusive breastfeeding for 6months after birth. Led by one ofthe mothers in the community andcollaborating with local health pro-moters, the use of immediatebreastfeeding and exclusivebreastfeeding are up by 47% and85% respectively.

When we asked the trainer whytheir village has been so success-ful in implementing nutritional im-provements, he responded that“community organization is key. Aunited community has a betterchance of success”.


This was the most exhilaratingfield trip ever to be planned as partof an IVACG symposium. Fourdays and three nights spent be-tween 2,800 and 3,200 meterswas not for the faint-hearted butour travel agents, Condor Travel,allocated our time with utmost ef-ficiency and clockwork precisionto ensure that we neither wasteda moment nor lost any of our col-leagues through natural or un-natural circumstances.

The field excursions encom-passed a tour of historic sites inand around Cusco on our day ofarrival, a day-long visit to one ofthe 10 UNICEF-supported ChildDevelopment Centers in themountains surrounding Cusco onday two and a day-long visit toMachu Piccu on day three. We re-turned to Lima on day four wheneverybody was just about accli-matized to the altitude and manywould have been pleased to stayon for another week. However, theunexpected intensity of the sun onthe previous day in Machu Piccuhad given several people a rosyappearance that resembled agood week’s exposure!

Altitude sickness was on theminds of many participants as we

disembarked from the plane inCusco. Our various guideswarned us of possible headaches,breathlessness, difficulty in sleep-ing etc., and it was a mixture ofrelief and pleasant surprise thatnone of these symptoms struck usas we moved out of the airport toour waiting coach and onwards tothe hotel. We were welcomed withtea made from coca leaves and ashort rest was prescribed to helpus prepare for the exertions tocome. Our luggage was whiskedupstairs and it was then we dis-covered we had drawn one of theshort straws. Our room was on thesecond floor and as we labori-ously staggered up the secondflight of stairs we realized we werein urgent need of extra red cells!Breathlessly we collapsed ontothe bed and drifted off into a wel-come slumber but all too soon, itseemed, we were making our wayto the coach for our visit to thetemple of Sachsayhuaman.

Our guide, Juan Carlos, was anincredible source of knowledge onInca and Spanish history as wellas that of earlier civilizations. Noquestions seemed beyond hisreach and we certainly put him tothe test on many occasions. Witha folder of carefully selected pic-

tures, diagrams and maps he il-lustrated aspects of architecturallayout or Inca ingenuity in the con-struction and use of their buildingsand temples. Cusco was the capi-tal city of the Incan Empire andJuan Carlos showed us how thetemple of Sachsayhuaman hadbeen built in such a relation to thetown of Cusco that, from above,the built-up area as it then was hadthe shape of a puma with Sach-sayhuaman forming its head.

Unfortunately, much of the walledsuperstructure at Sachsayhua-man had been re-used by theSpaniards in rebuilding projects inCusco after the defeat of the IncanEmpire. So it was not possible toknow the real height of the tem-ple walls or the decorations thatmight have appeared upon them.However, one could not help butmarvel at the skill needed by theIncas to build the walls we couldsee. Huge stones had beenmoved into precise locations andcarved in situ to provide smoothwalls which inter-locked with sur-rounding stones without mortar.This structure had resisted earth-quakes over the last 5–600 years.The largest of the stones atSachsayhuaman was estimatedto weigh around 128 tons. Juan

UNICEF supported project Buen Inicio (Good Ini-tiatives) on early child growth and developmentStudy tour to Cusco in conjunction with the XXII IVACG meeting

David I Thurnham1 and Christine A Northrop-Clewes21 Howard Professor of Human Nutrition, University of Ulster, Coleraine, Northern Ireland2 ORISE Fellow, Atlanta, USA


Carlos graphically described thenumbers of people that wouldhave been needed to move sucha stone. With suitable ropes androllers, 12 people are needed tomove one ton. Scaling up, morethan one thousand people with agreat many ropes, pulleys and le-vers would have been needed tohave moved such a stone eventhough the quarry from where itwas obtained was probably notmore than two to three milesaway.

Little remained of the buildingfrom which the ruling king wouldhave addressed the assembledcitizens of Cusco at the Summerand Winter solstices, apart fromthe temple mound. However, itwas apparent that many thou-sands of persons could havegathered in the temple courtyardand that the surrounding templewalls must have provided cleveracoustics to enable the king’swords to have been heard. Ourguide attempted to illustrate howsound was magnified within thecourtyard by clapping his handsbut the full effects may have beendampened by the intermittentheavy showers of rain. The rainyseason began the day before ourarrival!

The rest of the first day’s tour wasspent mainly visiting the Spanish-built cathedral. As many will know,after conquering the Incas theSpaniards introduced Catholicismto replace Inca religions. Incatemples were razed to the groundand Spanish churches were builton the foundations. Once againour guide illustrated fascinatingaspects of how the Spaniards hadmodified the symbols of Catholi-cism to make them relevant toIncan religious ideas. The Incasbelieved that their souls lived onin the heavens after death, but toreach the heavens the soul hadto be transported by a rainbow upthe mountains to the sky. As thesoul continued to live, mummifiedbodies were given new clothesand regularly provided with food.The Spaniards persuaded theIncas to use candles to symbol-ize the food, and the Virgin Marywas always depicted in profileshowing her dressed in large widedresses, symbolizing the moun-tains. Juan Carlos emphasized thateven today although everybody isoutwardly a Catholic, religiousideas are very much a symbiosisof Catholicism with Inca beliefs.

Day two began a little more lei-surely than our day of arrival and

we breakfasted in the sunlit hotelcourtyard before boarding ourcoach for our visit to the UNICEFproject sites. As the group wasrather large we were split intothree parties and each went ourseparate ways. All groups had firstof all to travel higher to cross themountains to the east of Cuscobefore we could descend into thesacred valley of the Incas. As tobe expected we again saw re-mains of Incan outposts or fortsthat are found roughly a day’swalk apart all across the IncanEmpire, but the principle excite-ment in store for us today was tobe the incredible views of snow-capped mountains, luxuriant fieldsof new corn or potatoes stretch-ing out along the valleys and ter-races and tortuous winding roadsno wider than our coach which weclimbed for several hours up anddown mountain sides to reach ourdestination. We made the usualpit stops, paused to examine thecolorful items on sale for touristsand gazed in amazement at thecurious-looking lamas and al-pacas but otherwise drove ondeterminedly.

Our first stop as part of the studytour was at the Health Centre inLamay that was in the sacred val-


ley itself. A doctor and one of theobstetricians kindly described tous aspects of their work. Therewere five obstetricians based inthe health centre and they servedapproximately 6000 people livingin the surrounding districts.Women were encouraged to givebirth in the centre and we weretold there was a small dormitoryavailable so that women couldstay somewhere in advance oftheir delivery. However, the over-all objective of the NGOs support-ing the centers was to reducechronic malnutrition. The smallstature of many of the local peo-ple indicated that stunting was anendemic problem. The doctorsindicated that although they hadonly been in operation for fouryears they felt that they were re-ducing the problems. Anthropom-etry was recorded for children upto five years of age and motherswere encouraged to bring theirchildren regularly for checkups;seven times below one year, fourtimes between one and two yearsand twice a year up to four years.Children were issued with growthcharts that contained a lot of use-ful information on child growth anddevelopment, important foods toeat and psycho-social milestonesetc. Unfortunately the cards werewritten in Spanish although thelocal language is Ketchua, and inany case many women are notable to read, so it may be someyears before their usefulness tothe local people is fully realized.Changes are happening in thesemountainous areas. It was clearlyapparent that the tourist industrywas booming in Cusco and ourguide assured us that they were

doing their best to spread thewealth from the industry as widelyas possible. However, the BuenInicio project will be needed forsome time yet as it focuses onthose regions least influenced bytourism and needing most help.

Having said our goodbyes inLamay, we departed once morefor one of the 10 communitycenters supported by the BuenInicio project in the surroundingmountains. We climbed remorse-lessly up the narrow windingroads, crossing bridges whichappeared to become more andmore fragile the higher weclimbed. The streams underneathsplashed and gurgled pleasantlyas if revitalized by the recentrains. Eventually we stopped justahead of a clearing surrounded bysome newly built and paintedbuildings, where adults and chil-dren in brightly colored clotheswere gathered. We were not cer-tain at first whether the reason forour stop was the very rickety na-ture of the bridge ahead or if thiswas our destination. As we allclambered down from the coach,I wondered just what the driverwas going to do. I could not re-member any turning point behind

us for many miles and I could notenvisage him reversing downthose roads! However, as soon aswe were all off, a roar of the en-gine told us that he was over thebridge without problem.

We had arrived at CommunitariaJanac Chuquibamba, where awelcome committee of villageelders, mothers and some of itsunder-five recipients were assem-bled to greet us. Unfortunately theheavens opened at that momentand as we donned our colorfulplastic ponchos we must havelooked a very strange crowd of


visitors. Bunches and garlands offlowers were presented to us andsome unusual musical instru-ments were played but as it con-tinued to rain, we very quicklysqueezed into the director’s officefor a description of the center’sactivities.

The overall objective of the cen-tre was to improve the health andnutrition of the family members inthe community. It was supportedby UNICEF and World Vision un-der the guidance of the NGORicchary Ayllu. It especially tar-geted pregnant mums and under-five children for individual atten-tion but it also had an agenda forthe social and financial improve-ment of the community. Therewere 50 families in this village and23 children under three years. Lifeexpectancy was 60 years for thewomen and 55 for the men. Theinability of many villagers to readwas clearly recognized and ad-dressed. Scenarios depicting thepast, present and future were dis-played as colorful pictures on theoffice walls. The dreams of thecommunity leaders and the cur-rent problems that might preventtheir achievement were likewisedisplayed. Low agricultural pro-duction featured high on the listof problems and as the commu-nity was heavily dependent on ag-riculture for its income, its nutri-tion and its health, land allocation,planning of crop production andthe sale of surpluses were highon the list of solutions. One prob-lem that was well recognized butappeared to be receiving little ac-tive attention, was alcoholism inyoung men, resulting in prematuredeath from liver cirrhosis andhepatitis. The center identifiedthree missions: to work, to wantand to know. Villagers needed toknow how to make their workmore effective, they needed tohave aspirations that would ben-efit the family and the community,and knowledge needed to be im-proved for all.

Other parts of the buildings weredevoted to antenatal monitoringand services and a schoolroomfor 3–5 year olds. Wall charts andvillage plans featured prominentlyon the walls. Green dots indicatedpregnant women who had re-ceived their health checks whilered dots showing a glum face in-dicated mothers who had not yetattended the center. Lastly we vis-ited the school room and as weentered they all turned to us anda sea of happy smiling faces cho-rused “buenos dias”. Theirteacher, who was from Lamayand paid by the Government, thenprompted them to display theirvocal and numeracy talents andit was clear that this generationwould have many advantagesdenied to their parents. Finally itwas time to leave and with morephotographs, smiles and waveswe boarded the coach for our re-turn journey.

Returning along the same narrowroad was at times more fraughtthan the upward journey in themorning. The tight hairpin bendsnecessitated many a three-pointturn when the front of the coachappeared to project unnervinglyover the steep hillside. All wentwell, however, until about halfwaydown to Lamay when, at one par-ticularly tight corner, a grindingwrench and a cascade of small

stones indicated that a boulderwas jammed under the body ofthe coach. We all climbed out toview the problem and to take ad-vantage of the unscheduled stop.Obviously this situation was notnew to our driver who quicklyplaced a smaller bolder under therear wheel and inched the coachforward onto the second stone.Willing hands were then able toretrieve the first boulder that wasnow free. Nothing further of notehappened until our next stop forcomfort and food. We had noteaten since breakfast and it wasnow 4 p.m. so the prospect ofbuying a loaf of freshly cookedbread from a small town bakerywas very appealing. After that itwas back to Cusco, an eveningmeal for those with the staminaand then early to bed. The nextitem on our itinerary was MachuPiccu and that meant a train tocatch at 6.30 a.m.

I won’t say we woke bright andearly next day as the altitude wasstill having its effect. However,everyone was excited and no-onemissed the train. Machu Piccuwas a 1000 feet lower than Cuscoso the demands on our red cellswould be lessened somewhat.The train rose out of Cusco ratherlike the coach winding its way upthe hillside, by shuttling back-wards and forwards through theswitchbacks, gradually making itsway upwards before descendinginto the lush vegetation of thetropical rain forest. Juan Carloswas our guide again, and as be-fore he kept us entertained andinformed as we passed throughthe foothills and then very rapidlyinto the steep-sided mountainousregion where Incas mounted theirlast opposition to the invadingSpanish conquistadors.

Finally we arrived at the foot ofMachu Piccu and transferred totwo small buses for our journeyup the mountain. Occasionally aswe turned a corner we caughtglimpses of grey stonework at the


top or the precipitous drop downthe side of the mountain butmostly we could only see thedense vegetation around us. Itwas no wonder that the buildingsabove had remained hidden fromsight for so many years. In thisenvironment, vegetation growsvery quickly; wooden structuresrot and trails quickly disappearfrom view. Juan Carlos explainedthat while the Spaniards pursuedand captured the retreating Incasin the valleys they were far lesssuccessful in the mountains. Itmay have been some 40 years ormore after the main conquest be-fore the Spaniards attempted toventure into some of the higherareas in this region by which timeMachu Piccu and other similarsettlements had been unused formany years and so remained un-touched and hidden by the for-ests. Thus Machu Piccu remaineddeserted for 400 years or moreuntil rediscovered in 1911.

Eventually we reached the top ofthe mountain and piled out of thebuses. Deadlines were explainedto us, plans were announced andwe offloaded surplus luggage atthe hotel. We then set off to ex-plore. Marching through the turn-stiles we felt amazed to see thevirtually complete buildingsahead, the beautifully preservedand ordered terraces and the pre-cipitous sides of the mountainsloping down to the river a 1000or more feet below. All that ap-peared to have been lost in thelast 400 years were the roofs tothe buildings. Again our guidefilled in the gaps! Excavations hadshown that the walls and terraceswere constructed to allow the high

rainfall to drain away without dam-aging the retaining structures.Terrace walls were backfilled withlarge stones, smaller stones andfinally sand to permit drainagebefore the soil on top was added.The sand and the types of stonesused suggested that they hadbeen brought up from the riverbelow. Whether this was doneentirely by manual carriage orwhether ropes and pulleys mighthave been used is not known. Ei-ther way it was a remarkable featto have lifted the materialsneeded to that height. There wasonly one place where some sub-sidence had occurred and thatwas at a temple that had beenunder construction as the occu-pants left the site. Our guideshowed us how some of thestonework at the rear of the tem-ple had still not been finished.Projections from the surface ofone large stone were still evident.Such projections would probablyhave been used to enable thestone to have been levered intoplace. Furthermore the surfacewas rough and projected out be-yond the rest of the wall. However,it was evident that it was under-going treatment for the corner wasalready in line with the rest of thebuilding, and this would have pro-vided a guide for the workmenremoving the excess stone fromthe surface.

When Machu Piccu was first dis-covered and the initial explora-tions carried out, 179 skeletonswere recorded and, because oftheir small size, were believed tobe from women. This inevitablyled to interpretations of ritual sac-rifices, but more recently thebones have been re-examinedand are now believed to havebeen from male priests or personsof noble birth. In other words, thepersons living on the site did verylittle manual labor and they weresupported by the activities of thefarming communities all around.The houses in Machu Piccu arebuilt separately from the terraceson the south side where farmingwas done. Terraces on the steep


western side of the site were prob-ably not used for farming and mayhave provided stability to the maintemple mound. Likewise the smallterraces within the living area mayhave provided stability and sym-metry.

The main site that we visited isoverlooked by the towering moun-tain on the northern side. Thismust rise another thousand feetor so and there were more build-ings and terraces on that land too.We think our guide was pleasedthat there was not sufficient timefor any of us to attempt the climb.He assured us that there weresteps all the way up but that therewere all too frequently fatal acci-dents. The last most recent deathwas of a Russian tourist who,while having his photograph takenat the top by his Peruvian guide,was struck by lightening andkilled. It is obvious that there aresome surprising advantages tosmall stature if you live and workon mountains!

Walking around the site it becameapparent that the quality and fin-ish of the stone walls varied bothbetween buildings and within thesame surface area. Most of thehouses had fine quality stoneworkat the base but the upper half wasrough and probably provided akey for surface plaster to adhereto make it water-proof. Whetherthe plaster was painted and deco-rated or plain like the Inca streetsin Cusco we will never know. Nostatues were found on the site andthe Incas may have only used ormodified pre-existing stoneearthworks to resemble items thatwere important in their culture. Forexample there were two largerock structures that had the pro-file of the mountains behind them.Unfortunately, low cloud obscuredthe full effects on one of these butthe other was plain to see. Otherstructures, particularly wheremummified remains were kept,may have been modified to re-semble the condor in order to re-

tain earthly contact with the heav-ens. A particularly fine example ofthis was the grotto below the tem-ple of the sun where exquisitelycarved rocks and carved-stone-infill created the Royal Tomb.What was also especially notablethroughout the site was the lackof perpendicularity of the walls,doors and windows. This mayhave been both functionally andculturally determined. Culturally,the inward-sloping walls resem-bled the slopes of the surround-ing mountains and the buildingshad a pleasing, inherent symme-try: functionally, the structure mayhave provided protection againstearthquakes.

Finally the time to leave arrived.We had walked around the site forthree to four hours in beautifulsunshine, learning somethingnew at every stop about this an-cient civilization. It was so differ-ent from anything we have in Eu-rope that it was difficult to realizethat this civilization existed in ourMiddle Ages – only 500 years ago.Juan Carlos had captivated ourimaginations with his descriptionsof the origins of Machu Piccu, whyit had been lost, who were its origi-nal inhabitants and the circum-

stances which led to their leaving.What was its original name – itscurrent name is derived from themountain on which it was found.What is being done to preservethe site for future generations? Iffour trains run each day thatamounts to 2000 tourists, not tomention all the back-packers whowalk the Inca trails. Experts havecalculated that the site is slippingat the rate of a centimeter a year.This does not sound very muchbut in 30 years the movement by30 cm could cause a lot of dam-age. Hopefully the problem willbe addressed before that hap-pens. Tourism provides muchneeded help to the people livingin Cusco and the surroundingdistricts but if the site becomedangerous or it loses its appealbecause of deterioration, we willall be the losers.


Dietary diversificationThe complexity and many facets ofdietary diversification were reflectedin the poster session on this topic. Itwas the session that had the great-est number of posters – 30 abstractswere accepted and 23 posters pre-sented – demonstrating the contin-ued effort directed towards this long-term and definitive approach to com-bating vitamin A deficiency.

Several posters reported the levelsof β-carotene and other carotenoidsin foods, with emphasis on local ortraditional foods, such as green leafyvegetables from Sri Lanka (Chan-drika et al.), carotenoid-rich bananasand other foods from Micronesia(Englberger et al.), squashes andpumpkins from Brazil (Garcia et al.)and totai (Acrocomia totai) fruit fromBolivia’s Amazon region (Vasquez-Tato et al.). Also presented were thecarotenoid contents of processedfoods, such as the powder and oil ofthe Vietnamese gac (Momordicacochinchinensis) fruit (Duc et al.) andcommercial processed carrots fromBrazil (Tawata and Kimura). The β-

carotene concentrations of ripe andhalf-ripe mangoes, as well as of driedand stored mango, were also deter-mined in Burkina Faso (Zagré et al.).

β-carotene content, retention and invitro accessibility varied widely in SriLankan green leafy vegetables(Chandrika et al.). However, β-caro-tene retention was similar in threetraditional cooking preparations (withscraped coconut, with water or co-conut milk, fried). All three cookingmethods improved in vitro β-caro-tene accessibility.

Seasonality was found to play amajor role in the availability of locallyproduced β-carotene-rich vege-tables in a rural community in SouthAfrica (Faber and Benadé). This ob-servation has led the authors to em-phasize the importance of process-ing and development of post-harvestproducts to overcome the periods oflow availability.

An updated Brazilian database oncarotenoids (β-carotene, α-carotene,β-cryptoxanthin, lycopene, lutein, ze-axanthin and violaxanthin) was pre-

sented, consisting of 238 food items,including fruits, vegetables, roots andprocessed foods (Rodriguez-Amayaet al.). Only 33 of these food itemscould be found in the U.S. databaseand 26 in the European database.Variations in the carotenoid contentsdue to variety, maturity, productiontechnique, climate, type of process-ing and different brands were dem-onstrated. However, a Brazilian sur-vey of food purchases suggestedthat, despite the wide geographicaldistribution and abundant sources ofcarotenogenic foods, Brazilian urbandwellers appeared to be ingestingamounts of provitamin A carotenoids,lutein and zeaxanthin that fell shortof what would be considered satis-factory (Padovani and Amaya-Farfan). This phenomenon seemedto be related to eating habits and wasmore pronounced in the lower incomebrackets.

A survey in Senegal showed that theproportion of mothers of childrenunder five years of age who judgedthe availability of vitamin A rich foodsfavorably was significantly higher invillages where more than 30% of the

Poster presentations at the XXII IVACG meeting,15–17 November 2004, Lima, PeruJaime Amaya Farfan and Delia B. Rodriguez-Amaya, Universidade Estadual de

Campinas, Campinas, BrasilCarolien Bouwman, University Medical Center Nijmegen, NL Nijmegen, Netherlands;Machteld van Lieshout, Department of Nutrition, North-West University, South AfricaMalavika Vinodkumar, Sundar Chemicals Private Limited, Chennai, Tamil Nadu, IndiaFrank Tammo Wieringa, University Medical Center Nijmegen, NL-Naarden, NetherlandsMarjoleinen Dijkhuizen, University Medical Center Nijmegen, NL-Naarden, NetherlandsMahmoud El Mougi, AI-Azhar University, Cairo, EgyptSantosh Jain Passi, University of Delhi, Dept. of Nutrition and Inst. of Home Economics,

New Delhi 110 016, IndiaLiseti Solano, Centro de Investigaciones en Nutrición, Facultad de Ciencias de la Salud,

Universidad de Carabobo, VenezuelaChristine Stabell Benn, Department of Epidemiology Research, State Serum Institute,

Copenhagen, DenmarkLina Mahy, Helen Keller International, Bamako, MaliGil Cusack, Helen Keller International, Conakry, GuineaTaskeen Chowdhury, Helen Keller International, Bangladesh


households had gardens; and nightblindness during the last pregnancywas less important for these moth-ers (Bendech et al.). The authors sug-gested that the perception of theavailability of vitamin A-rich foods bymothers could be a simple indicator,complementary to the prevalence ofnight blindness in pregnant women,in evaluating programs promoting theproduction and consumption of thesefoods. In Ghana, a project designedto strengthen agriculture, nutritionand gender linkages demonstratedthat integrated planning, informationand resource sharing and strength-ening of institutional bridges had acombined potential for successfullarge-scale food-based programs(Amoaful et al.).

Dietary vitamin A intake and factorsinfluencing it were investigated inseveral countries. In Micronesianchildren, vitamin A intake was low andthere was no statistically significantassociation between vitamin A intakeand gender, caretaker education orsocio-economic status (Englberger etal.). It was concluded that a broad-based intervention was needed toimprove vitamin A intake. Ethnogra-phy was critical for survey tool devel-opment, detecting caretaker-child dif-ferences, and perceptions onTaiwang, the most commonly con-sumed carotenoid-rich banana.Specifying cultivars and maturity im-proved assessment. In theAnnarpurna district of Nepal, a studyto determine the intake of keymicronutrients, including vitamin A,from foods and supplemental sourcesin the diets of mothers and children<5 years showed that the diets wereacceptable (Rigby and Shrestha).The national vitamin A supplementa-tion program was found to have agreat impact on the health status ofNepalese children. In Zimbabwe, anational survey was conducted toverify the different reasons why yel-low maize met resistance in the popu-lation, preliminary results suggestinga gender difference in preference(Malaba et al.). However, in both gen-ders attitudes shifted when the nutri-tional benefits of yellow corn werehighlighted, leading the authors tobelieve that a communication strat-egy was needed to change attitudesfavorably. Two cross-sectional stud-ies in a rural area in Burkina Fasorevealed provitamin A-rich foods’ con-

sumption in children was limited bysocial practice, economical con-straints and food habits (Constanceet al.). Taking these cultural barriersinto account to develop and imple-ment food-based programs might re-sult in a change in behavioral andfood consumption pattern.

