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

OBJECTIVE: To examine whether the relationship between vitamin A intake, from plant and animal foods, and vitamin A status is the same throughout a population. DESIGN: Analysis of cross-sectional data on vitamin A intake, vitamin A status, physiological condition and socio-economic status. SETTING: Central Java, Indonesia. SUBJECTS: Women with a child < or =24 months old (n = 600). RESULTS: Mean serum retinol concentration of women with animal vitamin A intake below or above the median (50 RE/d) was 1.28 and 1.38 micromol/L, respectively (P<0.05). For those with intake above the median the distribution curve for serum retinol concentration was shifted towards the right, to higher concentrations. Serum retinol concentration of women with plant vitamin A intake below or above the median (279 RE/d) was 1.30 and 1.36 micromol/L, respectively (P<0.05). Again, the distribution curve for serum retinol was shifted towards higher concentrations for women with an intake above the median, except for the subgroup of 25% with the lowest serum retinol concentration (<1.10 micromol/L). These women did not seem to benefit from their relatively high vegetable intake. They also had the lowest socio-economic status. CONCLUSIONS: The subgroup that was most in need of vitamin A could not obtain it from plant foods. It may well be that, because of their lower socio-economic status, their hygiene conditions were worse and therefore host-related factors that affect carotene bioavailability, such as parasitic infestation, were less favourable in this group. They depended on supplements and, if affordable, on animal foods, fruits and/or fortified products.

Reappraisal of the role of vegetables in the vitamin A status of mothers in Central Java, Indonesia.

Food-based approaches for controlling vitamin A deficiency and its consequences, such as increased mortality, more severe morbidity, and anemia, have become increasingly important, thus prompting a reassessment of the relation between vitamin A intake and status. A nutrition surveillance system in Central Java, Indonesia, assessed the vitamin A intake and serum retinol concentration of women with a child < or =24 mo old with a semiquantitative 24-h recall method that categorized vitamin A-containing foods into 3 categories of plant foods and into 2 categories of animal foods and identified portions as small, medium, or large. Median vitamin A intake was 335 retinol equivalents (RE)/d (n = 600) and vitamin A intake from plant foods was 8 times higher than from animal foods. Serum retinol concentration was related to vitamin A intake in a dose-response manner. The multiple logistic regression model for predicting the chance for a serum retinol concentration greater than the observed median (> or = 1.37 micromol/L) included physiologic factors, vitamin A intake from plant [odds ratio (95% CI) per quartile: 1st, 1.00: 2nd, 1.23 (0.75, 2.02); 3rd, 1.60 (0.97, 2.63); and 4th, 2.06 (1.25, 3.40)] and animal [1st and 2nd, 1.00; 3rd, 1.31 (0.86, 2.02); and 4th, 2.18 (1.40. 3.42)] foods, home gardening [(no, 1.00; yes, 1.71 (1.12, 2.60)], and woman's education level [< or =primary school, 1.00; > or =secondary school, 1.51 (1.02, 2.22)]. Despite the fact that plant foods contributed 8 times as much vitamin A as did animal foods, serum retinol concentrations did not reflect this large difference. Home gardening and woman's education level seemed to reflect longer-term consumption of vitamin A-rich plant and animal foods, respectively.

Production of fruits and vegetables at the homestead is an important source of vitamin A among women in rural Bangladesh.

BACKGROUND: Vitamin A deficiency is considered to be an important public health problem in Bangladesh. A universal biannual distribution of high-dose vitamin A capsules has been in place for over the past two decades. This supplementation has been beneficial for preschool children. Bangladesh has been exploring more sustainable approaches for all segments of the population. To support this initiative, Helen Keller International has implemented a homegardening promotion project since 1993. This project is executed on a large scale and currently reaches an estimated 244,000 families. METHODS: This paper presents data from 7341 women of reproductive age which were collected as part of the baseline census of a community monitoring system whose objective is to track progress and measure the impact of home-gardening activities. RESULTS: Vitamin A intake in this population derived almost entirely from the consumption of fruits and vegetables. Logistic regression analyses showed that maternal vitamin A intake was determined by qualitative indicators of homestead gardens (type of home garden, the total quantity of provitamin A-rich food produced and the number of fruits and vegetables varieties grown in the garden) after adjusting for socio-economic status. CONCLUSIONS: These results indicate that traditional production of provitamin A-rich fruits and vegetables in the homestead may provide a valuable contribution to vitamin A intake in communities where alternative dietary sources of vitamin A are scarce.

Impact of nutrition education and mega-dose vitamin A supplementation on the health of children in Nepal.

