The prevalence of clinical vitamin A deficiency (VAD) has declined
considerably in India, as compared to previous years. However, this
decline was not uniform throughout India. The prevalence of clinical VAD
(tip of the iceberg of VAD), in terms of Bitot’s spot, an objective sign
of VAD among rural pre-school children ranged from nil in Kerala to 1.4%
in the state of Madhya Pradesh. The national level prevalence (0.8%) was
still higher than the figures recommended by the WHO (³0.5%),
indicating the public health significance in rural pre-school children of
India [1]. While in case of blood vitamin A deficiency (<20µg/dL),
the prevalence (61%) was a public health problem (³20%)
[2] in all NNMB states , ranging from 52% in Maharashtra to 88% in Madhya
Pradesh. The proportion of severe blood VAD (<10µg/dL) was (21.5%)
also ³5% indicating severe public
health problem [2] in all the NNMB states [3]. Though the Indian Council
of Medical Research multicentre study [4] carried out during 1997-2000 in
16 districts of 11 states reported low prevalence of clinical VAD, the
prevalence was significantly higher in districts of Gaya (4.7%), Patna
(3.1%) and Bikaner (1.1%), where the consumption of vegetarian diet is
predominant (NFHS-3) as compared to other districts from north and
northeast states. The sub-clinical vitamin A status of these children
would have given true status VAD, because the clinical VAD may be nil as
reported in children of Kerala, while the prevalence of sub-clinical
VAD was very high (79.4%) among the same children [3].
The consumption of foods rich in vitamin A was very
poor among rural pre-school children in India. The mean intake of leafy
vegetables and milk& milk products, the rich sources of vitamin A were
deficit by 80-85% and 71-75%, respectively as against the RDI, while the
intakes of fruits and flesh foods were still worse. Similarly, the diets
of rural pre-school children were grossly deficit in terms of vitamin A,
where the median intakes were deficit by 66-81% as against the RDA of 400
µg. The median vitamin A intakes of 84% of pre-school children were
not even 50% of their RDA [5]. Similarly, 55% pre-school children had
underweight and 51% had stunted growth [5]. The bi-annual massive dose
vitamin A supplementation coverage was also very poor, where only 23% of
rural pre-school children had received the stipulated two massive doses of
vitamin A during the preceding year [1]. The knowledge about VAD was also
very poor among the mothers of rural pre-school children, where only 12%
of them aware that the VAD is the cause of night blindness and only 4%
reported Bitot’s spot as the sign of VAD [1]. However, there was a paucity
of the above information in urban and slum areas of India.
As many infectious diseases are still major causes for
under-five mortality in India, the supplementation of bi-annual massive
dose vitamin A, would certainly benefit in improving the immunity status
of under-fives and decreasing the incidence and severity of morbidities
and thereby minimizing mortality rates. The 2nd International meeting of
the Micronutrient Forum was also reported evidences for the same based on
national surveys. The Micronutrient Forum also stressed the need to
sustain vitamin A supplementation programmes until the underlying factors
affecting deficiency have improved and/or alternative interventions
improve vitamin A intake [6]. The massive dose vitamin A supplementation
programme initiated in India during 1970 under "The National Program for
Prevention of Nutritional Blindness" as a short-term intervention and an
adjunct to long-term food-based approach for prevention and control of VAD.
Despite the programme has been in operation for more than three decades
and various national nutrition supplementation programmes, the vitamin A
status of pre-school children continues to be very poor.
Therefore, it’s very important to sensitize the
community towards the VAD and its adverse effects on health, and
encouraging them to consume vitamin A rich foods through health and
nutrition education (HNE) and behavioral change communication (BCC). It is
also very essential to undertake comprehensive and well-designed national
representative studies in rural, urban and slum settings of India, to
estimate both clinical and biochemical vitamin A status as well as diet
surveys to assess dietary pattern of vitamin A. Latham in his article "The
great vitamin A fiasco" was not in favour of universal vitamin A
supplementation, and recommended the sustainable food-based approaches and
pertinent public health measures for prevention and control of
VAD(7).Though, these long-term interventions were known for decades, much
progress was not achieved in this direction in India. Therefore, until the
dietary intakes are satisfactory, blood vitamin A levels increased to
optimal levels and the public health measures improved, the decision to
stop supplementation of vitamin A to pre-school children should not be
taken hastily, as depriving vitamin A during formative years may
detrimental in terms of morbidity and mortality.
References
1. National Nutrition Monitoring Bureau (NNMB).
Pre-valence of Micronutrient deficiencies. Hyderabad, India: National
Institute of Nutrition, Indian Council of Medical Research. Report No 22;
2003.
2. World Health Organization (WHO). Indicators for
assessing Vitamin A deficiency and their application in monitoring and
evaluating intervention programmes. Geneva: WHO; 1996.
3. National Nutrition Monitoring Bureau (NNMB).
Pre-valence of vitamin A deficiency among rural pre-school children.
Hyderabad, India: National Institute of Nutrition, Indian Council of
Medical Research. Report No 23; 2006.
4. Toteja GS, Singh P, Dhillon BS, Saxena BN. Vitamin A
deficiency disorders in 16 districts of India. Indian J Pediatr.
2002;69:603-5.
5. National Nutrition Monitoring Bureau (NNMB). Diet
and Nutritional status of population and Prevalence of Hypertension among
Adults in Rural areas. Hyderabad, India: National Institute of Nutrition,
Indian Council of Medical Research. Report No.24; 2006.
6. Kramer K. The 2nd International meeting of the
Micronutrient Forum. Micronutrients, Health and Development:
Evidence-Based Programs, IX Report. Switzerland: Sight and Life Press;
2009. p.21-32.
7. Latham M. The great vitamin A fiasco. World Nutrition. 2010;1:12-45.