A South African study showed a redpalm oil-based spread to be effectivein improving vitamin A status, espe-cially in children with low serum reti-nol concentrations, and hemoglobinstatus in anemic children (vanStuijvenberg et al.). Diets based onbaobab (Adansonia digitata) leaf(Nnam) and sorrel (Hibiscussabdariffa) calyx (Nnam and Onyeke)were also shown to improve the vita-min A status of children in Nigeria,while consumption of Spirulinaplatensis was reported to reduce vi-tamin A deficiency in Malagasy chil-dren (Razafiarisoa et al.).

A United States study in mice indi-cated that the mammary tissue wascapable of increasing the uptake ofvitamin A from circulation when vita-min A deficiency was sensed(O’Byrne et al.). Moreover, the mam-mary tissue appeared capable of tak-ing up very high concentrations ofvitamin A when it was available in thepostprandial circulation, with nomechanism to set an upper limit ofvitamin A incorporated into milk. Theauthors pointed out that this couldresult in adverse physiological con-sequences for the postnatal develop-ment of the skin, testes and possiblyother tissues.

The challenges facing food-basedinterventions were assessed in a Tan-zanian study (Mulokozi et al.). Provi-tamin A carotenoids constituted themain dietary source of vitamin A inthe studied communities. Post-har-vest handling and processing meth-ods had major effect on retention andin vitro accessibility of β-carotene.There was significant variability in theβ-carotene content and accessibilityin yellow/orange fruits and orange-fleshed sweet potato prepared usingdifferent methods. The color and tasteenhanced preference of carotenoid-containing foods by young children.The authors concluded that food in-tervention strategies have the poten-tial of addressing vitamin A deficiencyif food varieties with high content and

accessible provitamin A carotenoidsare consumed regularly and prepa-ration methods that enhance the ac-cessibility and bioavailability of pro-vitamins A are promoted.

In Burkina Faso, out of 26 foodsources of vitamin A, liver, red palmoil, whole milk, eggs, mango fruit,néré (Parkia bioglobosa) fruit, orangesweet potato and green-leaf sauceswere considered the top eight in vita-min A score (Zagré and Delisle). Athree-step strategy was suggested:step 1 – promotion and consumptionof the eight selected foods accordingto seasonal availability and vitamin Asupplementation once a year; step 2– replacement of vitamin A capsulesof step 1 by fortified foods; and step3 – a global dietary diversification withstrong and reliable food system. Redpalm oil is the key food in this plan,thus its production, distribution andpromotion are needed.

Bioavailability andbiofortificationMs Bouwman et al. reported on a sta-ble isotope study with 24 healthyadults in The Netherlands, who con-sumed capsules with 55µg [13C10]β-carotene and 55µg [13C10]retinyl pal-mitate daily for 21 days plus a control-led diet containing 4.5mg β-carotenein oil/d. With the plateau isotopic en-richment model the researchers foundthat 3.2µg (95% CI 2.7– 3.7) has thesame vitamin A activity as 1µg retinol,which is in line with previous studies.

Drs Burri and Clifford reported quali-tative findings observed in specimencollected from volunteers consuming14C-labelled β-carotene and lutein.Worldwide only 30 laboratories areequipped with accelerator massspectrometry (AMS) equipment, usedfor detection of isotopic enrichment ofcompounds of interest, even uniden-tified metabolites of cleavage. Limitedaccess to AMS may hamper progressof this technique. Dr Burri advised thatthe technique, although still in its in-fancy, should be developed further forstudying carotenoid metabolism inwell-designed studies with adequatepower.

Dr Haskell et al. reported on the useof the paired deuterated retinol dilu-tion (DRD) technique for estimatingtotal body vitamin A stores of 70


healthy dewormed Bangladeshi men,with adequate vitamin A status, be-fore and after supplementation for 60days with one of 5 treatments:2.25mg β-carotene/d in orange-fleshed sweet potatoes (OFSP), “In-dian spinach”, or oil, or 1.37 mg retinylpalmitate/d in oil, or a low vitamin A-vegetables diet and a placebo cap-sule. The researchers found the fol-lowing vitamin A equivalency factors(β-carotene:retinol, wt:wt): OFSP~13:1, Indian spinach ~10:1 andβ-carotene in oil ~6:1. Unfortunately,no measure of spread around theseestimates was provided. Hence it isdifficult to compare them with previ-ously reported estimates.

Biofortification includes increasing thenutrient content of foods via conven-tional breeding or transgenic methods,and also altering the content of effec-tors in order to improve bioefficacy/bioavailability of nutrients. Dr Bendechet al. reported about the determinationof the carotenoid content of 10 varie-ties of sweet potatoes. The high andhomogeneous β-carotene content ofthe Jewel variety combined with itsgood agricultural yield makes it thebest variety for promotion in garden-ing at the village level in Burkina Faso.However, the Jewel variety containsa lot less β-carotene than the OFSPvariety studied by van Jaarsveld et al,1.9 vs. 10-19mg β-carotene/100g. DrKapinga et al. reported about the Vi-tamin A for Africa (VITAA) partnershipand one of its food-based initiatives,i.e. increased utilization of OFSP. Ex-ante impact assessment showed thatreplacement of traditionally con-sumed, colorless sweet potato by aslittle as 100 g of OFSP/d (containing~10mg b-carotene) could resolve vi-tamin A deficiency completely for 85-95% of those children most at risk incountries such as Rwanda, Burundiand Uganda. It is our opinion that be-cause of its low bioefficacy provitaminA-rich fruit and vegetables may havelimited potential for reversing existingvitamin A deficiency, but they shoulddefinitely be promoted as a prophy-lactic measure against vitamin A defi-ciency. Dr van Jaarsveld et al. pre-sented 2 posters on the β-carotenecontent of OFSP. In an elegantly de-signed series of studies, it was foundthat carotenoid biosynthesis continuedin both in-ground and room tempera-ture stored OFSP. As a preservationtechnique, OFSP can be cut into chips

and dried, either by the sun or in anoven. Drying results in lower β-caro-tene concentrations in the chips.Losses are greatest in chips dried infull sun, followed by drying in theshade. Losses were smallest in oven-dried chips, especially in the thickerslices. These results show the impor-tance of choosing β-carotene-rich rawmaterial for processed products. DrVebamba et al reported about identi-fying practices related to the produc-tion, conservation, and consumptionof sweet potato, both white and or-ange-fleshed varieties, in 16 villagesin Burkina Faso. Sweet potato was of-ten consumed as a snack in betweenmeals. Although the results presentedwere only based on a limited numberof villages, findings are promising,which indicates that production andconsumption of OFSP should be pro-moted in Burkina Faso and manyother countries.

FortificationProf. Aguenaou presented a studywith the objective of setting up a reli-able spectrophotometric method toassess the vitamin A content in forti-fied oils and to validate it against anHPLC method. Soyabean and sun-flower oil were fortified with retinylpalmitate and fortified samples in rep-licates were analysed by Carr- Priceand HPLC methods. Each methodwas statistically evaluated forrepeatability and reproducibility. Theobserved variations in the mean re-sults obtained by the two methods foreach level of fortification was 5.7%and 6% for soyabean oil and sun-flower oil (P>0.05). The coefficient ofvariation was <10%. Since mean re-sults for given levels of fortificationwith vitamin A were similar for HPLCand the Carr-Price method, the meth-ods are comparable and supply sta-tistically identical results.

Dr Capanzano presented a poster onthe takal system of packaging sugarin the Philippines. The stability of vi-tamin A repacked in opaque andtransparent polyethylene (PE) andpolypropylene (PP) bags and storedin simulated market conditions (fluo-rescent light and indirect sunlight)was studied. The sugar was moni-tored by spectrophotometric methodsfor color and vitamin A content. It wasshown that the vitamin A content ofsugar stored in transparent or white

PE bags in indirect sunlight fell from15.4 µcg/g to 4.6 and 5.2 µcg/g re-spectively after only one month.When stored under fluorescent lightthe values dropped from 15.4 to 5.2(transparent PE) and 4.9 µcg/g (whitePE) after four months. Vitamin A lev-els of sugar stored in opaque PP bagsonly dropped from 14.5 µcg/g to 5.7mcg/g (sunlight) and 7.3 µcg/g (fluo-rescent light) in the course of eightmonths. These results would be use-ful to retailers using the takal system.

The objective of a study presentedby Prof. Diosady was to incorporateiodine (30–100 µcg/g), iron(1mg/g = 30% of RDA) and vitamin A(150 µcg/g = 30% of RDA) in salt. Theposter delineated the different com-binations of vitamin A, potassium io-date and ferrous fumarate or ferricEDTA and their encapsulation withdifferent materials such as HPMC,soy stearine, opadry and titanium di-oxide. Commercial household saltwas obtained from Kenya and Nigeriaand the vitamin A and mineral premixwas added at the 1% level. Salt sam-ples were followed through normalsalt distribution in four areas of Kenyaand Nigeria and also stored in envi-ronmental chambers in the labora-tory. The study confirmed that it istechnically feasible to produce triplefortified salt that will retain at least50% of the added vitamin A for thetypical time that salt is stored be-tween manufacturing and consump-tion. The used formulation retained45% of the vitamin A, 94% of iron inferrous form and 89% of iodine after3 months in the field.

Ms Medrano presented a poster onhuman milk response to one-year ofsugar fortification with vitamin A inNicaragua. The conclusions reachedwere that the vitamin A content ofbreast milk was generally adequate.The vitamin A content of breast milkdid not improve over time with in-creased duration of exposure to vita-min A. This may be because mater-nal milk was resistant to any effectfrom the fortificant in sugar or be-cause milk vitamin A response hadoccurred and stabilized before basalsamples were collected. The authorsattribute both adequacy and lack oftime-dependent improvement in milkvitamin A to the presence of fortifiedsugar in the market at both ends ofthe study.


Caroteno Tocotrienol carotene mixedconcentrate (CTCMC) is a reddishviscous odorless palm fruit derivativewhich has 75000 PPM of mixed αand β-carotene content. Tomato andgreen sauces were prepared with5.7% processed red palm oil. In con-clusion the authors feel that thestandard red palm oil is too dilute tomake a meaningful contribution ofvitamin A in a condiment sauce, butrecipes made from an appropriatelyadjusted oil derived from dilutedCTCMC should be able to providean efficacious and effective and safedietary source of vitamin A.

Prof. Rojas presented a poster on twonutritional programs developed by thegovernment of Peru – PANFAR forchildren and their mothers andPACFO for children 6–36 months.PANFAR delivers a food basket thatwas designed to cover 30% of theenergy and protein requirements of2 adults and 2 children under 5 yearsof age. PACFO delivers a fortified in-stant porridge that offers 30% of theenergy requirements and 100% ofvitamin A and iron requirement. Theaim was to quantify the consumptionof vitamin A and iron from comple-mentary foods and to determineanaemia prevalence in PANFAR andPACFO beneficiaries as well as se-rum retinol deficiencies of PANFARbeneficiaries. Results showed thatPANFAR contributed 3.2% and 6.5%of vitamin A and iron requirements.With the porridge delivered byPACFO over 100%of the require-ment of vitamin A and iron were cov-ered. Retinol deficiency was preva-lent in 27% of the children andanemia prevalence in PANFAR chil-dren was 48.9% and 61.5% of thechildren in the PACFO group wereanemic.

Mrs Vinodkumar presented a studyaimed at testing the efficacy of mul-tiple micronutrient fortified salt in im-proving the health status of schoolage children. The stability of themicronutrients during storage andcooking was confirmed, as was theirbioavailability. Thus the feasibility oftackling multiple micronutrient defi-ciencies through the use of commoncooking salt fortified with vitamin A,iron, iodine and B-complex vitaminswas demonstrated.

AssessmentThe theme Assessment was coveredby several posters presenting meth-odological innovation, improvementand validation.

The poster by N Craft titled ‘Use ofthe CRAFTi Portable Fluorometer toMeasure Vitamin A in Fortified Foodsand Blood’ featured an innovativeanalytical instrument to measure vi-tamin A in fortified foods and bloodsamples, offering very field-friendlytesting that is comparable to stand-ard methods. Comparison was madewith HPLC for plasma and HPLC andspectrometry for fortified sugar sam-ples. Correlation was 0.82 for theplasma analysis and more than 0.99and 0.98 for comparison with HPLCand spectrometry in sugar samplesrespectively.

In a poster titled “Validation of themodified relative dose response testagainst liver vitamin A for applicationto infants and women using a swinemodel”, SA Tanumihardjo showed thevalidity of current cut-offs of theMRDR test, and the feasibility of re-ducing sample volumes by more thanhalf. MRDR values were comparedto hepatic vitamin A reserves inweanling piglets and sows with abroad range of vitamin A status in pig-lets. MRDR results correspondedwell to vitamin A liver reserves in ani-mals with adequate, marginal as wellas deficient liver reserves. A samplevolume of only 200 microliter ofplasma will allow easier applicabilityof the MRDR, especially for infants.

T Issa-Some presented a poster ti-tled “HPLC methods for vitamin A inserum and carotenoid analysis: Re-sults of validation procedure”, a vali-dation study of HPLC methods forvitamin A and carotenoid analysis inBurkina Faso. Retinol and carot-enoids in hexane, and plasma sam-ples spiked with retinol were used forthis validation study. Results showedsatisfactory quality of the laboratoryanalysis, with good linearity (0.99),recovery (100% +10) and precision(coefficients of variation <10%).

The other posters on the theme ofassessment focused on indicatorsand definitions of deficiency. RBP andDried Blood Spot (DBS) methodologywere compared to retinol and serum

samples in a poster by N Craft titled“Comparison of indicators of vitaminA status in Thai children”. In this studyserum retinol corresponded less wellto DBS retinol than expected, but thecorrelation improved after correctingfor serum volume calculated from theDBS sodium concentration. Thestudy showed good comparabilitybetween RBP and serum retinol butunfortunately represented only a nar-row range of (almost normal) vitaminA states, with no vitamin A deficiencyand a very low prevalence of marginalstates represented.

S Sankaranarayanan presented aposter titled “Higher concentrations ofholo-retinol binding protein in vitaminA-sufficient compared to -deficientNepalese women”. In this study,RBP-concentrations in pregnancywere investigated in Nepal. In womenwho were not vitamin A deficient,holo-RBP concentrations were signifi-cantly higher later in pregnancy, whilein vitamin A-deficient women holo-RBP concentrations were not onlylower, but also did not increase laterin pregnancy. This implies that in vi-tamin A deficiency also transplacen-tal transport of retinol may be im-paired as indicated by continued lowlevels of holo-RBP in the last trimes-ter. Therefore vitamin A supplemen-tation during the last trimester is sug-gested in vitamin A deficient women.

The poster “Infection and inflamma-tion may influence multiple micronu-trient status in pregnant women: Find-ings from Nepal” by T Jiang raisesquestions concerning the determina-tion of status and definitions of defi-ciency. Micronutrient status assess-ment, combined with measurementof acute phase proteins (CRP andAGP) in 1165 pregnant womenshowed that raised acute phase pro-teins were significantly associatedwith lower (especially vitamin A, E,B6, and carotenoids) or higher con-centrations of several micronutrients.This indicates that infection and in-flammation can influence concentra-tions of some micronutrients, withconsequences for the validity of cut-off values presently used.

FT Wieringa, in the poster titled “Es-timation of vitamin A deficiency in in-fants”, questions cut-off values forretinol in infants that are currentlyused, based on results from studies


in Indonesia. After cross-sectionaldata showed a strong correlation be-tween micronutrient status of themother and infant, comparison of theprevalence of vitamin A deficiencyafter supplementation in mothers andtheir infants showed a much higherprevalence of vitamin A deficiency inthe infants than expected from theeffect of supplementation in the moth-ers. This could be explained by anover-estimation of deficiency in in-fants by using the present cut-off val-ues in this age group, and a moreappropriate cut-off of 0.50 µmol/l in-stead of 0.70 µmol/l is proposed formarginal deficiency in infants.

The poster “Development of screen-ing indicators for ranking areas at riskof vitamin A deficiency in Thailand” byK Maleevong presented an innovativeapproach towards surveillance. A setof proxy indicators were developedthat are cost-effective and not inva-sive, ranging from land ownershipand socio-economic status indicatorsto nutritional status and presence ofcertain infections. This set of indica-tors is then used as a screening toolfor large-scale assessment of risk forendemic vitamin A deficiency. Com-parison of the screening tool to re-sults from serum retinol assessmentsurveys in children was used to se-lect the six most efficient indicators andto validate the cut-offs, resulting in atool with >80% efficiency of identify-ing VAD as a public health problem.

InfectionThe association between vitamin Astatus and severity of acute respira-tory infection in infants and young chil-dren was studied by El Mougi et al.Cases (n=25) included 25 pneumoniaand severe pneumonia and controls hadcolds. Serum retinol was lower in pneu-monia and severe pneumonia versuscold; however, the difference did notreach statistical significance. ARI andin particular pneumonia and severepneumonia tend to be associated withlow or marginal serum retinol.

Sequestration of vitamin A in a mea-sles model in male rats was studiedby SH Gieng et al. Lower plasma reti-nol was accompanied by higher he-patic retinol. Hepatic and renal retinylpalmitate and retinoic acid and renalmegalin content and functionality didnot differ between groups. Low plasma

retinol may be explained by increasedretinol catabolism or by sequestrationin the liver. Beside the obviousmisclassification of vitamin A status dueto inflammation, more important is todetermine how retinol is sequesteredand whether vitamin A deficiency inextrahepatic tissues is caused. Theauthors suggest that, because reti-nol is sequestered in the liver duringinflammation, vitamin A deficiencymay be caused in other tissues.Therefore, Vitamin A supplements arerecommended during measles infec-tion. Comment: Before reaching thisconclusion, controlled clinical trialsneed to be performed on measlescases with known vitamin A status.

L Gouado et al. investigated the rela-tionship between vitamin A and E sta-tus and malaria among Camero-onians. Serum vitamins A and E weremeasured in 45 malaria patients and33 controls. Results demonstrated asignificantly lower vitamin E concen-tration (p<0.001) among malaria pa-tients as compared to the controls.Among malaria subjects 88.8%showed low vitamin A levels (< 20 µg/dl). The study suggests that plasmo-dium falciparum infection leads to adecrease in serum vitamin A and Econcentration. Comment: It can beconcluded from this study that thereis an association between malariainfection and vitamins A and E statusbut the design cannot tell whichcomes first, the infection or the defi-ciency i.e. cause and effect.

The case-control study by H Kouraet al. aimed to find a possible rela-tion between vitamin A status andseverity of dehydration in infants andchildren <5 years of age with diar-rhoea. Children (n=25) with some orsevere dehydration were comparedto controls (n=25) without dehydra-tion. The serum retinol was lower insome (n=20) and severe (n=5) de-hydration (23.5 ± 10.7 and 24.5 ± 20.0µg/dl) than no dehydration (28.2 ±8.6). The positive RDR test washigher among controls than casesand the difference was statisticallysignificant (p=<0.01). Vitamin A defi-ciency was not a risk factor for se-verity of dehydration.

The vitamin A status was assessedby conjunctival impression cytology(CIC) in a study presented by J Lealet al. They showed lower serum val-

ues of interleukin-10 in children withvitamin A deficiency disorders. Nochild presented with clinical evidenceof VAD. CIC showed that 67 (48.6%)had abnormalities indicative of sub-clinical VAD. Diminished serum IL-10was detected in VAD children in com-parison to those with normal CIC(controls) (4.41 ± 1.27 pg/ml vs. 6.03± 3.90 pg/ml) (p<0.03). The rest ofstudied cytokines did not show signifi-cant differences with respect to con-trols. Conclusion: The IL-10 diminu-tion in VAD children would be relatedto alteration of inflammatory responseat the level of respiratory and intesti-nal epithelia affected by infections.

The effects of multiple micronutrientsupplementation on the iron, vitaminA and zinc status of adult men (n=63)and non-pregnant and non-lactatingwomen (n=116) living with HIV/AIDSwas investigated by ASW Mburu etal. in a double-blind placebo-control-led study. As supplementation inter-vention the UNICEF multiple micro-nutrient with added β-carotene wasused. A food ration of precookedmaize:soya flour (90:10) was providedto both groups. Follow up was for aperiod of 6 months. In the placebogroup Hb at week 12 was significantlyhigher than baseline Hb (p<0.05).There were no significant longitudinaldifferences in the supplementedgroup. At week 12, β-carotene con-centrations in the supplementedgroup were significantly higher thanat baseline (0.262µmol/l and0.754µmol/l at week 12 (P<0.001)).β-carotene concentrations at week 12were higher in the supplementedgroup than in the placebo group(0.754µmol vs 0.210µmol/l). Therewere significant differences in retinolconcentration between baseline andweek 12 in both groups: supplements(baseline 1.23 µmol/l, week 12: 1.42µmol/l (P< 0.05)) and placebo (base-line 1.20 µmol/l; week 12: 1.37 µmol/l (P< 0.05)). Zinc concentrations didnot change significantly betweenbaseline and week 12 or betweenthe two groups. Zinc and retinol’splasma proteins are both negativeacute phase reactants, possibly ex-plaining the absence of significantdifferences between groups. Thesuppression of circulatory iron con-centration due to HIV induced in-flammation possibly resulted in theabsence of changes in Hb concen-trations in the supplemented group.


The protracted effects of inflamma-tion in HIV emphasize the impor-tance of identifying additional mark-ers less influenced by infection tobetter assess the effect of supple-mentation.

RZ Oumarou et al. investigated se-rum retinol, infection and intestinalparasites in vitamin A supplementedchildren in Niger in 102 children aged24–36 months. The rate of low se-rum retinol (<0.7µmol/l) 3 monthsfollowing supplementation wasbarely lower than before taking thesupplement (34.4 vs 39.8%). Intes-tinal parasites, protozoa (G.intestinalis, E. histolytica) werepresent in nearly 60% of children.Better vitamin A status was signifi-cantly associated with the absenceof intestinal helminthes (H. nana, E.vermicularis), presence of home la-trines and access to running water.Children with symptoms of infectionin the previous 2 weeks tended tohave lower serum retinol concentra-tions than children who had not beenill. It is concluded that additionalmeasures of sanitation and controlof infection/infestation are requiredto increase the effectiveness of vita-min A supplementation.

The effect of vitamin A supplemen-tation on children suffering from tu-berculosis was assessed by VPurushothaman et al. Patients(n=100) were 2–8 years old andwere selected from a TB sanatorium.They were subjected to Mantouxtest, chest x-ray and erythrocytesedimentation rate (ESR) test. Outof these, 15 children with active TBand low serum retinol were chosenfor supplementation. Another 15 withlow levels of serum retinol and andno TB were chosen from an elemen-tary school. Five children from eachgroup served as control while theremaining 10 were supplementedorally with vitamin A 200,000 IU threetimes (Comment: no mention of theschedule of vitamin A administrationregarding the timing, though authorsclaim that they followed the WHOsuggestions). After supplementationserum retinol in the vitamin A defi-cient children increased from 18.5 to23.5 µg/dl. Their ADA (adenosinedeaminase test) decreased and cell-mediated immunity increased. ESRdecreased and WBC count was notchanged. It is concluded that vita-

min A supplementation shows labo-ratory evidence of improved immu-nity among TB-afflicted children.However, it would be necessary tostudy the impact on the clinicalcourse or outcome.

A cross-sectional study on the effectof red palm oil on respiratory tract in-fection among adolescent school girls(13–15 years old) was conducted byN Sujtana et al. Each girl of the sup-plemented group received 4 biscuitsdaily made by adding red palm oilcontaining approximately 1500 ug ofβ-carotene for 90 days. (Comment:the authors did not mention how girlswere randomized and if the controlgroup received any placebo. Thestudy is also not blinded. Ninety daysis a relatively short period for observ-ing any meaningful change in height.Also the ARI is not defined or howfrequently recall information aboutARI was collected. Furthermore,compliance to intake of biscuits wasnot discussed, particularly measurestaken to assure the regular intake). A24-hr dietary survey revealed that themean vitamin A intake of study andcontrol groups were 748.5 ± 62 IUand 776.9 ± 72 IU respectively. Girlsreceiving biscuits had a 15% aver-age positive growth (height for age)while controls did not show suchchange. Incidence of ARI was re-duced from 38% to 17% with overallimprovement of 21%. This was notobserved in the control group.