The impact on vitamin A deficiency (VAD), wasting malnutrition, and excessive childhood mortality of two alternative approaches-nutrition education and mega-dose capsule distribution (6-12-month-olds: 100,000 IU; 1-5-year-olds: 200,000 IU)-in communities in Nepal are compared. Approximately 40,000 children from 75 locations in seven districts in two ecological settings (lowland and hills) took part in the study and were randomly allocated to intervention cohorts or a control group. At 24 months after the implementation of the project the reduction of risk for xerophthalmia was greater among children whose mothers were able to identify vitamin-A-rich foods (relative risk (RR) = 0.25; 95% confidence interval (CI) = 0.10-0.62) than among the children who received mega-dose capsules (RR = 0.59; 95% CI = 0.41-0.84). The risk of mortality at 2 years was reduced for both the nutrition education (RR = 0.64; 95% Cl = 0.48-0.86) and capsule distribution (RR = 0.57; 95% CI = 0.42-0.77) cohorts. The nutrition education programme was, however, more expensive to deliver than the capsule distribution programme. High rates of participation for children in the supplementation programme were achieved quickly. The nutrition education messages also spread rapidly throughout the study population (regardless of intervention cohort assignment). Practices, however, were slower to change. In communities where maternal literacy was low and channels of communication were limited the capsule distribution programme appeared to be more economical. However, there are economies of scale for nationwide education programmes that do not exist for capsule distribution programmes. Although nutrition education provides economies of scale and the promise of long-term sustainability, a comprehensive national programme requires both dietary supplementation and nutrition education components.

PIP: The effectiveness of two approaches to vitamin A deficiency prevention--nutrition education and mega-dose capsule distribution--was compared in a 3-year study involving almost 40,000 children 6 months to 10 years of age from seven ecologically diverse districts in Nepal. The nutrition education program promoted increased intake of vitamin A-rich foods during the dry season, serving wild greens, and primary health care service utilization. At baseline, 44.9% of the study villages did not have any cases of Bitot's spots; by the third year, 65.5% were free of this sign of vitamin A deficiency. 85% of community risk variation was explained by agricultural patterns, market food availability, household income, maternal literacy, sanitation, and the village's average nutritional status. At 12 months, capsule distribution had reduced the risk of new Bitot's spots by 55% (relative risk (RR), 0.45; 95% confidence interval (CI), 0.33-0.60); however, its impact had declined by 24 months and was non-significant at 36 months. At 24 months, the reduction of risk for xerophthalmia was greatest among children whose mothers were able to identify vitamin A-rich foods (RR, 0.25; 95% CI, 0.10-0.62) and were literate (RR, 0.06; 95% CI, 0.01-0.42). By 24 months, child mortality risk had declined in both the nutrition education (RR, 0.64; 95% CI, 0.48-0.86) and capsule distribution (RR, 0.57; 95% CI, 0.42-0.77) groups. Although the effects of both programs were similar, the capsule program achieved higher coverage rates at a lower cost while the educational intervention provided economies of scale and potential for long-term sustainability. Most feasible would be a comprehensive national program that included both these components as well as maternal literacy training.

Issues in the assessment of nutritional status using anthropometry.

Four issues in the use and interpretation of anthropometry are discussed at the level of the population and of the individual. The first issue is the index or indices of choice: weight-for-height versus height-for-age versus weight-for-age. The selection of an index or indices depends upon many factors, and no one index is completely adequate in all situations. Proposed criteria are provided to assess the severity of low anthropometry within populations. The second issue is the scale of the index: z-scores (or standard deviations) versus percentiles versus percent-of-median. z-Scores have several properties that make them superior to the other two scales. A third issue deals with limitations in the current growth reference; one of these is the disjunction between the growth curves at 2 years of age, resulting from the use of two different populations in the reference. It is important that this disjunction be recognized by researchers so that the anthropometric findings are interpreted correctly for this age range. Lastly, some issues to do with the collection of single versus multiple anthropometric measurements on children are discussed.

The indirect costs of obesity to society.

Losses in productivity due to illnesses associated with obesity are considerable. In addition, significant social costs resulting from underachievement in education, reduced social activity and job discrimination can be incurred. While social class appears to influence the prevalence of obesity, obesity has, in turn, an influence on social class, probably through employment discrimination; obese men and women have lower status jobs, a situation that is perpetuated through lower status marriages. A comprehensive review of both the direct and indirect consequences of this condition is necessary to identify the most appropriate measures to be taken, e.g. mass education to heighten social awareness and sensitivity. These issues should be considered in the formulation of policies and activities aimed at preventing obesity.

Assessment of nutritional status: effects of different methods to determine age on the classification of undernutrition.

The evaluation of nutritional status using anthropometry has been widely employed in field studies and nutritional surveillance programmes. Two of the primary indicators used, weight-for-age and height-for-age, require accurate age information for proper assessments to be made. Three data sets on nutritional status were evaluated using different methods to determine age: rounding to the most recently attained month, rounding to the nearest whole month, and ages computed from birth dates and visit dates. The impact of these different methods on the classification of nutritional status were found to be dramatic, especially in infants during the first year of life. In some cases, when ages are rounded to the most recently attained month, as few as 43% of the children classified as malnourished based on the indicator, height-for-age, and the cut-off point, less than -2 Standard Deviations from the reference median, are identified relative to when ages are computed from birth and visit dates. Beyond the discrepancies in estimating prevalence below specific cut-off points to designate undernutrition, the use of the different methods also affects entire distributions. The problem of using different methods to estimate age, and the impact they have on the classification of undernutrition are of critical public health importance, especially when this information is used to identify individuals and groups as well as for planning and policy development.

