Ординатура / Офтальмология / Английские материалы / Handbook of Nutrition and Ophthalmology_Semba_2007

or has severe repeated vomiting, and if parenteral therapy is used, water-miscible preparations of vitamin A should be used. Intramuscular injections of oil-miscible preparations of vitamin A are not well absorbed (285,1024).

7.2. Adjunct Treatments

Active xerophthalmia is often accompanied by diarrheal disease, measles, and intestinal helminthiasis, and it can also be associated with protein energy malnutrition. Secondary infections of the eye may also be present. All efforts should be made to treat the underlying conditions with appropriate hydration, supportive care, and antibiotics if indicated (598).

8. PREVENTION OF VITAMIN A DEFICIENCY

8.1. Dietary Modification

Increased consumption of vitamin A-rich foods is an ideal goal in populations that are at high risk for vitamin A deficiency, and strategies to increase consumption include nutrition education and promoting homestead food production. These approaches usually involve efforts to increase the intake of preformed vitamin A from animal sources (eggs, milk, fish liver oils, dairy products) and provitamin A carotenoids (dark green leafy vegetables, carrots, mango, papaya, red palm oil), and the groups that are initially targeted are infants, preschool children, and pregnant or lactating women. Fruits and vegetables are a major source of vitamin A among women of childbearing age in Bangladesh (1025). In Tanzania, nutrition and horticultural education improved knowledge and practices in regard to vitamin A intake in children (1026). Consumption of dark green leafy vegetables and eggs increased in Indonesia after initiation of a social marketing campaign to increase consumption of these foods (1027). In rural South Africa, vitamin A intake was higher among children from household with a home garden compared to those without a home garden (1028). Serum retinol levels were higher among preschool children in a village where home gardens and nutrition education were implemented compared to a control village (1028). In Burkina Faso, both vitamin A intake and serum retinol increased among mothers and children after implementation of a project promoting consumption of red palm oil (1030).

8.2. Food Fortification

Fortification of foods such as sugar, margarine, and noodles with vitamin A has been used to improve vitamin A status in populations (1031). As previously noted, vitamin A fortification of margarine and milk were recommended by the American Medical Association and practiced in the United States since the mid-20th century. The basic principles concerning food fortification are that the fortified food is (1) regularly consumed by the target population, (2) produced in a centralized fashion, (3) not noticeably different in taste, smell, or appearance to the nonfortified food, and (4) retains stability and bioavailability by the time it reaches the level of household consumption (1031). Thus, in riceproducing countries, rice would be a poor vehicle for fortification, because it is produced by many households and lacks a centralized point where the rice could be fortified. Fortification of sugar has been used in Central America since the 1970s (see Subheading 2.7.) (124). In households in Guatemala and El Salvador, sugar contains about 9 mg of vitamin A per kilogram and contributes 45–180% of the RDI for people older than 3 yr of age

(1031). Among poor urban toddlers in Guatemala, fortified foods (mostly fortified sugar, margarine, and Incaparina) contribute about one half of the RDI (1032). Fortification of MSG was used in pilot programs in Indonesia and the Philippines in the 1970s and 1980s (503,1033), but the color instability of the vitamin A in MSG and cost were some barriers to implementation of fortified MSG on a wider scale. Vitamin A-fortified margarine improved serum retinol levels and protected against xerophthalmia in Filipino preschool children (1034). Ideally, vitamin A-fortified foods should reach the most remote and impoverished families, as these constitute a higher-risk group for vitamin A deficiency. In remote Indonesia, salt and monosodium glutamate were widely consumed in most households, whereas instant noodles were consumed less in poorer families (1035).

8.3. Control of Infectious Diseases

Given the close relationship between some infectious diseases and vitamin A deficiency, the control of diseases such as measles (598) and diarrheal diseases would likely reduce the risk of xerophthalmia among infants and preschool children. Thus, programs aimed at more effective measles vaccines, prevention of diarrheal diseases, and malaria control would likely have an effect on reducing xerophthalmia. Treatment of intestinal parasites such as Ascaris lumbricoides may help to improve the vitamin A status of children who consume a diet high in provitamin A carotenoids (1036,1037).

8.4. Breastfeeding Practices

As noted previously, breastfeeding is protective against xerophthalmia because breast milk provides a major source of vitamin A for infants. Breast milk also provides other essential nutrients and immunological factors that help protect infants against infectious diseases. Maternal education and promotion of breastfeeding is a strategy that helps to reduce the risk of vitamin A deficiency among infants and young children.

8.5. Plant Breeding

Plant breeding has the potential to increase the provitamin A content of several staple foods crops such as rice and cassava (1038). The β-carotene synthetic pathway from the daffodil (Narcissus pseudonarcissus) has been introduced into the endosperm of rice (Oryza sativa) (1039). The resulting prototype line is known as “Golden Rice” (1040), but this genetically engineered rice has not yet seen widespread use. Transgenic tomato plants have been produced that have higher β-carotene content compared with the regular tomato (1041). Potential hurdles to the use of genetically engineered sources of vitamin A include special interest groups that are opposed to any form of genetically engineered crops.

8.6. Vitamin A Capsule Distribution

As noted under Subheading 2.7., as early as the 1970s, periodic high-dose vitamin A supplementation was implemented in various programs in different developing countries (1042–1044). Periodic high-dose vitamin A supplementation has now been adopted by many countries for the prevention of vitamin A deficiency among preschool children, such as Bangladesh, Indonesia, Vietnam, Nepal, the Philippines, and Thailand (1045– 1047). In developing countries where vitamin A deficiency is endemic, the dosage of vitamin A given for prophylaxis is 200,000 IU orally every 4–6 mo for children >12 mo of age and 100,000 IU orally every 4–6 mo for infants 6–12 mo of age (133). It is also

recommended that mothers receive 200,000 IU orally within 8 wk of delivery. Although many countries have policy recommendations regarding postpartum vitamin A supplementation to mothers, the coverage of these programs has been generally low. Vitamin A supplementation has been integrated with national immunization days in some countries (1048). Vitamin A capsule distribution was originally considered to be a short term measure to prevent vitamin A deficiency among preschool children while other measures, such as dietary interventions and food fortification were implemented, but many countries have had vitamin A control programs involving vitamin A capsule distribution for two decades or longer.

9. CONCLUSIONS

Vitamin A deficiency remains a leading cause of morbidity, mortality, and blindness among preschool children in developing countries worldwide. The consequences of vitamin A deficiency include impaired immune function, growth retardation, anemia, xerophthalmia, and blindness. Diverse long-term strategies, including nutrition education, food fortification, and homestead food production are needed to prevent vitamin A deficiency in developing countries. Ultimately, family-based approaches are required to address vitamin A deficiency, because pregnant women and women of childbearing age are at high risk of vitamin A deficiency in many countries and are not reached by vertical programs such as vitamin A capsule distribution. Xerophthalmia and blindness tend to occur among children who are not reached by programs aimed at improving vitamin A status through capsule distribution, fortification, and nutritional interventions. Further work is needed to characterize these households in order to formulate strategies to reach the remaining “out-of-reach” children.

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