Maternal and newbornoutcomesIn this section, the study entitled“Maternal vitamin A status and lev-els of vitamin A in breast milk: A studyconducted in a semi-urban commu-nity of Pakistan” aimed to assess thenutritional adequacy of breast milkof malnourished mothers as well asassess the serum retinol concentra-tions of these women during preg-nancy and relate them to the retinollevels in their breast milk. The resultsindicate that although the breast milkquantity was adequate, the meanserum retinol as well as the meanbreast milk retinol was significantlylow for meeting the vitamin A needsof the babies.

In another study, “Vitamin A: Dietaryintake and blood level at the begin-ning and the end of the gestational

period – Botucatu, Sao Paulo Bra-zil”, the vitamin A status of 235 preg-nant women was assessed at the20th and the 37th week of gestation.It revealed that vitamin A intake ofthe subjects was inadequate andthat their serum retinol levels werequite low (below the cut-offs) in boththe early and late gestational peri-ods.

A case-control study entitled “Mater-nal vitamin A intervention and infan-tile vitamin A nutriture” was designedto assess the impact of vitamin A in-tervention on maternal and infantnutritional status. Results of dietaryintervention (GLV) on 200 subjectswith sub-clinical VAD (cases) whencompared with the matched controlsrevealed that the intervention had agood impetus and directly influencedthe maternal as well as the neonatalvitamin A status. The infant’s nutri-tional status was influenced by ma-ternal weight gain and postpartumBMI while the serum retinol had abearing on hemoglobin status of themothers. Dietary interventions re-sulted in better outcome in terms ofweight gain during pregnancy, post-partum BMI, volume and retinol con-centration of breast milk, maternal(biochemical) parameters, birthweight as well as anthropometry ofthe infant.

The study “Low breast milk vitaminA and associated risk factors amonglactating women of the Karen tribein Northern Thailand” assessed thebreast milk quality and the associ-ated risk factors for xeropthalmiaamong lactating mothers (2 monthsto12 months postpartum). Resultsindicated that the breast milk vitaminA levels of the Karen (lactating)mothers were lower than normal.The risk factors associated with lowbreast milk vitamin A levels were lowmaternal energy/fat intake by thesemothers during the dry season aswell as by the mothers living in themountainous areas. Planned dietaryinterventions targeted at the moth-ers in the case-reported area couldimprove the quality of breast milk andcould control infantile xeropthalmia.

In the study entitled “Effects of vita-min A supplementation on immunityin pregnant and lactating Ghanianwomen” the effects of vitamin A sup-plementation (VAS) on cellular and


humoral immunity were studiedamong pregnant and lactating moth-ers. The results indicated that VASin pregnancy might increase cell-mediated immunity to malaria, re-sulting in a lower prevalence of ac-tive infection at delivery and, there-fore, lower levels of malaria specificIgG. Though requiring further inves-tigation, the study suggests that VASmay have clinically important effectson immune functions in pregnantand lactating women.

The study on “The role of grand-mothers “Muso koroba” in strength-ening postpartum vitamin A supple-mentation in Mali” aimed to strength-en the role of grandmothers as keyhousehold health advisors by in-creasing their knowledge about pri-ority nutrition practices. The resultsindicated that the influential grand-mothers motivated the young preg-nant/lactating women and those withyoung infants to attend specializedmedical care and consume vitaminA supplementation at the healthcenters, thus forming a basis for pro-moting the acceptance of new com-munity norms as well as facilitatingthe adoption of improved practicesby the families.

In a hospital based study “Changesin vitamin A status during preg-nancy”, the maternal vitamin A sta-tus of 132 Venezuelan women fromlower socio-economic strata wasassessed between 12 and 33 weeksof gestation. The results indicatedthat vitamin A status during preg-nancy is highly variable and that theserum vitamin A levels may de-crease even when the dietary in-takes increase.

The animal study “Vitamin A defi-ciency and transplacental vitamin Adelivery” aimed to understand howoptimal transfer of vitamin A to thedeveloping fetus is achieved (in ani-mal models) as well as to identify theorigin(s) of adverse consequencesassociated with impaired maternalvitamin A status. The findings indicatethat mice lacking RBP provide auniquely useful model to study theimpact of maternal vitamin A statuson transplacental delivery of vitaminA. The data elucidates the role ofmaternal retinol-RBP and postpran-dial vitamin A in maintaining normalfetal development. Moreover, in

cases where the deficiency is severe,adequate distribution of the vitaminto the developing tissues is affected.

The study “Strengthening vitamin Asupplementation programmesthrough effective monitoring: Expe-riences from India, South Africa andUganda” evaluated in detail themethods used to review, monitor andstrengthen the vitamin A supplemen-tation programmes in these coun-tries. The results indicated that in allthe three countries coverage of chil-dren 6–11 months was higher thanthose aged 12–59 months, particu-larly where supplementation wasprovided through routine services.The coverage varied by the catch-ment area, as well as by the level ofplanning and social mobilization.

The study entitled “Monitoring of vi-tamin A supplementation in UttarPradesh reflects challenges, needfor capacity building” was designedto determine the quality of servicesdelivered during vitamin A supple-mentation and routine immunization(VAS/RI) days and also assess thegaps in capacity building, informa-tion, education and communication(IEC), supply and logistics. The re-sults indicate that there are still widegaps in the VAS/RI service delivery,highlighting the need for training andcapacity building of the field-levelfunctionaries. Activities must beprioritized in order to ensure thatmothers and caregivers understandthe importance of Vitamin A and takeadvantage of the integrated pro-grams.

Multiple micronutrientsOnly one poster was presented inthis section, on the effect of vitaminA and zinc supplementation on im-mune response in Indonesian pre-school children. Kartasurya and col-leagues had noted that very fewstudies had addressed the effect ofcombined vitamin A and zinc supple-mentation on immune function. Theyrandomized children into two groupsthat received a daily supplement ofzinc or placebo for 4 months. Bothgroups also received a capsule ofvitamin A after 2 months. Blood sam-ples were collected just before vita-min A supplementation and after 4months. Thus four groups were com-pared, though not at the same time

point: zinc only, vitamin A only, zincplus vitamin A, and no zinc no vita-min A. There was a significant de-crease in the prevalence of VAD inthe zinc plus vitamin A group, but notin the vitamin A only group. The dif-ferent treatments had no effect ontotal IgG levels or mean total sali-vary IgA levels, and no interactionbetween zinc and vitamin A was ob-served, though a tendency towardshigher levels of IgG and IgA in thezinc plus vitamin A group was noted.

Determinants of vitaminA deficiencyThree studies reported on the deter-minants of vitamin A deficiency, in-cluding one on “Seasonal influencesof vitamin A intake in pregnancy out-come in women from urban slumsof Delhi”, wherein an effort has beenmade to assess different maternalfactors that influence the incidenceof birth weights. The study was alsoundertaken to assess whether fluc-tuations in seasonal availability andconsumption of fruits and vegetablesinfluence the pregnancy outcome/birth weight of the baby. The studyindicates the influence of maternalnutritional status on pregnancy out-comes and that the babies born inFebruary and March had the high-est, while those born in August hadthe lowest mean birth weight. Fur-ther, the incidence of low birth weightdeliveries was at a minimum duringMarch and highest during August.Seasonal availability of micronutrientrich foods particularly DGLV andother vegetables/fruits, and their in-creased consumption (even bywomen from poor communities)bring about an improvement in birthweight/pregnancy outcomes.

A case-control study entitled “Riskfactors for night blindness amongnon-pregnant women from Indone-sia” was carried out on 1,217 non-pregnant women (with clinical symp-toms of VAD) and 3,306 randomlyselected controls. The results indi-cated that the prevalence of nightblindness in non-pregnant womenwas high in some parts of Indonesiaand during pregnancy it was abovethe threshold of public health prob-lem. Night blindness during preg-nancy was strongly related topresent night blindness.


In this section another case-controlstudy entitled “Risk factors forxeropthalmia among mothers andtheir children and for mother-childpairs with xeropthalmia in Cambo-dia” covered >15000 households. Itwas found that xeropthalmia clustersamong mothers and children inCambodia are associated with di-arrheal disease. Interventions toaddress vitamin A deficiency shouldfocus on vitamin A intake as well asthe diarrhoeal disease and be aimedat the household level covering life-cycle approach.

Recent surveysThirteen posters were presented inthis section, coming from very differ-ent countries: Morocco, Eritrea, Is-rael, USA, South Africa, Jordan, Bra-zil, Venezuela, Nigeria, India, andVietnam. Most of the studies wereepidemiological studies at a nationalor community level. They were ori-ented to different aspects of vitaminA deficiency in vulnerable groups.Some of the studies were basedexclusively on vitamin A dietary in-take but most included anthropo-metrical measures and biochemicaldeterminations like retinol, iron andzinc levels.

El Kari, from Morocco, presented astudy designed to determine thedaily vitamin A intake and its impacton nutritional status in pre-schoolchildren. He showed that vitamin Adaily dietary intake is low, that theprincipal source is from vegetablesand that also the area of residenceand the number of children of thehousehold are risk factors.

Z Alemu, from Eritrea, presenteddata from a national survey in pre-school children on xerophthalmia,retinol levels, dietary intakes andgrowth status. CL Coles showed in-formation from Israel on vitamin Aprevalence and risk factors for sub-clinical deficiency in Arab Bedouinchildren. The results from Eritrea andfrom Israel indicated that vitamin Adeficiency is a public health problemamong the groups evaluated andthat concerted actions should be ini-tiated.

In desert Bedouins, IMD Khatib, fromJordan, measured retinol, α-toco-pherol, ferritin and hemoglobin and

assessed growth and food con-sumption patterns. Vitamin A defi-ciency is a public health problemamong the Bedouin children, as isanemia and iron deficiency. Factorssuch as urbanization, poverty andchanges in life styles are relevant forthe risk of deficiency.

In a community-based study fromSouth Africa, MA Dhansay deter-mined vitamin A, iron and zinc sta-tus in preschool children. He indi-cated that even though vitamin Adeficiency has not increased com-pared to the 1994 survey, other mi-cronutrient deficiencies have doneso. Multi-micronutrient supplemen-tation is required.

Interesting information from Brazilpresented by I Kruze estimated themicronutrient status of overweightand obese adolescents of an urbanarea of northern Brazil by anthropo-metrical, dietary and biochemicalindicators. Eating practices by over-weight and obese adolescents arekey factors predisposing to vitaminA deficiency, anemia and zinc defi-ciency.

A report from Maracaibo city, Ven-ezuela, by J Leal, showed a veryhigh co-existence of deficiencies ofmicro and macronutrients in pre-school children (24 to 84 months ofage) assessed by prevalence ofanemia, vitamin A deficiency andgrowth retardation. Vitamin A defi-ciency and anemia affected about22% and 40% of the population re-spectively, while stunting and under-weight were present in a smallernumber of children. L Solano, fromVenezuela, showed data from thelast national survey (2001-2002) onchildren from 6 to 59 months of age.Based on retinol levels a marginalstatus in 5.27% of the children wasfound. This means there is currentlyno public health problem with thisvitamin, but in order to prevent fur-ther deterioration a prophylactic pro-gram should be implemented.

Maziva-Dixon, from Nigeria, pre-sented data from a national surveyon food consumption and nutrition,particularly vitamin A status of pre-school children. Vitamin A deficiencyis a severe public health problemaffecting 29.5% of the children un-der five years of age, which differs

depending on the agro-ecologicalarea and living sectors.

A similar report was presented by NArlappa, from India. Preschool chil-dren from rural areas had milderforms of vitamin A deficiency but itstill is a public health problem. Assupplementation coverage and di-etary intake are low, strengtheningof prophylaxis programs is an urgentneed. Also from India, K Paintal pre-sented data on dietary intake of vi-tamin A and iron, as well as on thenutritional status of nursing mothers.The vitamin A milk content and itsimpact on growth and morbidity oftheir infants was studied. Paintalsuggested a possible relationship ofmaternal vitamin A and iron statuswith growth, development and mor-bidity of the child. Breastfeeding isimportant for the morbidity pattern,probably because of the decreaseof maternal vitamin A stores. A largenumber of children with growth fal-tering and moderate/severe under-nutrition was also reported. P Pathakinvestigated the prevalence of nightblindness amongst pregnant womenfrom a rural area in India. Night blind-ness and poor dietary intake ofβ-carotene were highly frequent inpregnant women, establishing theneed for more attention and effortsto improve vitamin A status duringpregnancy.

The prevalence of anemia, and zincand vitamin A sub-clinical deficien-cies in infants aged 5 to 8 monthsfrom the northern mountainous areaof Vietnam were studied by NX Ninh.Very high prevalence of anemia, zincand sub-clinical vitamin A deficiencywere reported in infants (5–8 monthsold) from the northern mountainousarea, representing a severe publichealth problem. Nutritional and prac-tical communication, multi-macronutrient supplementation orprovisions of complementary fortifiedfood are necessary.

Alternative sizesupplementsThe World Health Organization hassponsored a study involving severalcountries which suggested that thecurrent supplementation schedulerecommended by WHO for postpar-tum mothers (200,000 IU within 6–8wks after delivery) and young chil-


dren (one time administration of50,000 IU to children less than 6months old and 100,000 IU every 4–6 months for children 6–12 months)is inadequate and therefore unlikelyto sustain an adequate vitamin A sta-tus of these vulnerable groups. How-ever some countries are still attempt-ing to assess the effectiveness of analternative dosage of vitamin A.

One poster was presented on theimpact of different doses of vitaminA on childhood morbidity and mor-tality. Benn and colleagues arguedthat, based on existing studies ofdifferent doses, there may be poten-tial benefit to be derived from reduc-ing the dose of vitamin A supplemen-tation. During a combined oral poliovaccine (OPV) and vitamin A cam-paign they randomly assigned chil-dren receiving OPV and VAS to agroup receiving the WHO recom-mended dose (100,000 IU to chil-dren 6–11 months of age, 200,000to children 12–59 months of age) orto one receiving half this dose. Therewas a tendency for mortality to bereduced among the children whoreceived the lower dose. Surpris-ingly, there was a strong sex-doseinteraction; whereas boys tended tobenefit more from the WHO recom-mended dose (MR=0.50 (0.19–1.34)), girls who received the WHOrecommended dose had significantlyincreased mortality in the subse-quent 6 months (MR=5.38 (1.55–18.6)). The optimal dose of vitaminA may differ for boys and girls.

SupplementationTo eliminate vitamin A deficiency(VAD), supplementation programshave proven a simple, low cost andmost effective solution. While long-term action to improve the vitamin A

content in the diet is crucial, it is noteasy to achieve for the entire popu-lation. For this reason, many govern-ments around the world have takenup supplementation of infants, pre-school children and postpartummothers through distribution of vita-min A capsules (VAC). Several post-ers presented the coverage ratesand other findings related to supple-mentation programs.

Data (Akhter et al.) from the Nutri-tional Surveillance Project (NSP) ofHelen Keller International (HKI)showed that the VAC coverageamong 6–11 months old children isonly 70.6% and coverage variedamong sub-districts (9–96%) al-though the national policy is to sup-plement all children by the age ofnine months along with measles im-munization. Findings from Indonesia(Halati et al.) on assessment of di-etary intake of Vitamin A among chil-dren who received or did not receivea VAC showed that the dietary in-take of vitamin A was lower than thedesired level in children aged 6–59months in both a rural and an urbanpoor area, and that non-recipients ofVAC had an even lower intake in theurban poor area. These findingspoint out the alarming situation thatmay arise if programs are not cor-rectly directed.

A poster from Cameroon (Haselowet al.) described the efforts beingmade to solve the vitamin A defi-ciency problem of this countrythrough involving health workers.The country is now planning to useworkers involved in control of on-chocerciasis to provide vitamin Acapsules to children aged 6–59months and postpartum mothers, inorder to establish a channel to pro-vide the capsules twice annually.

Postpartum VAC coverage in Indo-nesia (Martini et al.) is low and it iseven lower in Bangladesh (Chow-dhury et al.) (3.6%). This calls forconcerted efforts for vitamin A sup-plementation for women in these aswell as most other countries. TheIndonesian data also showed thatdelivery in a health center or a ma-ternity clinic, having a doctor or quali-fied birth attendant at the time ofdelivery and mothers’ activities as ahealth cadre are factors positivelyinfluencing coverage.

Groups of investigators in Ghana(Tchum et al.) are currently lookingat two effects after vitamin A supple-mentation: the length of time forwhich serum concentration of retinolremains at an effective level and thedegree of dilution of two differentdoses of vitamin A in the bloodthrough MRDR test and 13C2-retinolisotope dilution assay respectively.The research has been initiated andresults are awaited.

Experience in Madagascar (Rako-tonirina et al.) demonstrates how anationwide community mobilizationby trained health workers and com-munity mobilizers, use of communi-cation materials and the partnershipof several organizations and agen-cies can help in raising the vitamin Acoverage rate to the highest level.

Supplementation:Post-NIDsMany countries have used the op-portunity provided by National Immu-nization Days (NIDs) to channel vi-tamin A supplementation (VAS) andto administer VAC to pre-school chil-dren. As polio is eradicated in manycountries, the NIDs will be discon-


tinued. These countries will thereforeneed to shift to other effective ap-proaches to administer VAC to chil-dren. Unlike polio, eradication ofVAD will be difficult, and until the dietcontains enough vitamin A, twice-yearly administration of VAC will benecessary. The posters under thissub-group presented the experi-ences of different countries.

In Cote d’Ivoire (Adou et al.), despitethe conflicts caused by rebels, thenutrition supplementation programhas continued unabated. Consider-ing the importance of the supple-mentation program the volunteers/distributors provided VAC for door-to-door distribution to mothers andchildren. This approach has beenfound to be effective as more than70% coverage for the one dose in2003 was achieved. The need toprovide a second dose annually waspointed out.

In addition to VAS for children, in-tensive efforts have been made ona pilot basis for postpartum supple-mentation of women in Cote d’Ivoire(Adou et al.). The community sen-sitization and training of health per-sonal has been found to be very ef-fective as women voluntarily attendhealth centers to demand the sec-ond dose of VAC on the second dayafter delivery. A survey on the impactof supplementation in the countrywould be beneficial.

Some countries are using a ‘piggy-back’ approach by linking VAS withother programs to ensure cost-effec-tive VAC coverage beyond the NIDs.The Philippines have introduced abiannual ‘Pre-Schoolers HealthWeek’ (Barquilla et al.), Bangladeshhas introduced a ‘Vitamin A pluscampaign’ (Farida Khatun et al.)

(twice a year from 2006), Guinea haslinked it with a measles immuniza-tion campaign (Toure et al.) andNiger with a ‘National MicronutrientDay’ (Dania et al.) for supplement-ing under five children. All these pro-grams were able to sustain high VACcoverage rates (above 80%).

Tanzania (Mlay et al.) has been im-plementing post-NIDs VAS strate-gies since 2001, by using nationwidecommunity supplementation twice ayear. The country is now trying toaddress the challenge of supple-mentation for hard-to-reach groups,pockets of low coverage and post-partum mothers, a majority of whomdeliver at home, as well as to sus-tain the high national coverageamong underfives.

In the Philippines (Puertollano et al.),since 1991 the decentralized systemof government has given the respon-sibility for management of programsand projects to local governmentunits. At the beginning of the Micro-nutrient Supplementation Programsupport from the local governmentwas very limited. After HKI’s involve-ment in social mobilization and ca-pacity building of local task forces forgenerating support from the localchief executives and stakeholders,the latter included micronutrientsupplementations in their annualbudgets. The VAC coverage rateamong children 12–-59 months rosefrom 92.2% in 2001 to 99.6% in 2003in the intervention area.

ProgramsSince VAD is prevalent in developingcountries where resources are limited,it is important to develop cost effec-tive approaches and programs. In thefollowing, posters with diverse experi-

ences from various countries are sum-marized.

In San Martin, Peru, a ‘Child SurvivalProgram’ (Alegre et al.), including thepromotion of active feeding practices(diet diversification) and vitamin A sup-plementation, has been shown to dra-matically decrease the prevalence oflow serum retinol concentrations(<0.70µmol/l – 68% in 1997 to 12% in2000). This illustrates the potential ofsuch programs as a solution for VAD.

Collaboration of governments,(inter-) national agencies and NGOshas proven successful. In Cambo-dia, HKI (Diekhans et al.) and WorldVision (Yaren et al.), together withtheir collaborating partners, wereable to increase VAC coverage andreduce night blindness respectivelyin their program areas. Similar re-sults were seen in Zambia (Kasawaand Chisanga) with VAC coveragerates of 98% in 2003. The VAS pro-gram was implemented together withgeneral MCH services in partnershipwith community and non-govern-mental organizations.

For enhancement of programachievements, training of communityhealth workers and volunteers, andmid-level managers (Mwela et al.;Messier et al.) as well as the pro-duction, distribution and use of IECmaterials for all types of communi-cation channels (Witten et al.) havealso brought about fruitful results.However, in overworked hospitals,IEC have not proved viable yet(Witten et al.). Exposure of mothersto IEC messages increased boththeir own vitamin A supplementationcoverage and that of their children(Rice et al.).


Two studies among school childrenin Sri Lanka (Madatuwa et al.;Mahawithanage et al.) evaluated theexisting vitamin A supplementationprogram as well as its impact onhealth status and school absentee-ism. The former study results showthat after considering age, sex, par-ents’ education and type of house,vitamin A levels were significantlyhigher in supplemented children ascompared to controls only when sup-plementation had been done withinsix months. As expected, the sup-plementation effect gradually woreoff and the current VAS strategy(100,000 I.U. at school years 1, 4and 7) may need adjustment. Thelatter study showed that vitamin Asupplementation with 200,000 IUevery 4 months over a 1-year periodhad no impact on health status orschool absenteeism of children inspite of improved vitamin A status.

A study in Maputo, Mozambique,(Khan et al.) evaluated a post-partum supplementation pilotproject. It showed that staff membersof all the maternity wards weretrained for VAS and guidelines werealso provided. Although some moth-ers were missed, the evaluation re-sults were very encouraging (80%coverage).

A poster from Bihar, India, (Pathaket al.) interestingly reflected that im-

As with the previous IVACG meetings, two separate symposia followed the XXII IVACG meeting, focusingon the worldwide problems of iron and zinc deficiency.

2004 INACG symposium and IZiNCG symposium,18–19 November 2004, Lima, PeruMaria Wijaya-Erhardt MSc, Juergen Erhardt PhD, SEAMEO-TROPMED, Regional Centerfor Community Nutrition, University of Indonesia, P.O. Box 3852, Jakarta 10038, Indone-sia, [email protected]

munization coverage improvedalong with VAC coverage. Thisshowed the beneficial effect of link-ing a vitamin A supplementation pro-gram to other components such asimmunization.

In Guinea, National MicronutrientSupplementation programs includetwice-yearly vitamin A supplementa-tion for children aged 6–59 monthsand iron/folate and chloroquine tab-let distribution during pregnancy. Across-sectional survey was con-ducted in Guinea (Touaoro et al.) toevaluate these programs and theKnowledge, Attitude and Practice(KAP) of health workers regardingmicronutrient deficiency. It was foundthat there is a substantial differencebetween the official VAC coveragerate and the coverage rate found inthis study (93% and 67% respec-tively). However the iron/folate andchloroquine supplementation pro-gram was found to be efficient inreaching a large population of preg-nant women (80.4% and 90.8% re-spectively). It was also suggestedthat to reduce micronutrient deficien-cies, nutrition should be reinforcedin pre-service and in-service cur-ricula.