Assesment of nutritional status: effects of different methods to determine age on the classification of undernutrition [published erratum appears in Bull World Health Organ 1989;67 (6):757]

The evalution of nutritional status using anthropometry has been widely employed in field studies and nutritional surveillance programmes. Two of the primary indicators used, weight-for-age and height-for-age, require accurate age information for proper assessments to be made. Three data sets on nutritional status were evaluted using different methods to determine age: rounding to the most recently attained month, rounding to the nearest whole month, and ages computed from birth dates and visit dates. The impact of these different methods on the classification of nutritional status were found to be dramatic, especially in infants during the first year of life. In some cases, when ages are rounded to the most recently attained month, as few as 43 percent of the children classified as malnourished based on the indicater, height-for-age, and the cut-off point, <-2 Standard Deviations from the refrence median, are identified relative to when ages are computed from birth and visit dates. Beyond the discrepancies in estimating prevalence below specific cut-off points to designate undernutrition, the use of the different methods also affects entire distribution. The problem of using different methods to estimate age, and the impact they have on the classification of undernutrition are of critical public importance, especially when this information is used to identify individuals and groups as well as planning and policy development. (AU)

The global prevalence of obesity--an initial overview of available data.

Methods of measuring obesity are briefly reviewed. The more precise methods of measuring the body-fat mass are too complex and expensive for use in regular public health practice or individual screening. Anthropometry can, however, provide useful information. Two anthropometric indicators of obesity or overweight are recommended for classifying obesity. For adults, the body-mass index is reasonably easy to obtain and correlates well with mortality and morbidity risk. For children, "overweight" is indicated by a weight-for-height above the median NCHS value plus two standard deviations. Data compiled by the WHO Nutrition Unit, using these two indicators, are presented for a number of countries worldwide in Table 1 & Fig. 1.

The use of anthropometry to assess nutritional status.

Anthropometry (the use of body measurements to assess nutritional status) is a practical and immediately applicable technique for assessing children's development patterns during the first years of life. An evaluation of their growth also provides useful insights into the nutrition and health situation of entire population groups. Anthropometric indicators are less accurate than clinical and biochemical techniques when it comes to assessing individual nutritional status. In many field situations where resources are severely limited, however, anthropometry can be used as a screening device to identify individuals at risk of undernutrition, followed by a more elaborate investigation using other techniques. Similarly, growth monitoring permits the detection of individuals with faltering growth, who can then be appropriately referred to specialized care. Thanks to the standardization that has taken place in recent years, changes in trends over time with respect to the nutritional situation can be evaluated in countries where national food and nutrition surveillance systems have been developed, or where nationally representative cross-sectional surveys have been conducted some years apart using identical, or nearly identical, methodologies. Although data that can be used to evaluate trends are limited, some insight can be gained into the nutritional situation and changes occurring over time in a number of countries. Prevalence figures for underweight (low weight-for-age) have been prepared using standard methods of data collection, analysis and presentation, for several countries in Africa, the Americas and Asia. As such, they fail to differentiate between wasting and stunting, or to evaluate differences between age groups. Also, they do not necessarily reflect trends in other countries in the same or other regions. Still, it is interesting, if not statistically significant, that there has been a general improvement in the nutritional status of preschool children. Intercountry trend comparisons are difficult for two main reasons. Firstly, the time between surveys is occasionally different and, secondly, despite efforts to standardize data analysis and presentation, different cut-off points have been used to calculate prevalence figures and estimate the extent of undernutrition. However, the use of identical cut-off points is not essential for making intercountry trend analyses since it is the general trends in growth deficit and nutritional status over time which are being evaluated.(ABSTRACT TRUNCATED AT 400 WORDS)

PIP: Over the past 20 years, there has been substantial progress in the standardization of anthropometry, which is the use of body measurements to asses the nutritional status of individuals and groups. This brief examination of use of anthropometry to assess nutritional status has tried to highlight its possibilities for exploring nutritional status trends over time. Although other methods have been employed for this purpose, including clinical and biochemical techniques, none is as immediately applicable in purely practical terms as anthropometry. Children's development patterns during the 1st years of life, when growth is the most rapid, provide much information about their nutritional history, both immediate and cumulative. An evaluation of this growth provides useful insights into the nutrition and health situation not only of individuals but also of entire population groups. An admitted drawback in the present analysis is the limited availability of data despite the wealth of country information that is known to have been collected nationally and regionally. It nevertheless demonstrates how such data, when used judiciously, can permit the identification of risk groups, contribute to the development of appropriate food and nutrition policies, and serve as a baseline against which change over time can be realistically evaluated. It is hoped that with increased cooperation among those responsible, nationally and internationally, for growth assessment and nutritional epidemiology, both the quantity and quality, and the successful management and application of this information will increase.

Evaluación del estado de nutrición: La clasificación de la desnutrición varía según el método usado para determinar la edad / Assessment of nutritional status: Effects of different methods to determine age on the classification of undernutrition

Se publica en el Bulletin of the World Health Organization 67(2), 1989