A poster from Mali (Cissé et al.)shared the experience in setting upoil fortification with vitamin A. Col-laboration at all levels (government,

private sector, donors, civil society)resulted in the successful involve-ment of the only vegetable oil pro-ducer of the country in fortification.The poster provides lessons that willbe helpful for others.

Similar findings with regard to multi-sector collaboration have been seenin the Economic Community of WestAfrican States (ECOWAS) (Thiam etal.). The ECOWAS Nutrition Forumhas taken up a prominent role inadvocacy, technology update, ex-change of information on best prac-tices and capacity building. It hasalso been a catalyst in donor coor-dination in the region.

In Zambia (Mwela et al.), the healthsystem was decentralized in 1996,resulting in some confusion regard-ing the source of funding for the VASprogram. The National Food andNutrition Commission played an im-portant role in advocacy for a VASprogram to the Inter-sectoral Com-mittee on Child Health, in combina-tion with good results of the integra-tion of the VAS into Child HealthWeeks; the national governmentencouraged all districts to allocatefor VAS in the regular budget.

International Nutritional Anemia Consultative Group(2004 INACG Symposium). Iron deficiency in earlylife: Challenges and progress

Dr Frances Davidson from USAIDopened the INACG meeting andcalled for attention to focus onstate–of-the-art research and in-

novative programming for themost vulnerable populations inrelation to iron deficiency – in-fants, children and pregnant

women. This was followed by twopresentations about ‘Maternalnutritional status, fetal growth andiron status during infancy’ and‘Iron requirements and iron sta-tus during infancy’.

In Spring 2004 a WHO/CDCmeeting was organized to find a


standard set of indicators tomeasure iron status. A combinedmeasurement of hemoglobin, fer-ritin and transferrin receptorsseems to be the most useful indi-cator for assessing the iron sta-tus of populations. Since ferritinlevels are raised during infection,measurement of CRP as an indi-cator for infection is also recom-mended. It is obvious that this ap-proach is not a simple or inexpen-sive way to measure iron status.

One controversial topic at thisINACG meeting was data fromtwo iron supplementation studiesin Tanzania and Nepal (areas withand without malaria). There wasa significantly higher risk for mor-bidity and possibly mortality innon-anemic children in malariaendemic regions when they re-ceive iron/folic acid supplements.In Nepal, where there is no ma-laria but there are other infectiousdiseases, this effect could not befound. Further research is neededto evaluate the appropriate rec-ommendations for universal iron/folic acid supplementation in ma-laria endemic regions and poten-tial strategies for targeting chil-dren who are iron-deficient. Theseare the ones who would benefitfrom the supplementation, withpositive effects on motor and cog-nitive development and laterachievements in school.

In the Program Implementationsession, studies from Asia andAfrica demonstrated that fortifica-tion of staple foods and condi-ments with iron salts is a validapproach to reducing iron defi-ciency anemia in children andwomen who are at risk. De-worm-ing and vitamin A supplementa-tion are additional factors in re-ducing anemia.

Further information on the INACGmeeting with the abstracts of thepresentations can be found athttp://inacg.ilsi.org/

The IZiNCG meeting opened withan overview of zinc function andnutrition. Zinc is present in everyliving cell and involved in morethan 300 enzymes and other pro-teins. It is conserved very well inthe body by decreasing excretionand increasing absorption, and insevere cases by reducing growthand breaking down muscles. Zincis critical for normal growth, im-munity and neurocognitive func-tion. These topics were furtherdiscussed in presentations of zincand developmental outcomes,susceptibility to and treatment ofpneumonia and zinc as adjuncttherapy for HIV infected persons.Conclusions of these presenta-tions were:

- zinc supplementation can havea positive influence on develop-mental outcomes- 70 mg of zinc once weekly re-duces pneumonia, severe pneu-monia and mortality in young chil-dren in Bangladesh andzinc supplementation is safe inHIV infected persons and haspositive effects on the frequencyof diarrhea and pneumonia.

The second session containedpresentations about experiencesin national assessments and situ-ation analysis. Large-scale sur-veys completed in Mexico andNew Zealand were useful for iden-tifying high-risk segments of apopulation. Even in a country likeNew Zealand, which is not con-sidered to have a problem withzinc deficiency, there are parts ofthe population which are at risk.

The third and fourth sessionswere about programmatic expe-riences and recommendationsregarding zinc supplementationand fortification.

A new recommendation fromWHO and UNICEF for zinc in thetreatment of diarrhea is to givechildren 10–20 mg zinc/day for10–14 days, distributed with ORS.Because of its positive effects, itis estimated that country-widezinc supplementation duringdiarrhea in Bangladesh could re-duce under-five mortality by400,000–500,000 lives per year.Zinc supplementation could havea slight negative impact on theeffect of iron supplementation butzinc alone does not seem to havea negative impact on iron statusand is safe and efficacious.

Fortification programs are recom-mended in high-risk populationsto increase dietary Zn intakes.Milk and cereal products are themost common foods fortified withzinc sulfate or zinc oxide, the twoleast expensive zinc forms whichare generally recognized as safefor human nutrition and have nonegative impact on the sensoryproperties of foods in the recom-mended concentration. Reliabledietary data is necessary to de-sign fortification programs, andinformation on food zinc andphytate content are needed. Sev-eral countries have initiated large-scale zinc fortification programsbut additional information is stillneeded on the nutritional andfunctional impacts of these inter-ventions.

Further information on thisIZiNCG Symposium can be foundat: http://izincg.ucdavis.edu. Thiswebsite also contains a link to asupplement of the Food and Nu-trition Bulletin which is currentlythe most comprehensive and up–to-date collection of informationabout zinc in human nutrition.

International Zinc Nutrition Consultative Group(IZiNCG Symposium)Moving Zinc into the Micronutrient Program Agenda


Prevention and control of vitamin A deficiency inCameroonGouado Innocent, Faculty of Science, University of Douala, Cameroon; Ejoh Abba Rich-ard, Department of Food Sciences and Nutrition, University of Ngaoundéré, Cameroun

The problem

Vitamin A deficiency (VAD) iscaused by insufficient intake offoods rich in vitamin A or provita-min A carotenoids to meet the re-quirements for growth, infections,pregnancy and lactation (WHO,1996). As indicated by the workof West (2002), vitamin A defi-ciency affects yearly close to 127million children of pre-school ageand more than 7.2 million preg-nant women. Similarly each year4.4 million children and more than6 million women have xerophthal-mia, a major consequence of thisdeficiency. An estimated 250,000children of preschool age becomeblind each year (WHO, 1992) dueto VAD. This makes VAD a seri-ous cause of morbidity and infantand maternal mortality (Hum-phrey et al. 1996).

In Cameroon, the development ofa strategy to eradicate VAD as apriority health problem which af-fects childhood was implementedin several phases.

Experiment with the production ofchips in the biochemistry laboratory.

Situation in Cameroon

Cameroon is a country in CentralAfrica, with a very diverse climate,ranging from the Sahel zone in thenorth, through the sub-equatorialclimate and vegetation in thesouthern and eastern provinces tothe tropical and temperate climatein the west and north-west prov-inces and the coastal zones. Be-cause of the ecological diversitythe foods (tubers, cereals, fruitsand vegetables) which are cur-rently produced in the differentregions are also very diverse. Inspite of this, nutritional problemsstill exist, as revealed by resultsof food surveys. The national foodsurvey on VAD and anemia (Kolloet al. 2001) showed vitamin A de-ficiency to be a major public healthproblem in Cameroon.

Localization andprevalence

Results were collected intwo major stages, Re-search in rural and urbanzones or in some specificpopulation groups (Gimouet al, 1993, Goupeyou1996, Gouado et al,1997,1998; Sibetcheu et al1999, Zambou et al, 1999)revealed that there aremany areas in which VADis permanent. Those mostaffected are children, therural population and thoseinfected by diseases likemalaria and measles.

These data were used toraise the awareness ofpublic health authoritiesand, with the support of

A great variety of fruits, symbol of diversity inCameroon.

international organizations MSP,UNICEF, Helen Keller WorldWide, SIGHT AND LIFE andWHO, to launch the national sur-vey on Vitamin A and iron defi-ciency.

This first survey covering the en-tire territory showed that VAD asdetermined by serum retinol lev-els affects 38.8% of the children.The prevalence of this deficiencyvaries from 24.9% in the high pla-teaus of the west to 35.10% in thecoastal zone and 38% in the for-est zone. This problem affectsboth sexes and all age groups.However, the same survey re-veals that palm oil is widely con-sumed in the south of the countrythough bleaching is widelypracticed (Kollo et al, 2001)


For some time now research workhas been focusing on the meansand solutions for prevention, con-trol or eradication of VAD in theentire country.

Causes of VAD

In spite of the large diversity offoods rich in vitamin A (milk andmilk products, animal liver, meat,eggs) or provitamin A (red palmoil, fruits and vegetables) theseare not within the reach of all so-cial groups. Moreover, traditionalprocessing (bleaching of oil, ex-cessive cooking of leafy vegeta-bles) or technological treatment offoods (sun drying of vegetables),in association with the seasonalshortages of food, increases orprovokes these deficiencieswhich are more aggravated incases of infections like malariaand measles.

Prevention and controlstrategies

For prevention and control to beefficient it is necessary to considerdietary habits and the natural foodresources available in each regionor population group. It is in thisdomain that a lot of research isfocused.

Trials on food supplementationwith palm oil in two Sahel villages

where this oil is not part of the foodhabits of the population resultedin a reduction of the prevalenceto 27.27%. It was found that theoil can easily be incorporated intothe diet of the indigenous popula-tion (Gouado and Mbiapo, 2001).Unfortunately, the purchasingpower of the population is low, lim-iting the possibility for them to usethe oil. Thus a national price har-monization was proposed forthis important food product, as isalready practiced for other prod-ucts, such as beer.

The other rich sources of carote-noid provitamin A, such as the α-carotene, β-carotene and β-cryp-toxanthin found in sweet potatoes,and yams (yellow, red and orangevarieties), carrots, mangoes, paw-paw, tomatoes, water melon,guava and leafy vegetables areproduced and consumed season-ally. Development projects andtraining centers for techniques offood processing have been veryuseful in improving availability offoods rich in provitamin A allthrough the year. Examples in-clude natural juice production orthe amelioration of methods ofproduction of banana and plantainchips from very rich sources of β-carotene, as well as the amelio-ration and promotion of drying offruits and vegetables using solarenergy.

Agricultural research is trying todiversify the sources and improvethe yields of foods rich in provita-min A, for example in the volcaniclittoral region, in recent years highyielding Solo varieties of pawpaware being produced in abun-dance. Studies are also beingcarried out in the Nutrition andPublic Health Laboratory of theFaculty of Science, University ofDouala, on the bioavailability ofprovitamin A carotenoids (α-car-otene, β-carotene, β-cryptoxan-thin) of four fruits (mangoes, pa-paya, guavas and water melon)commonly consumed in Cam-eroon. Other studies on process-

ing and preservation of vitamin Arich sources of fruits and vegeta-bles are currently going on in theFood Science and Nutrition De-partment of the University ofNgaoundéré. These studies willprovide information on the bestsources of fruits and vegetablesand best method of processingand preservation that will mini-mize losses of this nutrient andoptimize provitamin A intake andavailability throughout the year.

The nutrition education of womenwho visit the prenatal clinics (Cen-tre de protection maternelle et in-fantile – PMI) has been institution-alized, but it remains to review theschool program with the aim ofincluding the notion of nutrition, inpreparation for the “world freefrom hunger”.

Promotion of homegardening is gainingmore groundsDistribution of vitamin A capsuleson National Vaccination Day hasbeen effective in some regions ofthe country. However, the cover-age is still low and there needs tobe a twice yearly distribution forproper follow up.

A program for micronutrient defi-ciency (zinc, magnesium, cal-cium, selenium, and vitamins A

Varieties of plantains that are rich incarotenoids (experiments in the In-stitute of Agricultural Research,Njombé).

A large pawpaw plantation (Solovariety) in the volcanic littoral region.


and E) and malaria is presentlygoing on.

Conclusion

Cameroon is a country with richagricultural diversity. Many effortshave been deployed for the pre-vention and control of micronutri-ent deficiency, notably VAD. Foran effective campaign againstthese deficiencies it is importantto have co-ordination and a fol-low-up team (made up of severalpartners: NGOs, educationists,researchers, personnel in health,agriculture, social welfare andwomen’s affairs) as in the case forHIV/AIDS and malaria. This willlead to the orientation and com-bination of all efforts towards acommon objective.

ReferencesGimou L, Louis FJ, Arrive P, (1993)

Carence en vitamine A dansl’Extrême-Nord du Cameroun.Résultat d’une première enquêtebiochimique. J Cam Med 2:38–40

Gouado I, Tchouanguep FM, FokouE.(1997) Statut vitaminique A & E

d’une population rurale de l’OuestCameroun. Sc. Tech. Dev. 5(1):25–28

Gouado I, Mbiapo TF, Moundipa FP,Teugwa MC (1998). Vitamin A & Estatus of some rural populations in thenorth of Cameroon. Internat J Vit NutrRes 68:21–25.

Gouado I, Mbiapo TF (2001) Effet de lasupplémentation en huile de palmesur les sujets déficients en vitamineA, E. Sci Technol Dev 8(1): 15–18.

Gouado I, Ejoh, AR, Kenne M, Ndifor F,Mbiapo TF (2004) Vitamin (A & E) sta-tus and lipid profile in rural area ofNorth Cameroon. (in press Ann NutrMetab).

Goupeyou Wandji IA (1996) Etude de lasituation de la vitamine A chez lesenfants malades, âgés de 0 à 5 ansà Bangoua. Doctoral thesis in medi-cine, Faculté de Médecine et desSciences Biomédicales, Université deYaoundé

Humphrey JH, Agoestina T, Wu L,Usman A, Nurachim M, Subardja D,Hidayat S, Tielsch J, West KP,Sommer A. (1996). Impact of neonatalvitamin A supplementation on infantmorbidity and mortality. J Pediatr128:489–496.

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vitamine A et l’anémie au Cameroun.MSP, UNICEF, Helen Keller World-wide, SIGHT & LIFE, WHO. 60P

Sibetcheu D, Nanka M, Mbiam D,Toukour H. (1999) Role of nutritioneducation in the improvement of vita-min A intake from colostrum in newborn children of the far North Prov-ince of Cameroon. Report of the XIXInternational Vitamin A ConsultativeGroup Meeting, Durban, South Africa

West KP (2002) Extent of vitamin A defi-ciency among preschool children andwomen of reproductive age. J Nutr132: 2857S–2866S.

WHO (1992). Prevention of childhoodblindness. Geneva: World Health Or-ganisation

WHO (1996). Indicators for assessingvitamin A deficiency and their appli-cation in monitoring and evaluatingintervention programmes. Geneva:World Health Organisation

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Report on activities linked to the battle againstvitamin A deficiencyDr P Mayala, Vanga Hospital, Kinshasa, Democratic Republic of the Congo

Training seminar

The Vanga Baptist mission organ-ized a training seminar from 5–6February 2004 on the subject of“Vitamin A deficiency: the realityand the strategy to combat it”.This opportunity arose as a resultof financial support from SIGHTAND LIFE. The aim of the semi-nar was to enable participants toshow the importance of an ad-equate supply of vitamin A to ru-ral populations, to recognizesymptoms of deficiency in the vi-tamin, to administer preventiveand curative doses and to apply


the strategy to combat vitamin Adeficiency correctly.

Screening

Since epidemiological data areavailable in our region, we haveresearched the cases of defi-ciency and predisposing illnessesamong children in pediatric hos-pital units and in the nutritionalcentre in Vanga hospital. An in-vestigation into specific symptomsand an eye examination were car-ried out on 60 children. No casesof obvious deficiency were foundbut 53 children, that is, 88%, pre-sented predisposing illnesses, inparticular kwashiorkor.

Survey of prevalence

The results obtained duringscreening led us to study the

prevalence of vitamin A deficiencywithin the population. In 2003, inthe Vanga health area, 48% ofchildren below 5 years of agewere malnourished and malnutri-tion represents the primary causeof death. The survey describesthe population of children below5 years of age from three loca-tions (750 children) in terms offactors and signs of vitamin A de-ficiency. During the survey wewere able to treat the cases foundwith vitamin A capsules providedby the SIGHT AND LIFE TaskForce.

The results of the survey are sum-marized below. Among the 750children studied, the rate ofkwashiorkor was 3.5%, while nochild had had measles. Repeatedand prolonged diarrhea and per-sistent eye infections were a prob-

lem in 0.1% of the children, while0.4% of them presented with aproductive and persistent cough.Just one child (representing 0.1%)suffered from night blindness.

Conclusion

Clinical vitamin A deficiency isvery rare in our rural health regionwhere foodstuffs rich in vitamin Aare available. Protein-calorie mal-nutrition is the main factor predis-posing children below 5 years ofage to vitamin A deficiency. Wewould like to thank SIGHT ANDLIFE for their support of this work,both the financial support and thesupply of vitamin A capsules andeducational material.


Introduction

Blindness and childhood mortal-ity due to vitamin A deficiency isstill a severe public health prob-lem in Nepal. Several programshave been launched in the coun-try but it is a well-known fact thatthis problem cannot be tackled byimplementing one or two meas-ures alone. The elimination ofpoverty, immunization coverage,access to health care facilities, ahigh literacy rate, an increment inknowledge about sources of vita-min A rich foods, an improvementin dietary habits, hygiene andsanitation, etc. have to go to-gether if we really want to elimi-nate this problem.

This is a report of HRS activitiesbased on the fund provided bySIGHT AND LIFE. The programwas implemented as an interven-tion for early identification andmanagement of children withmeasles, malnutrition and malab-sorption (chronic diarrhea) utiliz-ing existing health care facilities.Children reported with measles,malnutrition and malabsorption(3-Ms) were recorded at thehealth post or sub-health post ofthe program area, treated with thevitamin A capsule as per stand-ard vitamin A treatment protocol,the knowledge, attitude and prac-tices of mothers assessed andhome-based nutrition educationdelivered by professionals to thechild’s doorstep.

Objective

The objective was to implementan intervention program whichcould effectively reach the vulner-able groups and thus help in re-

ducing childhood mortality andblindness.

This was achieved by assessingthe knowledge, attitude, and prac-tices (KAP) of mothers regardingchild nutrition and wellbeing be-fore and after the intervention.The behavior of mothers andhousehold members was moni-tored and coaching was providedto identify and overcome con-straints to behavior change.Those not previously reachablewere reached through early iden-tification and management of chil-dren with measles, malnutritionand malabsorption. Awarenesswas created among specific tar-get groups regarding preventionand the timely use of availablehealth care services.

Methods

Areas of the northeastern Kat-mandu valley were selected, andbased on previous experiencepriority was given to those com-munities where the prevalence ofvitamin A deficiency was found tobe comparatively high. Prior tostarting the program, the DistrictPublic Health Officer of the Min-istry of Health was contacted andbriefed about the activities. Somenecessary vitamin A related edu-cation materials were collectedfrom the National Vitamin A pro-gram (NTAG) and some from Ne-pal Netra Jyoti Sangh (NNJS).

Six health posts (HP) were usedto implement the activities. TheHP is a first contact place for anypeople with health problems in thecommunity. Each HP providespromotive and preventive healthcare services to a total population

of about 5–7 thousand. There areFemale Community Health Volun-teers (FCHVs) for every 2–5 hun-dred people whose task is to de-liver primary health care mes-sages to every family member inthe community. Optimal use isbeing made of this important man-power by providing them with ori-entation training prior to startingthe program. FCHVs early identi-fied and referred cases of 3-Msin the community. Cases of 3-Mschildren under 12 years of agewere recorded and vitamin Aawareness activities implementedat the six assigned health postsof the area. Vitamin A capsules

Measles, malnutrition and malabsorption (3-Ms)management in childrenMahendra Chalise, Helpless Rehabilitation Society, Arubari, GPO Box 8619, Katmandu,Nepal


were given as per standard treat-ment protocol. Similarly, teachersof each school in the program ar-eas were also oriented in earlyidentification and referrals of 3-Msfollowed by a nutrition awarenesscampaign at school level. With thehelp of FCHVs, cases of 3-Mswere monitored and their homesvisited once a month, when nutri-tion education was delivered.

The preparation of nutritious foodwas demonstrated and nutritiousfood supplied to some of the verybadly affected children at HRSDay Care cum EducationalCenter, where about 65 CarpetWorkers’ children are benefitingfrom our help.

Achievements andsummary

A total of 178 children under 10years of age suffering from mea-sles, malnutrition and malabsorp-tion benefited directly from theprogram through timely detectionand treatment.

About 70% of mothers still do notknow about the causes of vitaminA deficiency among children,about 80% did not know about pre-ventive measures and very fewmothers were using health carefacilities during illnesses (3-Ms).

The mothers of the children ben-efited from the nutrition educationdelivered and were also taughtabout regular feeding of their chil-dren with vitamin A rich diets andgiving special attention during ill-nesses.

In the one-year period a total of178 cases (4.33%) of 3-Ms weredetected and treated from among4112 children less than 10 yearsof age. Most of these childrenwere less than three years old.

Knowledge amongmothers

HRS assessed knowledge, atti-tude and practice (KAP) by inter-viewing 1242 mothers at the sameHPs where the children weretreated. Questions were about vi-tamin A and other topics such asbreastfeeding

About 70% of mothers still do notknow about the causes of vitaminA deficiency among children, andexcept at the Jorpati HP, about80% had no knowledge of preven-tive measures.

Regarding the duration ofbreastfeeding, about 10% ofmothers said they did not know,15% thought they should feed aslong as there was a supply ofbreast milk and 75% said theyshould breastfeed their child atleast for two years.

On the question of what to dowhen the child has measles ordiarrhea, 45% said they take theirchild to the nearest health post,18% said a child does not needany treatment for such problemsand 37% said they use traditionalremedies.

Lesson learnt

Providing adequate services andaccess to the health care servicesis not in itself sufficient for peoplewith a low educational status.They need to be made aware andeducated about the services pro-vided and what they are for. Wehave found a considerable in-crease in the percentage of moth-ers taking their children to receivea vitamin A capsule during massdistribution. However, the major-ity of mothers still did not realizetheir importance and why theywere being distributed. Publichealth planners should take thisinto consideration so that peoplewill demand such programs in thefuture. In comparison to the otherareas under study, the people ofthe Jorpati HP were found to bemuch more aware about nutrition-related matters. This is becauseall HRS activity for the last 10years has been focused in thisarea. This also indicates that thereshould be continuity in programsto create awareness and changepeople’s behavior.

In conclusion: it is important tocontrol predisposing factors like 3-Ms first, before vitamin A defi-ciency and childhood mortalitycan be reduced.


Background information

The journey of leprosy control inPakistan started in 1956 inKarachi, from a tiny shed built bythe leprosy patients themselvesfrom wooden fruit crates, underthe guidance of a young MexicanSister. In 1960, Dr. Ruth Pfau, ayoung German doctor, joined theleprosy work and gradually devel-oped it into the National LeprosyControl Program. The compre-hensive approach attended to themedical as well as the social prob-lems of the patients, who lived inabsolute poverty and isolation.

The Marie Adelaide LeprosyCenter has now grown into acountry-wide Leprosy ControlProgram, gradually linking up withthe Provincial Health Depart-ments and working in the majorpart of Pakistan including North-ern Area and Azad Kashmirthrough more than 160 Leprosy /TB / Eye clinics.

In 1996 the Marie Adelaide Lep-rosy Center achieved its objec-tives of Leprosy Control throughits hard working, motivated andefficient field force. However,eradication will still take 50–60years, mainly because leprosyhas a very long and variable in-cubation period from 3 to 40years.

Thus arises the need to includeother health disciplines to guar-antee the presence of leprosytechnicians in the field. Ophthal-mology was always familiar tothem, as leprosy is one of the sys-temic diseases having most ocu-lar complications. The averageage is increasing, and eye dis-eases are or will be associated

with almost everybody above theage of 40. With poor hygienic con-ditions, malnutrition, etc. thechance of children having eye dis-eases is quite high, as seen in vi-tamin A deficiency and trachoma.

In the late eighties, it was decidedto initiate a primary Eye Care Pro-gramme, and Balochistan, beingthe largest and most sparselypopulated province with leastnumber of ophthalmologists, wasselected. Leprosy technicianswith some basic training in eyediseases were retrained as Lep-rosy Ophthalmic Technicians(LOTs) by well reputed institu-tions. The LOTs start their workdoing OPD’s, house to house andrandom surveys, school screen-ing along with health education.

They treat common conditions likeconjunctivitis, trachoma, refractiveerrors and vitamin A deficiency andrecord curable / non-curable blind-ness to provide / facilitate optimalmanagement. Surgical campswere arranged to relieve the suf-fering of the poor and out-reachedpopulation at their doorsteps.

Situation analysis

Blindness prevalence inPakistan 1.78%Sindh 1.14%Balochistan 2.69%NWFP 1.00%Punjab 2.17%

Eighty percent of blindness is cur-able / preventable. Cataract is themajor cause of blindness at 60–70% of total blindness. Othermajor causes include refractiveerrors, trachoma, vitamin A defi-ciency, glaucoma, trauma andothers.

Eight out of 10 people live in ruralareas with meager income, lackof roads and transport and negli-gible medical facilities. The femalepopulation always lacks timelymedical / surgical interventionbecause of the social structure.

Nearly 48% of Pakistani childrensuffer from vitamin A deficiency,and enhancing its supplementcould help decrease child mortal-ity by 25%.

Report on the utilization of vitamin A capsulesDr Ashfaq Ali Khan, Chief Executive Officer, Marie Adelaide Leprosy Centre, Saddar,Karachi, Pakistan


One to two million pregnant moth-ers suffer from VAD in South Asiaand nearly 60,000 women die ofchildbirth-related deficiency,mostly caused by complicationswhich could be reduced throughbetter nutrition, including provi-sion of vitamin A.

Overall child mortality could bereduced by 25% through the sup-plement of vitamin A, as deathscaused by measles have beenreduced by 50% and thosecaused by diarrhea by 40%.

Vitamin A supplementation is vi-tal to combat infections. Everyyear, 200,000 children die in Pa-kistan of diarrhea and 250,000 ofpneumonia. Vitamin A is the bestremedy to counter these severeconsequences.

There was the felt need for inte-grating children’s vitamin A sup-plementation with routine immu-nization to ensure optimum effectand in the last couple of years vi-tamin A supplementation has be-come an essential part of NationalImmunization Days, along withpolio, in children under 5 years ofage.

The micronutrient status of Paki-stan is quite low in the world andaccording to a survey conductedin the slums of Karachi, almosthalf of the children under 6 yearsof age were suffering from sub-clinical vitamin A deficiency (Foodconsumption survey for micronutrient fortification in Pakistan byN Hafeez, M Khan and others,XIX IVACG Meeting, March1999). A recent nutrition surveycarried out after a gap of five yearsto assess the nutritional status ofchildren in the country revealedthat the deficiency of vitamin A,

which was 35% five years ago,had been reduced to 11%, reflect-ing the successful implementationof vitamin A supplement pro-grammes.

There is a need to highlight theimportance of food containing vi-tamin A such as meat, milk, cornflour, liver and green vegetablesfor children, as some of themhave a high level of carotene con-tent, which helps produce vitaminA. There is a need to fortify cook-ing oil and vanaspati ghee, goodsources to overcome deficiency ofvitamin A in children and this kindof fortification is a common prac-tice in foreign countries.

Administration of vitamin A sup-plements to mothers three daysafter delivery helped them to ca-ter to the requirements of new-born children for the first sixmonths and adherence with thepresent program is likely to pro-duce more beneficial results infuture. An advocacy seminar onvitamin A was organized by theHealth Oriented Preventive Edu-cation (HOPE) in collaborationwith UNICEF.

Vitamin A supplemen-tation methodologyof the Marie AdelaideLeprosy Centre

Being employees of ProvincialGovernments, Leprosy Ophthal-mic Technicians are actively in-volved in the National Immuniza-tion drive against polio and vita-min A deficiency conducted

throughout the country twice ayear. During these days teams godoor-to-door asking about chil-dren under 5 years of age. Suchchildren are registered and aregiven the age-specific prophylac-tic dose.

The blindness control activities ofthe Marie Adelaide Leprosy Cen-tre are based on primary eye care.Trained technicians conductOPDs and school surveys in themost neglected urban and ruralareas to screen the population forcataract, trachoma, vitamin A de-ficiency, refractive errors andother causes of curable and pre-ventable blindness. They provide/ facilitate optimal managementlike provision of tetracycline eyeointment or age-specific doses ofvitamin A, and arrange necessarysurgeries besides giving mobilityand sensitivity training to any in-curably blind person.

As the nutritional status in thecountry is quite low and 30–35%of the population is living belowthe poverty line, vitamin A defi-ciency is not uncommon inschool-going children, especiallyBitot’s spot (X1B) and night blind-ness (XN).Our target population for vitaminA supplementation is children inthe age group of 6–10 years.

Our teams conduct school andpopulation surveys in under-served and remote areas to de-tect children of school-going agewith clinical vitamin A deficiencyor apparent malnutrition (usualdaily meals of bread and blacktea) at risk of developing vitaminA deficiency. Our teams ensureprovision of full therapeutic or pro-phylactic (age-specific) doses toneedy children with regular follow-ups to avoid and prevent this un-necessary blindness.

We thank SIGHT AND LIFE forthe vitamin A capsules.

www.sightandlife.org


Introduction

Xerophthalmia needs serious at-tention in West Java Province, es-pecially after the economic crisis.The program to distribute vitaminA has been implemented, but westill find xerophthalmia in someareas of Indonesia (SouthSumatra and West NusaTenggara provinces). This is areminder that we need anotherway to solve the xerophthalmiaproblem.

Cases of xerophthalmia de-creased in number before theeconomic crisis, with the resultthat health workers in the field areforgetting the signs and symp-toms of the condition, and also therisk factors associated withxerophthalmia, delaying its detec-tion. Malnutrition is one of theserisk factors, and because of theeconomic crisis, many childrenunder 5 years old have beenfound to suffer from malnutritionin West Java Province.

To encourage early detection ofxerophthalmia, the West JavaProvince government providedtraining for trainers for generalpractitioners, nutritionists andnurses working in all the districtsand cities of West Java Province(9 cities and 16 districts).

Aim and objectives

After taking part in the training,which includes a series of lectures,participants should understandabout xerophthalmia and be able

to spread information about xeroph-thalmia to other health workers intheir own areas, as well as man-age xerophthalmia themselves.

Topics covered by the training in-clude:• Understanding the anatomy

of the eye• Understanding about

xerophthalmia• Explaining early detection

of xerophthalmia• Explaining the diagnosis,

management and referralof xerophthalmia

• Explaining about preventionof xerophthalmia

• Passing on training in theirown area to local healthworkers who work directlywith the community.

Discussion

The field work was carried out into two areas (Andir sub-district inBandung city and Ciparay sub-district in Bandung district), wherechildren were measured to as-

sess their nutritional status on thebasis of body weight and height.The eyes of children with low bodyweight were examined to deter-mine whether they have xeroph-thalmia.

Facilitators

Ophthalmologists from CicendoEye Hospital,Manager of the Health Office Nu-trition Program, West Java Prov-ince,Manager of the Health Office Spe-cific Health Care Program, WestJava Province

Participants

There were about 77 participantsfrom all districts and cities in WestJava Province, consisting of gen-eral practitioners, nutritionists andnurses. We divided them into twoparallel classes. The twofacilitators, both from CicendoEye Hospital, were Dr Syumarti(Ophth) and Dr Bambang SetioAdji (Ophth).

Training trainers for early detection of xeroph-thalmia in West Java ProvinceSyumarti1 MD, Cicendo Eye Hospital, Jalan Cicendo, Bandung 40117, West Java, Indonesia

Teaching in class.

1 was one of the Students supportedlast year to study in London bySIGHT AND LIFE.


Promoting eye health through educationalprograms in the communityDr Lin Yan, 202-1, Building 11, No.7 Dong Jiao Min Xiang, Dong Cheng District, Beijing100730, China

Data has been collected on thefield work: In Andir sub-district inBandung city 444 children wereexamined and their nutritional sta-tus found to be as follows:• 13 with very low weight (2.9%)• 93 with low weight (20.9%)• 331 with good weight (74.5%)• 7 with overweight (1.6%)

Cadres and a participant measuring a child’s body weight (left). A participant examining a child’s eyes. The authorexamining a child’s eyes (right).

No cases of xerophthalmia werefound.In Ciparay sub-district in Bandungdistrict 289 children were exam-ined. Their nutrutional status was:• 14 with very low weight (4.8%)• 46 with low weight (15.9%)• 227 with good weight (78.5%)• 2 with overweight (0.7%)

We found no clinical signs ofxerophthalmia in children withvery low and low weight in theseareas. Since we did not take bloodsamples for the determination ofserum retinol we could not assesssubclinical xerophthalmia.

Background

It is well known that vitamin A de-ficiency impairs eye health andthe immune system, increasingthe risk of child mortality by about23% (1,2). However, it is not easyto convince staff working withhealth authorities in developingcountries to believe this and takeappropriate action. In the past tenyears, SIGHT AND LIFE has beensupporting our attempts to im-prove this situation through thepublication of educational mate-rials in local Chinese languages.These publications cover threemain areas:

1.Educational material on vitaminA deficiency and its impact onhealth (Vitamin A deficiency andxerophthalmia: Vitamin infor-mation status paper; SIGHTAND LIFE Manual on vitamin A Desert in Gangcha County in Qinghai.

deficiency disorder, 1st & 2nd

editions; SIGHT AND LIFEslides on vitamin A deficiencydisorder)

2.Specific technology for assess-ment (Assessment of vitamin Astatus by impression cytology)

3.General information on eyehealth (Healthy Eyes ActivityBook, Chinese, Tibetan andEnglish versions).

The Healthy Eyes Activity Book(HEAB) is an active teaching ma-terial used to promote eye healthin the community. With the sup-port of SIGHT AND LIFE theHEAB has been translated intoMandarin, one of the most widelyspoken Chinese languages. Cop-ies of the HEAB were distributedthroughout Mainland China inApril 2003 and are used primarilyby those working in primary


school, kindergarten and othereducational institutions. Staff in-volved in primary health care, chil-dren’s health and health promo-tion also use the HEAB to delivereye care knowledge to the public.

Later in 2003, following a requestby the Department of Health andDepartment of Education inShannan Prefecture, Tibet, aswell as some non-governmentalorganizations (NGOs) working inTibet, the HEAB was translatedinto Tibetan. The first copies weredistributed to primary and middleschools and proved so popularthat the book was reprinted inSeptember 2004 (3).

Distribution – problemsand solutions

China has a comprehensivemedical and health administrativesystem nationwide, consisting ofthe Ministry of Health, ProvincialDepartments of Health, Prefec-ture Health Bureaus and CountyHealth Bureaus. This should pro-vide an efficient distribution net-work for educational materials,and in the initial phase, from 1994-1996, publications were mainlydistributed through this system.However, after several years pain-ful experience, we have found thatthis system alone is not sufficientto ensure publications reach theirtarget users. We found the mainreasons to be: 1. Lack of funds;2. Lack of dedicated staff; 3.Lackof public awareness

SIGHT AND LIFE supports distri-bution from the central to provin-cial levels, but redistribution mustbe funded by the provincial, pre-fecture and county authorities,who often do not have sufficientfunds for the task. Due to lack ofinterest and awareness of theproblems, staff at these levels failto promote the materials andsometimes distribute them to peo-ple unable to make full use ofthem.

Recently we have been usingmore innovative approaches, in-cluding:1.Collaboration with NGOs in-

volved in the delivery of primaryeye care or primary health care;

2.Collaboration with professionalassociations such as the Na-tional Committee for Preventionof Blindness and the Associa-tion of Rural Health Workers;

3.Distribution during professionalmeetings and training courses;

4.Responding to individual re-quests.

Tibet is a good example of theproblems faced and innovativeresponses. Due to its high alti-

tude, poor transportation and lackof primary health care services,the health status of Tibetans ismuch poorer than that of otherChinese. Therefore, in addition tothe Chinese Government, moreand more international NGOs areproviding support to improve thehealth, including eye health, of theTibetan people. Originally theHEAB was distributed through thehealth administrative system inTibet, but the book was reprintedmainly in response to requestscoming from various NGOs andgovernment organizations witheye health programs in Tibet orother parts of China. These in-clude the British NGOs Save the

Children in Gangcha County in Qinghai reported to have night blindness.

In Tibet: right the author Lin Yan.


Children and KunDe, the SwissRed Cross and the USA-basedSeva Foundation, all of which areusing the three language versionsof the HEAB to train teachers andcommunity health workers, as wellas distributing them – in particularthe Tibetan version – to schools.

On 24–27 May 2002, the TibetanHealth Bureau, Tibet Develop-ment Fund and Seva Foundation(USA) jointly organized a TibetEye Care Workshop in Lhasa. Atthe request of the organizers, thewriter dispatched the SIGHT ANDLIFE Manual on vitamin A defi-ciency disorder (VADD manual) toevery participant, together withthe WHO publication SAFE strat-egy: preventing trachoma.

The VADD manual has been de-livered to the medical administra-tions and disease control centersin Guangxi Province and QinghaiProvince. 42.7% of children in ru-ral Guangxi suffer from vitamin Adeficiency. About 30% of the popu-lation of Qinghai Province are no-mads with virtually no access tohealth services and their overallhealth status is unknown. It is diffi-cult to meet their vitamin needsunder these circumstances.

Kuandian County in LiaoningProvince has been implementingan eye care project supported byChristoffel-Blindenmission (CBM)since 2001. One of the compo-nents of the project is to providetraining for township doctors andvillage health workers in primary

eye care via various trainingcourses. We have used this op-portunity to promote knowledge ofvitamin A through a 2-hour teach-ing session using the VADDmanual as a textbook for everyparticipant. It was much appreci-ated by township doctors and vil-lage health workers.

In the past decade, outbreaks ofvitamin A deficiency in animal hus-bandry settings have been re-ported in China due to long-termfeeding with single-product fod-der. Therefore the VADD manualhas been provided to the Ministryof Agriculture Department of Ani-mal Production and Health, theNational Reference Laboratory ofAnimal Disease and other relatedinstitutions.

Public health staff in Hainan Tibetan Prefecture and Huangnan Tibetan Prefecture of Qinghai Province using theVADD manual.


In the Hulunbeier Prefecture inInner Mongolia, where most in-habitants are nomads dependingon animal husbandry, the prefec-ture has been receiving supportto control tuberculosis, includinga health promotion strategy. Al-though there is no available datato demonstrate the possible link-age between tuberculosis and vi-tamin A deficiency, the medicalstaff still believes that it would bebeneficial to encourage patientsto eat more vitamin A rich food:the VADD manual was sent to thePrefecture Tuberculosis Control

Center and many other health in-stitutions in 2003.

In Bijie Prefecture, one of the poorprefectures in Guizhou Province,both vitamin A deficiency andother causes of blindness arepublic health problems in ruralcommunities. The local healthbureau has submitted an applica-tion to CBM for support to addressthese problems. Both the VADDmanual and the HEAB were pro-vided to the Prefecture HealthBureau, which would like to dis-

tribute it to all the counties in theprefecture.

References1. UNICEF, MOH, Micronutrient Initia-

tive. Vitamin A and mineral deficiency:A damage assessment report forChina. Beijing, 3 September 2004.

2. Lin Yan. Recent survey on childrenwith vitamin A deficiency in China.SIGHT AND LIFE Newsletter 2/2001;37–39

3. Lin Yan. The Chinese and Tibetanversions of the Healthy Eyes ActivityBook. SIGHT AND LIFE Newsletter2/2004; 24–25

SIGHT AND LIFE continued to co-fund training in Community EyeHealth at the International Cen-tre for Eye Health in London. Al-though we also support the devel-opment of courses overseas, thepeople trained in London will be-come trainers in their own coun-tries, so the continued support ofthe courses in London is impor-tant to build up a trained facultyto teach community eye health inoverseas countries.

Below is some information fromthis year’s MSc students from Ni-geria, Tanzania and The Gambiawho were supported by SIGHTAND LIFE.

Dr Perpetua Ojo Odugbo

I am a Nigerian. I studied HumanMedicine at the Ahmadu BelloUniversity Zaria-Nigeria. I was aFellow of the West AfricanCollege of Surgeons (FWACS)and a Fellow of the MedicalCollege of Ophthalmologists(FMCophth). I have seven yearsworking experience in ophthal-

mology (duration of training inclu-sive). I was employed as a Lec-turer in the Faculty of MedicalSciences, University of Jos-Ni-geria in May 2004 and hopefullyshall be employed as a Consult-ant Community Ophthalmologistat the Jos University TeachingHospital, Nigeria on completionof the Master degree course inCommunity Eye Health at theLondon School of Hygiene andTropical Medicine.

My job entails clinical work in oph-thalmology, training of residentdoctors in ophthalmology andfamily medicine, medical stu-dents, community health officersand nurses. I am also involved inresearch work and in deliveringcommunity-based eye care serv-ices.

My studies in London have beenquite challenging and rewarding.My knowledge and skills in sci-ences necessary to conduct epi-demiological and qualitative re-search have improved im-mensely. My knowledge of the

epidemiology of blinding eye dis-eases has been further broad-ened and the entire concept andplanning of “Vision 2020” and itsachievements has been ad-equately explained. My computerskills, especially in the area ofData Management, have im-proved immensely. There is somuch to learn, and so many chal-lenges. I am facing them with alot of enthusiasm and I am look-ing forward to being fully equippedto work efficiently as a communityophthalmologist.

The majority of the causes ofchildhood blindness in Nigeria areeither preventable or treatable.Children are the most preciousresources of families. A blind childis a tragedy for his/her family. Achild whose blindness could havebeen prevented or cured is aneven greater disaster. Vitamin Adeficiency is a leading cause ofchildhood blindness in Nigeria. Aspart of my course, I intend to con-duct a “Blind school survey in Pla-teau and surrounding states inNigeria” with the sole aim of find-

Community Eye Health at the London School ofHygiene and Tropical Medicine: SIGHT AND LIFEsupported students


ing out what proportion of child-hood blindness is still attributableto vitamin A deficiency in thestudy area and to also find outmore about the underlying riskfactors that predispose to VADand blindness from VAD. This willprovide additional informationwhich can help inform furtherpublic health interventions. I amindeed very grateful to SIGHTAND LIFE for partaking in spon-soring me for this course.

Dr Ida M Ngowi

I am taking the MSc in Commu-nity Eye Health at the LondonSchool of Hygiene and TropicalMedicine, in London. Before join-ing this institution I worked in Tan-zania in the Songea GovernmentRegional Hospital. Songea is inthe southern part of Tanzania,known as the Southern High-lands. This region is bordered byMozambique in the south, andMalawi to the west. To the norththere are the Morogoro andMbeya regions, while eastwardthere is Mtwara region. It is lo-cated 1,000 kilometers from thecity of Dar es Salaam.

At the hospital my duties werecoordinating all eye services inthe region (which had three dis-tricts). Each district had a DistrictEye Coordinator (DEC). I was in-volved in planning of activities,coordinating various eye careactivities, and preparing budgetsfor regional eye care services incooperation with the RegionalMedical Officer. I then presentedthese plans to the National EyeCoordinator during the NationalEye Care meetings. The Tanza-nian government provides eyecare services in the region, incollaboration with Sight SaversInternational, who give financialsupport for all four districts.

I am also consultant Ophthal-mologist for the region and sur-rounding regions which are notserved by an Ophthalmologist.

My duties involve clinical consul-tation and surgery.

The MSc course is really chal-lenging and enlightening. I neverregret taking the course becauseeach day I realize how valuable itis for the set up that I work in.Training in researching, planningand budgeting are skills which Idesperately needed for a betterperformance in my job. The Vision2020 plan and the Primary HealthCare module describes the basicprinciples of a healthy communityand the need for inter-sectoralcollaboration for a better andhealthier community.

London is a beautiful city with themixture of different cultures onemay expect to find in a Europeancity. I just wish I had time to visitthe museum and the beautifulparks, and the Palace.

As part of my MSc course I willbe undertaking a dissertation. Mytopic is to identify factors whichdifferentiate preschool children incommunities in Morogoro regionfrom those in Singida in relationto vitamin A intake.

I would like to thank Task ForceSIGHT AND LIFE for paying partof my fees, which has enabled meto study on this MSc course. Thetraining will provide me with skillsto plan and manage eye care pro-grammes in Tanzania, in our fightto eradicate avoidable blindnessby the year 2020.

Dr Bitrus Jugul Danboyi

I am a Nigerian and an Ophthal-mologist working with theGambian Eye Care Programmesince 1994 with a study breakfrom March 1999 to December2001, to complete my clinicaltraining. I was fortunate to receivesponsorship from a number ofagencies including Task ForceSIGHT AND LIFE, to study on theMSc Community Eye Healthcourse at the International Cen-

tre for Eye Health at the LondonSchool of Hygiene and TropicalMedicine, University of London.

The causes of childhood blind-ness in the Gambia are not toodifferent from what is seen in otherdeveloping countries except thatvitamin A deficiency does not fea-ture prominently in the Gambia.The Gambian Eye Care Pro-gramme recognised the impor-tance of vitamin A as a cause or apotential cause of blindness andlow vision in children and there-fore included activities that ad-dressed this issue to prevent it.These included vitamin A and itsdeficiency related conditions andits prevention and treatment in thetraining curriculum for all catego-ries of eye care staff undergoingtraining in the tertiary center; alltrained graduates are providedwith vitamin A as an essential drugto distribute as supplements to allunder-fives attending maternaland child welfare clinics all overthe country and also to give to allmalnourished children and chil-dren with measles and cornealinfections.

All community ophthalmic nursesare trained to function as inte-grated eye care workers in thecommunity. They participate inmaternal and child welfare clinics,participate in community screen-ing activities, outreaches, andimmunization campaigns gradu-ates.

As an ophthalmologist, my rolehas been that of administration,participating in planning, imple-mentation and supervision, pro-viding clinical services (both medi-cal and surgical ophthalmology),carrying out operational research,training and providing technicalsupport to the Gambia and theother member countries of theHealth for Peace Initiative (HFPI)which included Senegal, GuineaConakry and Guinea Bissau.


The challenges I faced with theseresponsibilities included, amongstothers, the limited theoreticalknowledge of Community EyeHealth in epidemiology especially,for which this course is offeringme a great deal. I hope to returnwith this improved knowledge toprovide these services and per-form my role even better.

In conclusion this course will pro-vide me with in-depth knowledgein community eye health to enableme to perform my responsibilitieseven better and help me developmy career.

From left, Bitrus Jugul Danboyi, Perpetua Ojo Odugbo, Daksha Patel (CourseOrganiser), Ida M. Ngowi, Allen Foster (Director of the ICEH).

A digest of recent literatureDonald S. McLaren

IntroductionI would first like to add my personalgreetings and good wishes to thoseof our Editor for a peaceful and pros-perous New Year, 2005. This date isa memorable one in some ways. Atthe personal level it marks twentyyears since I was asked to take overthe editorship from Tony Pirie of theXerophthalmia Club Bulletin whichwas commenced by her in 1972. Atthe turn of the millennium the Bulle-tin was incorporated into this News-letter. This long experience of report-ing on the ongoing advances in thefield of vitamin A deficiency (VAD,VADD) has greatly helped SIGHTAND LIFE to make widely availablethis information in several languagesand at several levels. In this connec-tion readers will be interested to

learn that it is the intention to carryout extensive revision and updatingof previously published material, in-cluding a 3rd edition of the SIGHTAND LIFE Manual, a 2nd edition ofthe SIGHT AND LIFE Guide Book,and a new version of the PowerPointand slide presentations.

The year 2005 also brings a salu-tary reminder that we are half waythrough the first decade of the 21stcentury. A number of goals havebeen set to be attained by the year2010, or in some cases by the morefaint-hearted (or perhaps realistic inthe light of such total failures as“Health for all by the year 2000”)2020 etc. It is time to see how thingsare going on many fronts and so, ina very small way the Literature Di-gest might be put under the micro-scope with some profit.

First of all there would seem still tobe a real need for this service, judg-ing by such indications as the com-plimentary remarks that are received

from time to time and the fact, forinstance, that the XXII IVACG Meet-ing held in Lima, Peru, in November2004 (and reported extensively inthis issue of the Newsletter) attractedno fewer than 665 participants from79 countries.

We are always open to suggestionsfrom our readers for introducing im-provements in the Literature Digest.Currently available abstracts and inmany instances complete papers inthe field of vitamin A and related top-ics are read through, and a selec-tion made for those considered new,suitable, valid research etc. Probablythree or four papers are read andrejected on average for every onethat is included. Although it involvesextra work, it seems worthwhile togroup the abstracts according tosubject. Recently two new groupingshave been added “Multimicro-nutrients” and “Vitamin A and its rela-tives”. The first is in response to theevident present interest in the inter-relationships between vitamin A andother micronutrients – especially ironand zinc. There has probably beentoo great a tendency in the past toregard vitamin A as some kind of“magic bullet”. This was especiallytrue in the previous era when

* Address for correspondence:Prof. Donald S. McLaren12 Offington Avenue, Worthing,West Sussex BN14 9 PE, UK


vitamin A on its own did indeed treatand control xerophthalmia success-fully. Its role in alleviating morbidityand reducing mortality is undoubt-edly shared by many other factors.The second relates back to an arti-cle of that name in the SIGHT ANDLIFE Newsletter where I exploredthe rapidly expanding knowledge ofthe fascinating roles that carotenoidsand retinoids of many kinds play innature.

Under two other headings, experi-mental studies and basic research,which overlap to some extent, arepresented advances in our knowl-edge at a basic, often molecular bio-logical level. Much of this does notapply to humans at the present timebut it gives an indication where wemight be looking for studies in thenear future. The main purpose hereis to draw general attention to newwork of potentially broader impor-tance, without attempting to critiquethe paper, which in most cases isbeyond my competence.

One area of interest has been ex-cluded until the present, but on re-flection there seems to be a goodcase for its inclusion in future. Thisis “Vitamin A and carotenoids andcancer”. Nearly all the human workhas been done in communitieswhere VAD is not a problem. How-ever, these cancers occur in devel-oping countries and in some in-stances are on the increase there,as for example bronchial carcinomarelated to cigarette smoking. Someparts of the third world have highincidences of cancers that are notcommon elsewhere – for examplecarcinoma of the esophagus, lip, lar-ynx and liver. There seem to be fewstudies of these related to vitamin A.

In conclusion, it seems to me thatas basic science is revealing theubiquitous importance of retinoids inalmost every life process it behoovesthose ultimately concerned in oneway or another with vitamin A andhuman health to consider everbroader ways that lack of this nutri-ent may impair health. For examplethere is a growing body of experimen-tal evidence that suggests that vita-min A deficiency in early life may playa part in the development of congeni-tal malformations of the cardiovas-cular and central nervous systems.

Finally, there are some contributionswhich appear to me for various rea-sons to be worth paying special at-tention to. This is a personal choiceand others might have differentfavorites.

Community reports“Feast or famine?” by Surridge S.Nature 2004; 428:360–361.“Rice feeds more than half the world’speople; but not well and not for muchlonger.” This article opens with theseominous words. It is mainly about riceyields but “golden” or “miracle” rice,with its genetically engineered provi-tamin A carotenoids, receives men-tion and its effectiveness will, ofcourse, be affected if yields continueto fall. The article focuses on the un-settled argument going on about theSRI (System of Rice Intensification)developed in the 1980s with moresparsely planted and drier fields ver-sus the traditional method.

“Intraindividual variation in serumretinol concentrations among par-ticipants in the third NationalHealth and Nutrition ExaminationSurvey, 1988–1994” by Gillespie C,Ballew C, Bowman BA et al. Am J ClinNutr 2004; 79:625–632 (C Gillespie,Chronic Disease Prevention Branch,Division of Nutrition and PhysicalActivity, 4770 Bufon Highway NE,Mailstop K26, Atlanta, GA 30341–3724. E-mail: [email protected]).The biological variability in serumretinol concentrations has neverbeen examined in a large sample.This detailed analysis showed that“the actual population prevalence ofinadequate vitamin A status may be75% lower than the estimates previ-ously reported. Confirmation of vita-min A status may be needed for per-sons in the United States with ob-served serum retinol concentrationsnear the recognized cutoff”. (DonMcLaren: if this conclusion were tohold true for other populations thenthe magnitude of the problem of vi-tamin A deficiency may have beenconsiderably overestimated. Thismight also contribute to an explana-tion as to why so many underprivi-leged populations seem to remainapparently healthy while consuminglow levels of provitamin Acarotenoids. The authors call for“confirmation of vitamin A status” incertain circumstances – it would be

interesting to know what test theyhave in mind in this regard; on alarge population level this does notseem to be feasible).

“Socioeconomic and familialcharacteristics influence caretak-ers’ adherence to the periodic vi-tamin A capsule supplementationprogram in Central Java, Indone-sia” by Panganbaribuyan R,Scherbaum V, Erhardt JG et al. JTrop Pediat 2004; 50:143–148(SEAMEO-TROPMED RegionalCenter for Community Nutrition,University of Indonesia, Jakarta, In-donesia. E-mail:[email protected]).Adherence was assessed in caretak-ers of 677 children aged 1–5 yearsin rural and suburban areas. Care-takers with limited knowledge abouthealth benefits of vitamin A, house-holds with more than one preschoolchild, and households with children>36 months had significantly lessregular participation (p<0.01). Healthfacilities were significantly (p<0.001)better utilized in rural than suburbanareas.

“Safety and impact of vitamin Asupplementation delivered withoral polio vaccine as part of theimmunization campaign in Orissa,India” by Gorstein J, Bhaskaram P,Khanum S et al. Food Nutr Bull 2003;24:319–331 (Program for AppropriateTechnology in Health (PATH), 1455NW Leary Way, Seattle, WA 98107,USA. E-mail: [email protected])1811 children, aged 12–48 months,were studied at baseline and at 4and 16 weeks following vitamin Asupplementation. Coverage was97%. Bitot’s spot (X1B) prevalencewas 2.9% at baseline, 1.9% at 4weeks, and 3.6% at 16 weeks. Meanserum retinol was 0.62 µmol/l atbaseline, 0.73 at 4 weeks and 0.50at 16 weeks which was significantly(p<0.01) less than at baseline. Thissuggests that the benefit of supple-mentation was only transient.

“Carotenoid-rich bananas: a po-tential food source for alleviatingvitamin A deficiency” by Englber-ger L, Darnton-Hill I, Coyne T et al.Food Nutr Bull 2003; 24:303–318(Nutrition Program, Division of Inter-national Health, School of Popula-tion Health, University of Queens-land, Brisbane, Australia. E-mail:


[email protected]).Acceptable carotenoid-rich bananacultivars have been identified inMicronesia, and some carotenoid-rich bananas have been identifiedelsewhere. Bananas are an idealfood for young children and familiesfor many regions of the world, be-cause of their sweetness, texture,portion size, familiarity, availability,convenience, versatility, and cost.(Don McLaren: details are not givenof the type of carotenoids present orof their concentrations.)

“Daily consumption of Indianspinach (Basella alba) or sweetpotatoes has a positive effect ontotal-body vitamin A stores inBangladeshi men” by Haskell MJ,Jamil KM, Hassan F et al. Am J ClinNutr 2004; 80:705–714 (Program inInternational Nutrition, Departmentof Nutrition, University of California-Davis, One Shields Avenue, DavisCA 95616, USA. E-mail:[email protected]).The effect was assessed by thedeutered-retinol-dilution technique of60 d of daily supplementation with750 µg retinol equivalents (RE) ofeither cooked, pureed sweet pota-toes; cooked, pureed Indian spinach;synthetic sources of vitamin A orβ-carotene, or as control white veg-etables (0 µg RE/d) in addition to alow-vitamin A diet providing approxi-mately 200 µg RE/d, in Bangladeshimen. Overall mean (+/- SD) initialvitamin A stores were 0.108 +/- 0.067µmol. Relative to the control group,the estimated mean changes in vita-min A stores were 0.029 µmol forsweet potato, 0.041 µmol for Indianspinach, 0.065 µmol for retinylpalmitate and 0.062 µmol forβ-carotene. Vitamin A equivalencyfactors (β-carotene:retinol, wt:wt)were estimated as approximately13:1 for sweet potato; approx 10:1for Indian spinach; and approx 6:1for synthetic β-carotene.Conclusion: Daily consumption ofcooked, pureed green leafy vegeta-bles or sweet potatoes has a posi-tive effect on vitamin A stores inpopulations at risk of vitamin A defi-ciency.

“Carotenoids from native Brazil-ian dark-green vegetables arebioavailable: a study in rats” byGraebner IT, Siqueira EMA, DeSouza EMT. Nutr Res 2004; 24:671–

679 (De Souza, Universidade deBrasilia, Prog. Pos-Graducao EmNutr Humana, Depto Nutr, FaculdadeCie.Da S., Brasilia, Brazil. E-mail:[email protected]).Over a 30 day period different caro-tenoid sources were fed to vitaminA-depleted rats. Liver accumulationof retinol was measured. 1µg retinolaccumulated in the liver after the in-take of 43.1; 95.3; or 178.9µg β-car-otene from Sonchus oleraceus;Amaranthus viridis; and Xantho-soma agittifolium leaves respec-tively. These leaves are pest-resistant and widely distributed andmay be an inexpensive alternativesource of vitamin A to reduce VAD.

“Complex interactions with infec-tion and diet may explain sea-sonal growth responses to vita-min A in preschool-aged Indone-sian children” by Hadi H, DibleyMJ, West Jr KP. Eur J Clin Nutr 2004;58:990-999 (Hadi H, Ctr for Health/Human Nutrition, Faculty of Medi-cine, Gadjah Mada University, IKMBuilding, Jl Farmako, Sekip Utara,Yogyakarta 55281, Indonesia).A single high dose of vitamin A orplacebo was given every 4 monthsto 1405 children aged 6–48 months.4430 child-treatment cycles wereexamined. The study showed that asignificant effect of vitamin A supple-mentation on linear growth was ob-served in all seasons in children witha low burden of respiratory infections(<21 days with respiratory illness).In each season the highest effectwas found in children with low bur-den of respiratory infections and lowvitamin A intake (<400 RE/d).Children with a high burden ofrespiratory infection or high intake ofvitamin A benefited less for their lin-ear growth than children with a lowburden and low vitamin A intake.There was no benefit for linear growthfrom vitamin A supplementation inchildren with both high burden of res-piratory infection and high vitamin Aintakes regardless of season.

“Dietary vitamin A intakes of Fili-pino elders with adequate or lowliver vitamin A concentrations asassessed by the deuterated-reti-nol-dilution method: implicationsfor dietary requirements” byRibaya-Mercado JD, Solon FS,Fermin LS et al. Am J Clin Nutr 2004;79:633–641 (JD Ribaya-Mercado,

Jean Mayer US Department of Agri-culture Human Nutrition ResearchCenter on Aging at Tufts University,711 Washington Street, Boston, MA02111. E-mail: judy.ribaya-mercado@tufts edu).31 male and 31 female subjects(aged 60–88 yrs) with adequate(>0.07µmol/g) or low (<0.07µmol/g)liver vitamin A concentrations hadtheir dietary intakes assessed. Totalbody vitamin A was assessed as-suming liver weight is 2.4% of bodyweight and 70% of total body vita-min A is in the liver. Mean vitamin Aintakes of men and women with ad-equate liver vitamin A were 135 and134 µg RAE/day respectively. Thosewith inadequate liver vitamin A were75 and 60 µg RAE/daily respectively.An acceptable dietary vitamin A in-take in elders is 6.45 µg RAE/kgbody weight, or approx 500 and 400µg RAE/d for a reference 76kg manand a 61 kg woman respectively.

“Children aged 6 to 60 months inNepal may require a vitamin Asupplement regardless of dietaryintake from plant and animalsources” by Grubesic RB. FoodNutr Bull 2004; 25:248–255 (TexasWoman’s University College of Nurs-ing, 1130 John Freeman Blvd., Hou-ston, TX 77030, USA. E-mail:[email protected]).A cross-sectional survey was con-ducted during June and July 2000on children aged 6–60 months andtheir mothers. There were threegroups – regularly supplemented;supplemented only once; and neversupplemented. Over 500 householdsin over 80 villages were involved.“Regardless of the amount of vitaminA–rich foods consumed, children whowere regularly supplemented withhigh doses of vitamin A wereprotected against malnutrition,diarrhea, and acute respiratoryinfection at a higher rate than thosesupplemented only once or never”.

“Consumption of vitamin A bybreastfeeding children in ruralKenya” by Ettyang G, Oloo A, vanMarken Lichtenbelt W et al. FoodNutr Bull 2004; 25:256–263 (GAEttyang, Department of Human Nu-trition, Faculty of Health Sciences,Moi University, PO Box 4606,Eldoret, Kenya. E-mail: [email protected]).62 mother-child pairs were


assessed. Mothers with marginal(<0.70µmol/l) serum retinol andbreast milk deficient (<1.05µmol/l) inretinol accounted for 45.2% and77.4% respectively. A significant(p<0.05) proportion (40.3%) of moth-ers had breast milk deficient in reti-nol and marginal levels of serum reti-nol. The risk of VAD in breast-fedinfants older than 6 months washigh, because 89.5% of them did notconsume foods high in vitamin Acontent three times weekly. The pri-mary vitamin A source of infantsyounger than 6 months was breastmilk deficient in retinol. The evidencesuggests a very high risk of VAD inboth groups.

“Coping with a nutrient defi-ciency: cultural models of vitaminA deficiency in northern Niger” byBlum LS, Pelto GH, Pelto PJ. MedAnthropol 2004; 23:195–227(ICDDR, B Centre for Health andPopulation Research, Dhaka, Bang-ladesh).The Hausa-speaking people studiedtended to interpret the etiology ofnight blindness in young children andpregnant women in terms of food-related causes. In line with this therecommended treatments are homefood remedies, primarily involvingliver, meat or green leaves. The lo-cally attributed etiology for xeroph-thalmia is quite different. Peoplebelieve the primary cause is “heat”produced by acute infectious dis-ease (particularly measles). Visits tothe local dispensary or dependenceupon home remedies are the pre-ferred treatment options.

“A review of the epidemiologicalevidence for the ‘antioxidant hy-pothesis’” by Stanner SA, HughesJ, Kelly CNM et al. Public Health Nutr2004; 7:407–422 (SA Stanner, Brit-ish Nutrition Foundation, 52–54 HighHolborn, London WC1V 6RQ, UK).This hypothesis proposes that anti-oxidants such as vitamin C, vitaminE and carotenoids afford protectionagainst chronic diseases by de-creasing oxidative damage. Primaryand secondary intervention trialshave failed to show any consistentbenefit. Trials investigating the effectof a balanced combination of anti-oxidants at levels achievable by dietare awaited. The most prudent pub-lic health advice remains to increasethe consumption of plant foods.

“Epidemiological study of mea-sles in slum areas of Kolkata” byRay SK, Mallik S, Munsi AK et al.Indian J Pediatr 2004; 71:583–586(Department of Community Medi-cine, Medical College, Kolkata, In-dia). Cluster sampling was used,with 20 clusters each of 250 childrenunder 5 years who had a history ofmeasles in the past year. There wasan overall 5.76% incidence of mea-sles, which was equal in both sexesbut greater in infants. Among mea-sles cases only 19.7% had beenimmunized. 100% gave a history ofrash; 98.9% had fever; 82.8% re-ported rash started on face andspread towards abdomen and legs.Cough, redness of eyes, and discol-oration of skin were reported in97.5%, 83.8% and 65.2% respec-tively. Only 16.9% had received vi-tamin A before measles and 8.6%after.

“Serum vitamin A concentrationand the risk of hip fracture amongwomen 50 to 74 years old in theUnited States: a prospectiveanalysis of the NHANES I follow-up study” by Opotowsky AR,Bilezikian JP. Am J Med 2004;117:169–174 (Department of Medi-cine, College of Physicians and Sur-geons, Columbia University, NewYork, NY 10032, USA).Data on 2799 women, 50–74 y, fromthe NHANES Epidemiologic Follow-up Study were examined. Therewere 172 incident hip fractures dur-ing the 22-year follow-up period. Byanalysis of serum retinol levels it wasfound that there was a U-shapedrelationship between serum retinoland risk of hip fracture - fracture riskwas higher in both lowest quintileand highest quintile of serum retinol.

“Vitamin A status of pregnant Ni-gerian women: relationship to di-etary habits and morbidity” byAjose OA, Adelekan DA, AjewoleEO. Nutr Health 2004; 17:325–333(Department of Chemical Pathology,College of Health Sciences, ObafemiAwolowo University, PO Box 1089,OAU Post Office, Ile-Ife, Osun State,Nigeria).Two hundred pregnant women(aged 15–43 y) were studied. Vita-min A deficiency (serum retinol <0.35 µmol/l) was found in 17.5% ofsubjects, 37% had borderline status(0.35–70µmol) and 45.5% were nor-

mal (>0.70µmol/l). Although about80% of the subjects consumed redpalm oil daily, about 64% would heatthe oil to smoking for at least 10 min-utes before adding it to stew duringcooking. Green vegetables werealso boiled in hot water before add-ing to sauce, while liver is consumedon just about three days a month.

“Vitamin A intake and the risk ofhip fracture in postmenopausalwomen” by Lim LS, Harnack LJ,Lazovich D et al. Osteoporosis Int2004; 15:552–559 (LS Lim, Schoolof Public Health, Division of Epide-miology, University of Minnesota,Minneapolis, MN 55454, USA).34,703 postmenopausal womenfrom the Iowa Women’s HealthStudy were followed for a mean of9.5 years. Users of supplementscontaining vitamin A showed a 1.18-fold increased risk of incident hipfracture (n=525) compared withnonusers, but there was no evidenceof an increased risk of all fractures(n= 6502) among supplement users.There was no evidence of a dose-response relationship in hip fracturerisk with increasing amounts of vita-min A or retinol from supplements.These results also showed no asso-ciation between vitamin A or retinolintake from food and supplements,or food only, and the risk of hip or allfractures.

“Undernutrition as an underlyingcause of malaria morbidity andmortality in children less than fiveyears old” by Caulfield LE, RichardSA, Black RE. Am J Trop Med Hyg2004; 71(2):55–63 (Center for Hu-man Nutrition and Department ofInternational Health, The JohnsHopkins University BloombergSchool of Public Health, Baltimore,Maryland 21205, USA. E-mail:[email protected]).This review describes how poor nu-tritional status, especially with regardto deficiencies of vitamin A, zinc, ironand folate, is responsible for a sub-stantial proportion of malarial mor-bidity and mortality. It is recom-mended that nutrition programs beintegrated into existing malaria inter-vention programs.

“Serum values of cytokines inchildren with vitamin A deficiencydisorders” by Leal JY, Castejon HV,Romero T et al. Invest Clin 2004;


45:243–256 (JY Leal, Lab de Invest.en Malnutricion Inf., Inst. deInvestigaciones Biologicas,Universidad del Zulia, Apartado 526,Maracaibo 4001, Venezuela. E-mail:[email protected]).Serum concentrations of Th1-Th2cytokines in 138 slum children aged4–7 years with vitamin A deficiencywere determined. No child had clini-cal VADD. IL–10 was significantly(p<0.03) less than in controls. Othercytokines studied were not different.

“Detection of vitamin A deficiencyin Brazilian preschool childrenusing the serum 30-day dose-re-sponse test” by Ferraz IS,Daneluzzi JC, Vannuchi H et al. EurJ Clin Nutr 2004; 58:1372–1377 (ISFerraz, School of Medicine ofRibeirao Preto, USP, Department ofChild Care/Pediatrics, Av.Bandeirantes 3900, Ribeirao Preto,Sao Paulo, 14049–900 Brazil. E-mail: [email protected]).188 preschool children underwentthis test for vitamin A status in theliver. 74.5% presented + S30DR val-ues indicative of low status. Nonehad xerophthalmia, 3.7% were mal-nourished. (Don McLaren: DrHernando Flores is one of the au-thors, a joint originator of this testand well-known in VADD circles dur-ing his years in Recife. This andother similar tests need two bloodsamples, a requirement causing in-creasing difficulty in the field. Stableisotope tests obviate the need forthis).

“Vitamin A deficiency and xeroph-thalmia among school-aged chil-dren in Southeastern Asia” bySingh V, West Jr KP. Eur J Clin Nutr2004; 588:1342–1349 (KP West Jr,Department of International Health,Johns Hopkins Bloomberg School ofPublic Health, Center for HumanNutrition, 615 N Wolfe Street, Balti-more, MD 21205, USA).Various sources of information wereculled for prevalence of VAD(<0.70µmol/l) and xerophthalmia.The estimated prevalence of VAD inchildren aged 5–15 years in theregion was 23.4% or 83 million, and10.9% had mild xerophthalmia (Bi-tot’s spots, night blindness). Poten-tially blinding corneal xerophthalmiaat this age in the region appears tobe negligible. A future public healthresearch priority is to obtain nation-

ally representative data on preva-lence, risk factors and health con-sequences.

“Consumption of carotenoid-richfoods and central vision loss: amatched case-controlled study inKansas” by Holcomb CA. J NutrElder 2004; 24:1–18 (Department ofHuman Nutrition, Kansas State Uni-versity, Manhattan, KS 66506–1407,USA).168 rural elders were studied. Theonly significant direct association ofcentral vision loss with various di-etary data was with high consump-tion of corn bread.

“The night vision threshold testis a better predictor of low serumvitamin A concentration than self-reported night blindness in preg-nant urban Nepalese women” byTaren DL, Duncan B, Shrestha K etal. J Nutr 2004; 134:2573–2578 (Mand E Zuckerman Arizona Collegeof Public Health, University of Ari-zona, Tucson, AZ 85724, USA. E-mail: [email protected]).1401 pregnant women were exam-ined; 16% failed the NVTT, but only6.4% reported having night blind-ness. NVTT test failure was accom-panied by lower serum retinol. Se-rum retinol was correlated with theNVTT scores (p<0.001).

Multimicronutrients“Co-existence of anaemia, vita-min A deficiency and growth re-tardation among children 24–84months old in Maracaibo, Ven-ezuela” by Castejon HV, Ortega P,Anaya D et al. Nutr Neurosci 2004;7:113–119 (HV Castejon, Av. 3BEsq. Calle 72, Maracaibo 4001, Ven-ezuela).202 children, 24–84 months old (104girls, 98 boys) were tested. Anemia(Hb) was 38.11%; VAD (< 20µg/dl)was 21.78%; height/age and weight/age Z scores (less than or equal to–2SD) expressed stunting and un-derweight, 14.36% and 9.40% re-spectively. Anemia and VAD clus-tered in 7.92%; anemia + stuntingor + underweight coexisted in 5.94%and 2.97% respectively. Stuntingand underweight clustered with VADin 2.97% and 1.48% respectively.Three-way combination with anemiawas only seen with stunting in0.99%. Whilst individually each pa-

rameter appears to be of publichealth importance, there is no evi-dence of clustering.

“Thinking beyond deworming”editorial The Lancet 2004; 364:1993–4.At a meeting in Geneva in late No-vember 2004, Partners for ParasiteControl (WHO member states, theWorld Food program, the WorldBank, research institutes, universi-ties, and non-governmental agen-cies) presented convincing evidencethat helminth control is a crucial andneglected step towards improvingpublic health and reaching severalof the Millennium DevelopmentGoals. Worms infest more than onethird of the world’s population. From5–14 years the diseases account forloss of about 20% of disability ad-justed life-years and cause wide-spread anemia, vitamin A deficiency,stunted growth, poor intellectual de-velopment, impaired cognitive func-tion, and damage to the liver, intes-tine and urinary tract. Drug treat-ments are all very cheap. (DonMcLaren: it is doubtful if these con-siderations have been given suffi-cient attention in programs for thecontrol of VADD – see Introductionabove).

“Vitamin A and iron supplemen-tation is as efficient as hormonaltherapy in constitutionally de-layed children” by Zadik Z, Sinai T,Zung A et al. Clin Endocrinol 2004;60:682–687 (Z Zadik, Pediatric En-docrine Unit, Kaplan Medical Center,Rehovot, 76100, Israel. E-mail:[email protected]).102 boys 13.6–15.5 years old werereferred for short stature and de-layed puberty. Groups received 1)oxandrolone; 2) testosterone; 3) ironand vitamin A; 4) oxandrolone andiron plus vitamin A; or 5) passiveobservation. Good results were ob-tained in all the treated groups andthis suggests that children with ironor vitamin A deficiency should re-ceive nutritional supplements as wellas hormones.

“Vitamin A status, hospital-izations, and other outcomes inyoung children with sickle celldisease” by Schall JI, Zemel BS,Kawchak DA et al. J Ped 2004;145:99–106 (JI Schall, Division ofGastroenterol. Nutr. H., Department


of Pediatrics, Children’s Hospital,Philadelphia U., Philadelphia, PA,USA. E-mail:[email protected]).VAD (serum retinol <30µg/dl) waspresent in 66%. Compared withthose with normal vitamin A status,these 66% had significantly lowerBMI, Hb, Hct and 10-fold morehospitalizations, with increased painand fever episodes. VAD should belooked for and treated in childrenwith sickle cell disease.

“Full-term, peri-urban South Afri-can infants under 6 months of ageare at risk for early-onset anae-mia” by Sibeko LN, Dhansay MA,Charlton KE et al. Publ Health Nutr2004; 7:813–820 (Gray DK, Schoolof Dietetics and Human Nutrition,McGill University, 21 111 Lakeshore,Ste Anne de Bellevue, Que.H9X 3V9Canada. E-mail:[email protected]).Hemoglobin and serum retinol weremeasured in 113 breast-feedingwomen and their 1–6 month-old in-fants. 32% of mothers were anemic(Hb<12g/dl). When serum retinolwas measured 4.5% were deficient.Measurement of breast milk fat con-tent revealed 13% to be vitamin Adeficient. There was no correlationbetween maternal and infant serumretinol. For infants three cut-off levelswere used for anemia (<11g/dl=50%;<10.5g/dl=33%; <9.5g/dl=12%).Mean infant serum retinol was26.9µg/dl and 10% were deficient.32% of infants received weaningfoods at an exceptionally young age(less than or equal to 1 month).

“Vitamin A status and haemo-globin concentrations are im-proved in Indonesian childrenwith vitamin A and deworming in-terventions” by Tanumihardjo SA,Permaesih D, Muhilal. Eur J ClinNutr 2004; 58:1223–1230 (SATanumihardjo, Department of Nutri-tional Sciences, UW-Madison, 1415Linden Drive, Madison, WI 53706, USA.E-mail: [email protected]).131 Indonesian children infectedwith Ascaris lumbricoides and /orTrichuris trichuria. 210 µ mol vitamin Aand 400 mg albendazole were ad-ministered. It was concluded that“public health supplementation pro-grams to improve vitamin A statusmay also increase Hb concentra-tions and decrease anemia preva-

lence, especially when linked todeworming”.

“Relationship of vitamin A defi-ciency, iron deficiency, and in-flammation to anemia among pre-school children in the Republic ofthe Marshall Islands” by GambleMV, Palafox NA, Danchek B et al.Eur J Clin Nutr 2004; 58:1396–1401(RD Semba, 550 North Broadway,Baltimore, MD 21205 USA. E-mail:[email protected]).Among 367 children the relationshipof vitamin A and iron status andmarkers of inflammation, tumornecrosis factor-(alpha), (alpha) (1)-acid glycoprotein, and interleukin-10,to anemia were studied. The preva-lence of severe vitamin A (<0.35µmol/l) and iron deficiency (serumferritin <12 µg/dl) were 10.9 and51.7% respectively. The respectiveprevalence of iron deficiencyanemia, anemia with inflammation,and severe vitamin A deficiencycombined with anemia was 26.7,35.6, and 7.6%. It was concludedthat iron and vitamin A deficiencieswere independent risk factors foranemia, but inflammation was not asignificant risk for anemia in thesesubjects.

“Daily multivitamins with iron toprevent anemia in high-risk in-fants: a randomized clinical trial”by Geltman PL, Meyers AF, MehtaSD et al. Pediatrics 2004; 114:86–93 (PL Geltman, Whittier StreetHealth Center, 1125 Tremont St.,Roxbury, MA 02120, USA. E-mail:[email protected]).Control (n=138) and intervention(n=146) matched groups of healthy,full-term infants enrolled at their 6-month well-child clinic visit. Infantswere randomly assigned to receivestandard-dose multivitamins with orwithout iron (10mg/day). At 9 monthsanemia (Hb <11.0g/dL) was found in21%. 81% had iron deficiency on thebasis of 1 abnormal lab test and 49%on the basis of 2 abnormal. No dif-ference existed in the occurrence ofanemia and iron deficiency betweenthe 2 groups. In multivariate logisticregression, infants whose motherswere anemic during pregnancy were2.15 times more likely than othersto have any lab abnormalities. In-creasing adherence, regardless ofgroup assignment, was associatedwith a 0.56 times reduced risk of any

abnormality. Maternal anemia duringpregnancy appears of greatest im-portance.

“Exploiting micronutrient interac-tion to optimize biofortificationprograms: the case for inclusionof selenium and iodine” in the“Harvest Plus Program” by Lyons GH,Stangoulis JCR, Graham RD. NutrRevs 2004; 62:247–252 (School ofAgriculture and Wine, University ofAdelaide, Waite Campus, Urrbrae, SAustralia 5064, Australia).Micronutrient deficiencies increasethe risk of severe disease in approxi-mately 40% of the world’s popula-tion. This review points out the needfor “bioavailability trials with animalsand humans, using varying dietaryconcentrations of Se, I, Zn, Fe andvitamin A to elucidate important in-teractions in order to optimize deliv-ery in biofortification programs”.

“A randomized trial of multivita-min supplements and HIV diseaseprogression and mortality” byFawzi WW, Msamanga GI,Spiegelman D et al. N Eng J Med2004; 351:78–80 (Department ofNutrition, Harvard School of Publichealth, Boston MA 02115, USA. E-mail: [email protected]).In Tanzania 1078 pregnant womeninfected with HIV received daily sup-plements of vitamin A (preformedvitamin A and β-carotene), multi-vitamins (vitamins B, C and E) orboth, and progression of diseasewas monitored. Median follow-upwith respect to survival was 71months. Multivitamin supplementsdelayed the progression of HIV andresulted in higher CD4+ and CD8+counts and significantly lowered vi-ral loads. “The effects of receivingvitamin A alone were smaller and forthe most part not significantly differ-ent from those produced by placebo.Adding vitamin A to the multivitaminregimen reduced the benefit withregard to some of the end pointsexamined”.

Experimental studies“Hepatic stellate cells uptake ofretinol associated with retinol-binding protein or with bovineserum albumin” by Fortuna VA,Martucci RB, Trugo LC et al. J CellBiochem 2003; 90:792–805(Departamento de Histologia e


Embriologia, Instituto de CienciasBiomedicas, Universidade Federaldo Rio de Janeiro, 21941–970Cidade Univedrsitaria, Rio de Ja-neiro, Brazil).Hepatic stellate cells regulate accu-mulation and mobilization of retinolin the liver. This study showed “a di-rect influx pathway that facilitates theretinol uptake into hepatic stellatecells against the concentration gra-dients, and possibly protects cellmembranes from undesirable andpotentially noxious high retinol con-centrations”.

“Neonatal estrogenization leadsto increased expression of cellu-lar retinol binding protein 2 in themouse reproductive tract” byMatsuda M, Masui F, Mori T. Cell Tis-sue Res 2004; 316:131–139 (M Mat-suda, Department of Biological Sci-ences, Graduate School of Science,University of Tokyo, 7–3-1 Hongo,113–0033 Tokyo, Japan. E-mail:[email protected]).In perinatal life, during a critical pe-riod exposure to estrogenic sub-stances causes irregular develop-ment of the genital tract with ovary-independent proliferation and corni-fication in the vaginal epithelium ofmice. Retinol reverses this. VADmakes harmful effects greater.Estrogen acts by induction ofCRBP2 (cellular retinol binding pro-tein) gene expression, and “retinoidimbalance may contribute to thegenesis of irreversible effects ofestrogen on the vagina”.

“Plasma retinol-binding protein:structure and interactions withretinol, retinoids, and trans-thyretin” by Zanotti G, Berni R.Vitam Horm 2004; 69:271–295 (De-partment of Organic Chemistry, Uni-versity of Padova, 35131, Padua,Italy).This review characterizes the differ-ent forms of RBP. There is a highdegree of complimentarity betweenRBP and transthyretin (TTR), thecontact areas of which are highlysensitive to conformational changesand amino acid replacements.

“Structure and function of hepaticstellate cells” by Senoo H. MedElectron Microsc 2004; 37:3–15 (De-partment of Anatomy, Akita Univer-sity School of Medicine, 1–1-1Hondo, 010–8543, Akita, Japan. E-

mail: [email protected]).In arctic animals such as polar bearand arctic fox hepatic stellate cellsstore 20–100 times the concentra-tion of retinol in humans or rats. Inliver cirrhosis the cells lose retinoidsand synthesize a large amount ofextracellular matrix, such as colla-gen. Stellate cells also exist in pan-creas, lung, kidney and intestine.

“Vitamin A requirement for earlycardiovascular morphogenesisspecification in the vertebrateembryo: insights from the avianembryo” by Zile MH. Exp Biol Med(Maywood) 2004; 229:598–606 (De-partment of Food Science and Hu-man Nutrition, Michigan State Uni-versity, 234 GM Trout Bldg., EastLansing, MI 48824, USA. E-mail:[email protected]).Retinoic acid is known to be essen-tial in early stages of embryogenesisfor the initiation of organogenesis. Inits absence tissues develop abnor-mally and death results. Retinoicacid regulates the expression of thecardiogenic transcription factorGATA-4. During the crucial develop-ment window retinoic acid trans-duces its signals to genes for heartmorphogenesis via the receptorsRARalpha2, RARgamma, andRXRalpha. These results may leadto a better understanding of cardio-vascular birth defects.

“Collagen XVIII/endostatin is es-sential for vision and retinal pig-ment epithelial function” byMarneros AG, Keene DR, HansenU et al. EMBO J 2004; 23:8999 (De-partment of Cell Biology, HarvardMedical School, Boston, MA, USA.E-mail: [email protected]).This study demonstrates that micelacking the basement componentcollagen XVIII/endostatin have mas-sive accumulation of sub-RPE (reti-nal pigment epithelium) deposits,abnormal RPE and age-dependentloss of vision; as in age-relatedmacular degeneration (ARMD) inman. Progressive loss of visual func-tion is due to decreased retinal rho-dopsin (visual purple) content. Thesefindings may contribute to a betterunderstanding of ARMD.

“Minimal inflammation, acutephase response and avoidance ofmisclassification of vitamin A and

iron status in infants – importanceof a high-sensitivity C-reactiveprotein (CRP) assay” by AbrahamK, Mueller C, Grueters A et al. Int JVitam Nutr Res 2003; 73:423–430(Department of Pediatric Pneumol-ogy and Immunology, UniversityClinic Charité, Humboldt UniversityBerlin, Berlin, Germany. E-mail:[email protected]).A high-sensitivity test for CRP re-vealed highly significant associa-tions with parameters known to beinfluenced by the acute phase re-sponse. Using a limit of 0.6 mg/l(75th percentile) significantly lowerlevels were observed for trans-thyretin, iron, retinol, and β-carotenein the group with the higher CRP lev-els.

“The specific binding of retinoicacid to RPE65 and approaches tothe treatment of macular degen-eration” by Gollapalli DR, RandoRR. Proc Natl Acad Sci USA 2004;101:10030–10035 (Department ofBiological Chemistry and MolecularPharmacology, Harvard MedicalSchool, 45 Shattuck Street, Boston,MA 02115, USA).RPE65 functions as a chaperone forall-trans-retinyl esters. The studysuggests that RPE65 function israte-limiting in visual cycle function.Certain forms of retinal and maculardegeneration are caused by the ac-cumulation of vitamin A-basedretinotoxic products, called retinylpigment epithelium-lipofuscin. “Theidentification of RPE65 as the visualcycle target for the retinoic acidsmakes it feasible to develop usefuldrugs to treat retinal and maculardegeneration while avoiding the sub-stantial side effects of the retinoicacids”.

“Effects of retinol on developmentof osteopenic changes inducedby bilateral ovariectomy in rats”by Pytlik M, Cegiela U, FolwarcznaJ et al. Pol J Pharmacol 2004;56:345–352 (M Pytlik, Departmentof Pharmacology, Silesian MedicalUniversity, Jagiellonska 4, PL 41–200 Sosnowiec, Poland).Skeletal disorders occurring in ex-perimental osteopenia caused bybilateral ovariectomy in rats resem-ble those seen in postmenopausalwomen. The effects of retinol 700 IU/kg/day by mouth and 3500 IU/kg bymouth for 28 days on the development


of osteopenia induced by bilateralovariectomy in 3 month old Wistarrats were studied. It was concludedthat retinol (especially at the dose of3500 IU/kg daily) intensified thechanges in the osseous systemcaused by estrogen deficiency.

“Critical role for retinol in the gen-eration/differentiation of angio-blasts required for embryonicblood vessel formation” by LaRueAC, Argraves WS, Zile MH et al. DevDyn 2004; 230:666–674 (CJ Drake,Cardiovasc. Devmtl Biology Center,Dept of Cell Biology and Anatomy,Medical University of South Caro-lina, 173 Ashley Avenue, Charleston,SC 29425, USA.E-mail: [email protected]).This experiment demonstrated that“vascular abnormalities observedunder conditions of retinol deficiencyare due to a reduction in the numberof angioblasts and consequently aninsufficiency in the number of en-dothelial cells required to build com-plex vascular networks”.

“Effects of βββββ-carotene on cell vi-ability and antioxidant status ofhepatocytes from chronicallyethanol-fed rats” by Yang SC,Huang CC, Chu JS et al. Brit J Nutr2004; 92:209–215 (School of Nutri-tion and Health Sciences, TaipeiMedical University, 250 Wu-HsinStreet, 110, Taiwan, Republic ofChina).The study showed that β-caroteneimproved cell viability of hepatocytesand increased catalase activity andglutathione levels in hepatocytesfrom chronically ethanol-fed rats.

“Vitamin A deficiency alters thebioelectric parameters and RNAcontent of rat gastric mucosa invitro” by Ventura U, Ceriani T,Montini E et al. J Physiol Pharmacol2003; 54:523–532 (Department ofExperimental Medicine, Section ofHuman Physiology, University ofPavia, Pavia, Italy. E-mail:[email protected]).Vitamin A deficiency in gastric mu-cosa induced 1) decrease oftransmucosal potential and short-cir-cuit current; 2) increase intransmucosal electrical resistance;3) decrease in RNA content. Addedvitamin A restored parameters tonormal.

“Vitamin A deficiency impairs fe-tal islet development and causessubsequent glucose intolerancein adult rats” by Matthews KA,Rhoten WB, Driscoll HK et al. J Nutr2004; 134:1958–1963 (Departmentof Medicine, Joan C Edwards Schoolof Medicine, Marshall University,Huntington University, WV, USA).Vitamin A deficiency decreasedbeta-cell mass which was attributedto reduced rate of fetal beta-cell rep-lication in LM (low marginal) off-spring. This may contribute to im-paired glucose tolerance in later life.

“Characterization of the effect ofretinol on Plasmodium falciparumin vitro” by Hamzah J, Davis TME,Skinner ATS et al. Exp Parasitol2004; 107:136–144 (E-mail:[email protected]).“Retinol treatment was associatedwith increased vacuolization withinthe parasite food vacuole and evi-dence of parasite membrane rup-ture. These appearances were simi-lar to those seen with quinoline andartemisinin compounds. Althoughthese data do not support a role foracute retinol supplementation in thetreatment of falciparum malaria, theyadd to knowledge regarding poten-tial antimalarial therapies and justifyassessment of more potent retinoidsand their metabolites”.

“Retinol enhances differentiationof the gastric parietal cell lineagein developing rabbits” by KaramSM, Ansari HR, Al Daheri WS et al.Cell Physiol Biochem 2004; 14:333–342 (SM Karam, Dept. Anatomy,Fac. of Medicine and Health Sci-ences, UAE University, P.O. Box17666, Al Ain, United Arab Emirates.E-mail: [email protected]).Three-day retinol treatment inducedan increase in 1) production of pari-etal cells; 2) intensity of HK-ATPaseimmunostaining per cell; 3) activityof HK-ATPase; and 4) amount of HK-ATPase protein.

“Vitamin A distribution and con-tent in tissues of the lamprey,Lampetra japonica” by Wold HL,Wake K, Higashi N et al. Anat Rec2004; 276A (2):134–142 (Institute forNutrition Research, Faculty of Medi-cine, University of Oslo, Oslo, Norway).The authors suggest that in this spe-cies vitamin A storing cells derivefrom either splanchnic and interme-

diate mesoderm-derived cells(stellate cells) or somatic and dor-sal mesoderm (fibroblasts). Thehighest level of vitamin A was in theintestine with liver and kidney sec-ond and third. (Don McLaren: in hisclassic study Mori stated that in Ja-pan the oil and flesh of the lampreyhad long been used as a folk rem-edy for xerophthalmia – McLaren DS(2004) The Control of Xerophthal-mia: A century of contributions andlessons, pp 66).

“Vitamin A exhibits potentantiamyloidogenic and fibril-destabilizing effects in vitro” byOne K, Yoshiike Y, Takashima K etal. Exp Neurol 2004; 189:380–392(H Naiki, Department of Pathology,Fukui Medical University, Fukui 910–1193, Japan).Cerebral deposition of amyloid is aninvariant feature of Alzheimer’s dis-ease. Plasma or cerebrospinal fluidconcentrations of antioxidant vita-mins have been related to slowingof the progression of the disease.Order of activity is retinol = retinal >β-carotene > retinoic acid.

“Opposing actions of cellular reti-nol-binding protein and alcoholdehydrogenase control the bal-ance between retinol storage anddegradation” by Molotkov A,Ghyselinck NB, Chambon P et al.Biochem J 2004; 383:295–302 (GDuester, OncoDevelopmental Biol-ogy Program, Burnham Institute,10901 North Torrey Pines Road, SanDiego, CA 92037, USA. E-mail:[email protected]).“Our findings suggest that opposingactions of CRBP1 and ADH1 enablea large fraction of liver retinol to re-main esterified due to CRBP1 action,while continuously allowing someretinol to be oxidized to retinoic acidby ADH1 for degradative retinoidturnover under any dietary vitaminA conditions.”

“Vitamin A deficiency reducesliver and colon docosahexaenoicacid levels in rats fed high lino-leic and low alpha-linolenic aciddiet” by Zhou D, Zaiger G, Ghebre-meskel K et al. ProstaglandinsLeukot Essent Fatty Acids 2004;71:383–389 ( E - m a i l :[email protected]).This study showed that deficiency ofvitamin A inhibits DHA (docosa-


hexaenoic acid) and enhances OA(osbond acid) synthesis by differen-tial effects on the independent syn-thetic pathways in the mitochondria.

“Modulation of cytokine produc-tion by low and high retinoid di-ets in ovalbumin-sensitized mice”by Ruehl R, Garcia A, Schweigert FJet al. Int J Vitam Nutr Res 2004;74:279–284 (R Ruehl, Institute ofNutrition Science, University ofPotsdam, Potsdam-Rehbruecke,Germany).“Vitamin A and retinoid content of adiet influences the cytokine re-sponse in non-sensitized and alsoovalbumin-sensitized mice. Thesemolecules may serve as activemodulators of cytokine production invivo that are responsible for the in-duction and persistence of atopicdiseases.”

“Vitamin A exerts its activity atthe transcriptional level in thesmall intestine” by Zaiger G, NurT, Barshack I et al. Eur J Nutr 2004;43:259–266 (R Reifen, Institute ofBiochemistry, Food Science andNutrition, Hebrew University of Je-rusalem, Rehovot 76100, Israel.E-mail: [email protected]).The small intestines of VAD rats hadabnormal villi and enzyme levels.Maturation and differentiation proc-esses of the small intestine weremodified at the transcriptional andpost-transcriptional levels respec-tively.

“Physiological and microfluoro-metric studies of reduction andclearance of retinal in bleachedrod photoreceptors” by Tsina E,Chen C, Koutalos Y et al. J GenPhysiol 2004:124:429–443 (MCCornwall, Dept. of Physiology andBiophysics, Boston UniversitySchool of Medicine, 715 AlbanyStreet, Boston, MA 02118, USA. E-mail: [email protected]).It was found that flash response re-covery in rods is modestly acceler-ated in the presence of extracellularinterphotoreceptor retinoid bindingprotein (IRBP), suggesting that suchsubstances may participate in theclearance of retinoids from rodphotoreceptors, and that this clear-ance, at least in rods, may facilitatedark adaptation.

“Vitamin A deficiency increasesthe in vivo development of IL-10-positive Th2 cells and decreasesdevelopment of Th1 cells in mice”by Stephensen CB, Jiang X, FreytagT. J Nutr 2004; 134:2660–2666 (USDept Agriculture, Western HumanNutrition Research Center at theUniversity of California, Davis, CA95616, USA.E-mail: [email protected]).VAD impairs both T-helper type 1(Th1)- and type 2 (Th2)-mediatedimmune responses. This workshows that at the time of initial anti-gen exposure, VAD enhances thedevelopment of IL-10-producing Th2or T regulatory cells, and diminishesthe development of Th1 memorycells.

“Physiological concentrations ofretinoic acid granulocyte develop-ment in cultures of bone favourmyeloid dendritic cell develop-ment over marrow cells frommice” by Hengesbach LM, HoagKA. J Nutr 2004; 134:2653–2659(Medical Technology Program,Michigan State University, EastLansing, MI 48824, USA).Differentiation of hemopoietic pro-genitors to dendritic cells is a com-plex process involving many typesof factors. This work suggests thatvitamin A favors the differentiation ofmyeloid progenitors to immaturemyeloid dendritic cells instead ofgranulocytes. VAD may compromiseadaptive immune responses thatdepend on myeloid dendritic cellantigen presentation.

Clinical studies“Early infant multivitamin supple-mentation is associated with anincreased risk for food allergy andasthma” by Milner JD, Stein DM,McCarter R et al. Pediatrics 2004;114:27–328285 newborns were included and90% followed 3 years later. Supple-ments tended to be more commonin families with higher family incomeand higher maternal education. Informula-fed children vitamin supple-mentation in the first 3 months of lifewas associated with a 1.75 increasein the risk of subsequent food aller-gies. Asthma was not more commonexcept in Afro-Caribbean children inthe first 6 months. This community isespecially prone to develop asthma.

“Retinol-vitamin A in HIV-infectedpatients who are former intrave-nous drug users” by Zmarzyl A,Simon K, Krause K et al. Nutr Res2004; 24:427–434 (K Simon, Infec-tious Diseases Department,Wroclaw Medical University, ulKoszarowa, 551–149 Wroclaw, Po-land. E-mail:[email protected]).75 male and female patients (22controls and 53 HIV+ without AIDS).Over a 1-year observation period nodifferences in vitamin A status werefound between two groups, suggest-ing this was not a useful marker ofimmunity impairment in HIV.

“Vitamin A levels in patients withCF are influenced by the inflam-matory process” by Greer RM,Buntain HM, Lewindon PJ et al. JCyst Fibrosis 2004; 3:143–149 (RMGreer, Dept. of Paediatrics/ChildHealth, University of Queensland,Royal Children’s Hospital, Herston,QLD 4029, Australia. E-mail:[email protected]).138 cystic fibrosis patients werestudied, age 5–48 years. Serum reti-nol was inversely associated with C-reactive protein, as in the generalpopulation. Because of the almostconstant presence of respiratory andother infections this poses a prob-lem in diagnosing the presence ofVAD, as in other infectious diseasestates. Appropriate nutritional sup-plementation is recommended.

“Serum carotenoid and retinollevels during childhood infec-tions” by Cser MA, Majchrzak D,Rust P et al. Ann Nutr Metab 2004;48:156–162 (MA Cser, BethesdaChildren’s Hospital, Bethesda St. 3,HU-1146, Budapest, Hungary. E-mail: [email protected])Serum retinol, provitamin Acarotenoids (α, β-carotene, andβ−cryptoxanthin) and non-provitaminA carotenoids (lutein, zeaxanthin andlycopene) were all significantly lowerin children with acute infections thanin those without. There were signifi-cant negative correlations betweenC-reactive protein levels and thoseof β-carotene and retinol.

“The role of vitamin A in enhanc-ing humoral immunity producedby antirabies vaccine” by SiddiquiFQ, Ahmad MM, Kakar F et al. EastMediterr Health J 2001; 7:4–5


(Drugs Control and Traditional Medi-cines Division, Islamabad, Pakistan).20 pairs were matched for serumretinol level and other parameters;both groups received antirabies vac-cine, one also had supplemental vi-tamin A. The experimental group hadsignificantly greater (2.1 times) se-rum antirabies titer than the control.

“Nutritional supplements as ad-junctive therapy for children withchronic/recurrent sinusitis: pilotresearch” by Linday LA, DolitskyJN, Shindledecker RD. Int J PediatrOtorhinolaryngol 2004; 68:785–793(Dept. of Healthcare Studies, IonaCollege Graduate School of Arts andSciences, New Rochelle, NY.USA.E-mail: [email protected]).In a few selected cases cod liver oilwith multivitamin-mineral with sele-nium as adjunct therapy gave prom-ising results.

“Vitamin A levels in sputum-posi-tive pulmonary tuberculosis pa-tients in comparison with house-hold contacts and healthy‘normals’” by Ramachandran G,Santha T, Garg R et al. Inter J TubercLung Dis 2004; 8:1130–1133 (PRNarayan, Tuberculosis ResearchCentre, Mayor VR RamanathanRoad, Chetput, Chennai 600 031,India. E-mail:[email protected]).Serum retinol was measured in 47patients at start and end of treat-ment; in 46 healthy household con-tacts; and in 30 healthy ‘normals’.Mean for patients before treatmentwas 21.2 µg/dl; in healthy householdcontacts it was 42.2 µg/dl and48.1µg/dl in healthy ‘normals’. Thelow values in patients returned tonormal after treatment without anyvitamin A supplementation.

“Urinary excretion of vitamin A incritically ill patients complicatedwith acute renal failure” byGavrilov V, Weksler N, Ahmed A etal. Renal Fail 2004; 26:589–590 (VGavrilov, Pediatric Department, A,Soroka Med.Ctr./Fac.of Hlth.Sci.,Ben Gurion University of the Negev,PO Box 151, Beer Sheva, Israel. E-mail: [email protected]).Nine intensive care unit patients withacute renal failure all excreted reti-nol in urine (from 0.007 to 0.379µmolretinol/mmol creatinine).

“Survey of vitamin A supplemen-tation for extremely low-birth-weight infants: is clinical practiceconsistent with evidence?” byAmbalavanan N, Kennedy K, TysonJ et al. J Ped 2004; 145:304–307 (noreprints, correspondence to [email protected]).In the United States a pre-testedquestionnaire was distributed to all(n=102) neonatal-perinatal trainingprogram directors (TPD) and 105randomly selected directors of levelIII neonatal intensive care units (non-training program directors, NTPD).99% of TPD and 94% of NTPD re-sponded. Only 20% of TPD and 13%of NTPD supplement more than 90%of eligible extremely low-birth-weightneonates. In most programs(69%TPD, 82%NTPD) routine sup-plementation is not practiced. Mostcenters (91%TPD, 81%NTPD) sup-plementing vitamin A use a dose of5000 IU IM 3 times/week for 4weeks. The most common reasonTPDs give for not supplementing isthe perceived small benefit. ForNTPDs it is considering the interven-tion unproven. It is concluded thatthere is inconsistency in practicingevidence-based medicine inneonatal practice, where therapiesare often administered on the basisof weaker evidence of safety andbenefit than supports vitamin A sup-plementation. Educational interven-tions are required.

“Vitamin A for acute respiratoryinfection in developing countries:a meta-analysis” by Brown N,Roberts C. Acta Paediatr 2004;93:1437–1442 (MRC EnvironmentalEpidemiology Unit, SouthamptonGeneral Hospital, SouthamptonSO16 6YD, UK. E-mail:[email protected]).5 studies fulfilling criteria included2177 children (1067 intervention and1110 control). Main outcome meas-ures were: time to normalization offever, respiratory rate and oxygendependence, time to discharge, andmortality. There were no significantdifferences for any measure.

“Further evaluation of docosa-hexaenoic acid in patients withretinitis pigmentosa receiving vi-tamin A treatment” by Berson EL,Rosner B, Sandberg MA et al. ArchOphthalmol 2004; 122:1306–1314 .

208 patients with retinitis pigmentosaaged 18 to 55 years were randomlyassigned to 1200mg docosahexa-enoic acid plus 15,000 IU /d vitaminA or control fatty acid plus 15,000 IUvitamin A. It was concluded that forpatients beginning vitamin A therapy,addition of docosahexaenoic acid1200 mg/d slowed the course of thedisease for 2 years. Among patientson vitamin A for at least 2 years adiet rich in omega-3 fatty acids(0.20g/d) slowed the decline in visualfield sensitivity.

Vitamin A and its rela-tives - basic research“Role of purpurin as a retinol–binding protein in goldfish retinaduring the early stage of opticnerve regeneration: its primingaction on neurite outgrowth” byMatsukawa T, Sugitani K, MawatariK et al. J Neurosci 2004; 24:8346–8353 (S Kato, Dept. of MolecularNeurobiology, Graduate School ofMedicine, Kanazawa University, Ka-nazawa, Ishikawa 920–8640, Japan.E-mail:[email protected]).Unlike mammals, the fish optic nervecan regenerate after injury. Purpu-rin was discovered as a secretoryretinol-binding protein in developingchick retinas. In this study it wasshown that purpurin with retinol is thefirst candidate molecule of primingneurite outgrowth in the early stageof optic nerve regeneration in fish.(Don McLaren: in the future this workmight give hope of mammalian op-tic nerve regeneration).

“Noninvasive two-photonimaging reveals retinyl ester stor-age structures in the eye” byImanishi Y, Batten ML, Piston DWet al. J Cell Biol 2004; 164:373–383(Dept of Ophthalmology, Universityof Washington, 1959 NE Pacific St.,Box 356485, Seattle, WA 98195–6485, USA).Previously uncharacterized struc-tures – RESTS (retinyl ester storageparticles) or retinosomes – are de-scribed. Those located close to theretinal pigment epithelium (RPE)plasma membrane are essentialcomponents in 11-cis-retinal produc-tion.


“Holding it together in the eye” byJanmey PA, Discher DE. Nature2004; 43:635–636.“To form tissues, like cells mustclump together. The striking resem-blance between one cell aggregatein flies and a cluster of soap bub-bles points to a crucial role for sur-face mechanics in biological patternformation.” This line of research isworked out in the ommatidium of thecompound eye of an insect, whichcontains only around 20 cells. It fo-

cuses on a set of cone cells, usuallyonly 4, which lie above the light-de-tecting photoreceptor cells.

“Ciliary photoreceptors with avertebrate-type opsin in an inver-tebrate brain” by Arendt D,Tessmar-Raible K, Snyman H et al.Science 2004; 306:869–871 (E-mail:d e t l e v . a r e n d t @ e m b l d e ;jochen.Wittbrodt@emblde)Insects use rhabdomeric and verte-brates use ciliary photoreceptors.

These cells differ in their architec-ture and transduce the light signaldifferently. In the marine ragwormPlatynereis both cell types occur;rhabdomeric in the eye and ciliarythe brain. The latter use aphotopigment closely related to ver-tebrate rod and cone opsins. InUrbilateria, the last common ances-tor of insects and vertebrates, bothtypes of photoreceptor occurred,with distinct opsins.

New MOST publicationsMOST, the USAID Micronutrient Program, published 13 documents for distribution at the 2004 IVACG,INACG and IZiNCG meetings in Lima, Peru. A brief synopsis of each follows. Publications can be accessedon-line at www.mostproject.org or requested by phone +1 703 807 0236 or conventional mail (1820 NorthFort Myer Drive, Suite 600, Arlington, Virginia 22209, USA).

Diarrhoea treatmentguidelines

The need for guidance on how toimplement the new WHO/UNICEF recommendations for theuse of ORS and zinc supplemen-tation in the clinical managementof diarrhoea was articulated at ameeting at Johns Hopkins Univer-sity in June, 2004. On behalf ofUSAID, MOST initiated the effortto prepare the needed guidancein anticipation of the introductionof zinc supplementation into theprotocol for treating diarrhoea inseveral countries.

The draft is designed to prepareclinic-based health workers to im-plement the new recommenda-tions. The information is meant to

complement, not replace, morecomprehensive policy guidanceavailable from WHO on the man-agement of diarrhoea. The guide-lines presented in this documentare generic, that is, they will bemost effective when modified tosupport the particular strategybeing used to introduce the newrecommendations in each coun-try. These draft guidelines havenot yet been field-tested.

A strategic approach toanemia control

MOST has supported ministries ofhealth in the Democratic Repub-lic of the Congo, Eritrea, Ghana,Uganda, and Nicaragua to de-

velop approaches to addressanemia. This brief describes theMOST Project’s experiences to-gether with the options now avail-able for addressing anemia indeveloping countries. A strategicapproach to reducing anemia ispresented that is based on ad-dressing comprehensively itsmajor preventable causes in thetarget population.

Overcoming barriersto effective anemia inter-ventions during antenatalservices in Uganda

This report describes the processand results of a study undertakento identify barriers to implement-ing effective interventions aimedat addressing anemia in preg-nancy. The study was conductedin four districts in Uganda in2001–2002. The study findingswill be used to develop strategiesfor improving the implementationof effective interventions for ad-dressing anemia in pregnancy atthe district level.


Cost study synthesis –Ghana, Zambia and Nepal

Although a variety of vitamin Asupplementation programs havebeen implemented in developingcountries, little is known to dateabout their costs. The major ob-jective of this study is to provideresearchers and policymakerswith that cost information. Twomajor cost categories are empha-sized: program-specific, and per-sonnel and capital. Program-spe-cific costs are those incurred ex-clusively for the delivery of vita-min A, such as the costs of cap-sules, supplies, transportation,fuel and vehicle maintenance,training, and social mobilization.Personnel and capital are sharedresources — that is, resources notattributable to a single program orintervention.

Zambia cost study

The overall objective of this studyis to provide policymakers in Zam-bia with cost information on vita-min A supplementation – informa-tion that may help answer ques-tions concerning the efficiencyand sustainability of the campaignapproach vis-à-vis other modes ofdelivering vitamin A supplemen-tation. Specific objectives are todocument the Child Health Weekand National Immunization Dayprograms as they presently oper-ate, and to analyze the two pro-grams’ cost structures.

Ghana cost study

The primary objective of this studyis to provide the Ministry of Healthwith cost information on vitamin Asupplementation. The Ministry ofHealth intends to use this infor-mation to integrate the vitamin Asupplementation program intoroutine primary health care serv-ices over the next five years.

Improving maternal anemiainterventions in Africa

This brief describes the processused to develop a comprehensiveprogram to control anemia inpregnant women in four districtsof Uganda in 2002. MOST be-lieves that the development proc-ess used is generalizable to othercountries in the East and South-ern African region. The approachis expected to provide a founda-tion for scaling up Uganda’s pro-gram, and MOST expects that thisclose examination of the develop-ment process may provide usefulguidance to anyone seeking toestablish or improve maternalanemia control programs.

Zambia five-year strategy

This five-year strategic plan toprevent and control vitamin A de-ficiency in Zambia serves as amodel of a comprehensive, stra-tegic plan for any country wishingto develop a micronutrient defi-ciency prevention and control pro-gram.

Elements of a nationalfood-fortification programin Bangladesh

This study builds on a recent pilotwheat-flour fortification program inBangladesh. Performed throughMOST for USAID/Dhaka, the pi-lot program was a limited-termproject to improve vitamin A andiron status and also to reduceanemia through consumption offortified wheat flour with vitaminA, iron, zinc, B1, B2, niacin, andfolic acid. The study’s primaryobjective is to identify major ele-ments of a food-fortification strat-egy in Bangladesh, including mi-cronutrient formulation for thefood vehicles identified as suitablefor fortification.


Micronutrients lead the way

Discusses options and strategiesfor improving micronutrient healthin deficient populations. Providesdetails on USAID’s efforts to re-duce micronutrient deficiencythrough supplementation, fortifi-cation, and food-based programs.Updated in 2004 to include zincdeficiency as a significant publichealth issue.

Enquête sur la carence envitamine A / Madagascar

This document presents a surveydone in Madagascar to assessthe extent of the vitamin A defi-ciency and anemia problems ona national scale. The survey wasbased on a national sample of 600children aged 6 to 59 months anda sample of 300 women, rangingfrom 15 to 49 years of age. Inaddition, an investigation ofanemia in the primary schoolswas conducted to assess the ex-tent of the anemia problem inschoolchildren aged 6 to 14 years.The survey revealed that VitaminA deficiency is a serious publichealth problem for children aged6–59 months, as well as forwomen. It also shows that almosttwo of every five school childrenfrom the ages of 6 to 14 years isaffected by anemia, making it animportant public health problemamong school age children. [Thispublication is in French only.]

National MicronutrientSurvey translation of the2000 Summary Report –Nicaragua

The Government of Nicaragua haspaid special attention to micronu-trient deficiencies, particularly thoseof vitamin A, iron, and iodine, sincethe 1993 National MicronutrientSurvey. This summary report of thesubsequent 2000 survey providesinformation about the evolution ofthese deficiencies, which are con-sidered to be significant publichealth problems in Nicaragua.

Prototype of logistics man-agement system for micro-nutrient supplements

This document presents a proto-type logistics management sys-tem for micronutrient supple-ments that has been successfullyestablished by the Ministry ofHealth and Social Welfare(MSPAS) in El Salvador. The ap-pendix contains the proceduralmanual for this system. [Pub-lished in Spanish, English trans-lation is available on the MOSTwebsite: www.mostproject.org.]

Letter to the editor

Dear Sir,

Sincere thanks for your CD andthe new edition of the SIGHT ANDLIFE Newsletter. The CD is muchappreciated. The magazine hasbeen done very well. These areof great help for us in our schoolhealth education program as wellas for the adults. May I assure youthat we will share them with oth-ers interested in the prevention ofvitamin A deficiency.

Although you are concentratingon prevention of vitamin defi-ciency, would it be possible foryou to have a very comprehen-sive article in the SIGHT AND

LIFE Newsletter and if possible agood CD program on the variouscauses of anemia and the waysof prevention? The causes, suchas the absence of a well balanceddiet, worms, inability to absorbvitamin B12 and other vitaminsare not known to most people.

The photograph on the last pageof the cover of the SIGHT ANDLIFE Newsletter 3/2004 showsyoung girls who are pale and havelesions at the corners of theirmouths. This is not uncommon,mostly in rural areas. A well pre-pared CD on this subject, preven-tion of anemia, will be a greathelp. If this is not possible, an is-

sue of the SIGHT AND LIFENewsletter perhaps could be dedi-cated to prevention of anemia.

May I assure you that we willshare your information materialswith others.

With sincere thanks and all goodwishes for a happy and brightNew Year.

Yours sincerelyEmmanuel Mariam Pillai, Educa-tional Multi Media Association, St.Thomas Mount, Chennai-600016, India


We finished this year with threeissues of the SIGHT AND LIFENewsletter printed in colour. Manypeople commented positively onthis new look. It is not only a wayof showing that SIGHT AND LIFEis now part of DSM, but also dem-onstrates the technical develop-ment. We would like to stress thatthe printing costs per page havenot increased. New machines andnew technology have made thispossible. We are pleased thatthrough these developments wehave been able to publish in col-ours some of the pictures re-ceived with reports submitted tous. We thank all those who havesent us such lively reports andphotographic documentation oftheir work. We would love to visitso many places, and would un-doubtedly find it helpful and inter-esting, but unfortunately this is notpossible. The reports we receiveor request may to some extent fillthis gap. When we request reportsit is not with the intention of creat-ing unnecessary work, but ratherbecause we are convinced that bycritically reviewing and document-ing the work carried out, it is pos-sible to make more efficient useof resources as a whole and planfor the future better.

We have again been able to re-port in the Newsletter about ac-tivities linked to SIGHT AND LIFE.Moreover, authors feel increas-ingly that by publishing in theSIGHT AND LIFE Newsletter theyare reaching the readers theywish to reach. We are verypleased with this confidence andwill do our best to fulfil the expec-tations.

In particular the reports on meet-ings give a lively impression ofwhat is going on and what is con-sidered relevant.

Publications

The three Newsletters had a totalcirculation of almost 25,000 (seeFacts and Figures box). In addi-tion to mailing the Newsletter andthe CD we have sent almost10,000 items with 584 parcels tocountries throughout the world.

We consider the compilation ofthe Vitamin A Tables printed inNewsletter 1/2004 a remarkablesuccess. These and the VitaminA Intake Calculator (on CD or tobe downloaded) are powerfultools which are now available toour readers. Together they allowsimulations of dietary changes aswell as changes in bioavailability.It is no longer necessary to relyon the fixed conversion rates usedin many traditional tables. We arevery grateful to Juergen Erhardtfor his work and for updating thesetools.

The Healthy Eyes Activity Bookwas a big success everywhere.With the help of SIGHT AND LIFEit has been reprinted and trans-lated. It is now available in Chi-nese, Tibetan, Urdu and French,for example.

Research and technicalsupport

Research support continued withgrants and participation at variouslevels. Often it takes a long timefor research results to come in.Some reports from earlier projectssupported have already beenpublished. In this connection themany publications of researchsupported by the SIGHT ANDLIFE Research Institute at theJohns Hopkins University also de-serve mention.

Unfortunately, we are still waitingfor many reports, particularly mas-ter and doctoral theses, and it is

becoming more difficult to justifyinvesting further resources in thisarea.

We were very fortunate with thereport about supplementation withmulti-micronutrients in India. Itwas clearly shown that B-vitamindeficiency had been eliminated(NL 3/2004, pages 14–19). Theseresults underline the concept thathealthy nutrition means more thanthe fulfilment of requirements fora single nutrient. Although criticscould argue that this view is one-sided and based on business in-terests, it is not possible to over-look all the scientific evidenceshowing that good health de-pends on the fulfilment of all pre-conditions for good nutrition.

The research supported bySIGHT AND LIFE included foodfortification efforts in China, Viet-nam and Madagascar. Analyticalsupport was given through theanalysis of samples in our labo-ratories or by providing standardsamples. The carotenoid levels,for example in rare cultivars ofbananas, were assessed. An im-pressive example of the effort putinto research support and coordi-nation is the thesis written in theUSA by a student from Ugandausing samples collected inUganda and analysed in Indone-sia. It is the intention of SIGHTAND LIFE to foster collaborationas well as to support the devel-opment and the application of lo-cally adapted techniques. Wehelp to build local capacities byparallel analysis of samples aswell as by training and quality con-trol.

Training and education

Our published materials togetherwith small grants were used to ini-tiate many educational efforts ata local level. We have been im-

SIGHT AND LIFE Annual Report 2004


Facts and figures for the year 2004182 supported projects in 39 countries. Among them:

• 215 Vitamin A capsule donations for 155 projects• 5 Research projects• 6 Technical support projects• 16 Training and education projects

Activities allocated to regions:41% in Africa, 10% in Americas, 49% in Asia

Three issues, a total of 24,700 Newsletters, were sentout as well as one CD (7600) containing the SIGHT ANDLIFE website. The list of addressees has increased toinclude now nearly 6000 records. Additional copies of the

Newsletter and the CD were sent outin bulk and on request.Information materials mailed in584 shipments containing:

4469 Posters3691 Brochures805 Books

7608 CDs31 Slide sets

Vitamin A capsules: 4.03 millionstandard capsules were donated.

pressed by the work done inSouthern India as well as in thecentral region of Africa. The dif-ferent ways the SIGHT AND LIFEmaterials are adapted to localneeds gives us confidence thatwhat we are able to contribute isindeed of value.

Vitamin A donations

Again we donated over 4,000,000vitamin A capsules, each contain-ing 200 000 IU, for preventive andtreatment purposes. For preven-tion two of these are recom-mended per child per year. Interms of quantity, the amount isnot remarkable when comparedto many national vitamin A defi-ciency prevention programs.However, for many missions, hos-pitals and NGOs these vitamin Acapsules are one of the raresources of vitamin A. The cap-sules represent an excellent toolfor running a program and con-necting far-reaching training andeducation efforts. SIGHT ANDLIFE always covers all shippingcosts and some of the programsreceive small grants as well. TheSIGHT AND LIFE website showsthe world map with the number ofvitamin A capsule donations andfurther details.

Highlights

We have often been asked to re-call the highlights of our efforts.In this context it might be appro-priate to define the term highlightsin relation to the aims and mis-sion of SIGHT AND LIFE. EachNewsletter is a highlight in itself,as it reaches many people notreceiving other publications, andhigh level scientistsare among its read-ers. It is a highlightif an illiterate womanuses the HealthyEyes Activity Bookto learn to read. Themany meetingsSIGHT AND LIFEhas been able tosupport, such as theIVACG meeting inwhich SIGHT ANDLIFE was instru-mental by enablingtranslation into thelocal language, areall highlights.

As the aim ofSIGHT AND LIFE isto improve nutritionfor many people itseems best to focusnot on highlights but

rather on the improvementsachieved for the nutrition of all. Itmay be a long time before thisgoal is achieved. SIGHT ANDLIFE is participating in the effortsof many other organisations inworking towards this aim. Thevery broad response SIGHT ANDLIFE has achieved by mobilisinglocal efforts and local resourcesis really a highlight too.


Publisher:Task Force SIGHT AND LIFEEditor: Martin FriggAssistance: Anne-Catherine Frey,Translation: transparent - transla-tions GbR, Berlin, Yvonne BearnePrinter: Druckerei Dietrich, Basel

The Task Force SIGHT ANDLIFE is a humanitarian initiativeof DSM (for more information seethe SIGHT AND LIFE website:www.sightandlife.org). Its aim isto combat all forms of vitamin Adeficiency and to work for ahealthy nutrition for all. Apart fromvitamin A, SIGHT AND LIFE fo-cuses on micronutrients in gen-eral, a field in which DSM hasprofound expertise and scientificknowledge.

Low vitamin A intake, other mi-cronutrient deficiencies and in-sufficient and imbalanced nutri-tion are impairing the health of

Task Force SIGHT AND LIFEPO Box 2116, 4002 BaselSwitzerland. Tel.: +41 61 688 74 94Fax: +41 61 688 19 10E-mail: [email protected] 3-906412-26-1

children in numerous developingcountries. Increased health riskwith susceptibility to infectionsand increased child mortality arethe consequences.

SIGHT AND LIFE has alreadysupported many locally and in-ternationally active organiza-tions. It has sponsored researchand application projects, as wellas communication efforts inmany countries in Africa, Asiaand Latin America.

Support takes the form of contri-butions of vitamin A (mostly in theform of capsules), grants, infor-

mation and educational materi-als such as books, posters, re-prints, etc. Furthermore, SIGHTAND LIFE gives technical assist-ance where necessary and pro-motes training and education inorder to increase local knowl-edge and expertise and work to-wards sustainable improvementof nutrition.

SIGHT AND LIFE publishes edu-cational materials as well as thisNewsletter to promulgate knowl-edge on vitamin A and nutritionand to pass on relevant informa-tion on programs and scientificnews.

Opinions, compilations and figurescontained in the signed articles donot necessarily represent the pointof view of SIGHT AND LIFE andare solely the responsibility of theauthors.


In a rural area of the Democratic Republic of Congo children receive vitamin A.

sight and life€¦ · common agenda for micronutrients presentation highlights: vitamin a and the...

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