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Indian Pediatr 2011;48:
861-866 |
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Determinants of Vitamin A Deficiency amongst
Children in Aligarh District, Uttar Pradesh |
Sandeep Sachdeva, *Seema Alam, *Farzana K Beig, Zulfia Khan and Najam
Khalique
From the Departments of Community Medicine and
*Pediatrics, Jawaharlal Nehru Medical College, Aligarh Muslim University,
Aligarh, India.
Correspondence to: Dr Sandeep Sachdeva, 3/115 A,
Durgabadi, Marris Road, Aligarh, UP, India.
Email:
[email protected]
Received: June 22, 2010;
Initial review: July 22, 2010;
Accepted: October 28, 2010.
Published online:
2011 March 15.
PII: S0974755910INPE00040-1
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Objectives: To determine the prevalence and determinants of
xerophthalmia among children aged 0-60 months .
Methods: This cross-sectional study included 3571
children under 5 years of age from six villages and four periurban areas.
Children with xerophthalmia were identified and severity graded using the
WHO classification. The main outcome measures were socio-demographic,
nutritional and comorbidity related risk factors of xerophthalmia. A
pretested questionnaire carrying information on the above factors was
administered to the caregivers. Univariate and multivariate binary
logistic regression analyses were performed to examine the association of
each of these factors with xerophthalmia.
Results: The overall prevalence of xerophthalmia
was of serious public health importance at 9.1%. Prevalence of both mild
(night blindness, and Bitot’s spots) and severe forms (corneal changes) of
xerophthalmia increased with age. Bitot’s spots and night blindness were
the commonest manifestations. Rural dwelling, lower social class, maternal
illiteracy and occupation outside home were significant antecedent
socio-demographic risk factors on univariate analysis. Multivariate
analysis revealed low intake of proteins and vitamin A containing foods as
well as predominant maize diet to be significant dietary factors.
Nutritional wasting and a preceding history of measles were significant
comorbid determinants (P<0.05). None of the socio-demographic
variables emerged significant on multivariate analysis.
Conclusions: Vitamin A deficiency remains a
significant public health problem in Aligarh district. The proximal
factors in a child’s mileu viz nutrition and comorbidities were
more significantly associated with xerophthalmia than the distal
socio-demographic factors, thereby making a case for their cost effective
prevention. The high magnitude of the problem calls for intensification of
existing prophylactic measures in these areas.
Key words: Determinants, Deficiency, India, Prevalence, Vitamin
A.
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V itamin A deficiency (VAD) is an important cause of
preventable blindness among children and a major public health problem in
developing countries like India. It has also been established that VAD
increases the risk of childhood morbidity and mortality [1,2]. India
remains home to more than a quarter of the world’s preschool children
suffering from subclinical VAD and a third of the preschool children with
xerophthalmia [3]. Existence of focal pockets of xerophthalmia in several
areas makes it important to assess the true magnitude of the problem in
these areas so as to prioritize interventions. We estimated the prevalence
of xerophthalmia among rural and urban preschool children, and analyzed
the antecedent risk factors in 6 villages and 4 peri-urban areas in
Western Uttar Pradesh.
Methods
The present cross-sectional descriptive study was
undertaken between January and July 2009. The study population comprised
all the under-five children (0-60 months) residing in these areas (n=3679).
Of these, 108 could not be included because of various reasons; 3571
children formed the study subjects. Ethical clearance was obtained from
the Institutional ethics committee.
A house-to-house survey was carried out and information
was obtained as per a predesigned proforma that included the
identification data, and sociodemographic and environmental profile of the
child’s family. The social class of the child’s family was determined
using the Modified Prasad Scale [4]. Social classes I, II and III of the
modified Prasad’s classification are categorized as upper class and IV and
V as lower classes. A precise history of dietary intake and vitamin A
containing foods was elicited from the mother (recall of food items
consumed in last 24 hours). Appropriate breastfeeding was defined as
exclusive breastfeeding for six months of age and continued up to two
years along with semi solids. Complementary feeds given in recommended
amount and frequency as per WHO guidelines [5] was labelled as appropriate
feeding. Second part of the proforma consisted of anthropometry and
general physical examination of the child including signs of xerophthalmia.
One pediatrician and eight post-graduate students from the Departments of
community medicine and ophthalmology comprised of the field unit. All
children with positive clinical findings and a systematic sample of 1 in
50 of those with a negative clinical finding were examined by a senior
pediatrician. If any positives were detected from the negatives, then all
the negatives of that day were re-examined by the senior pediatrician. The
first four questions of the WHO algorithm listed below [6] for assessment
of night blindness were enquired from mothers of children above two years
of age, viz (i) Do you/does your child have any problem
seeing in the daytime? (ii) Do you/does your child have any problem
seeing in the evening or in low levels of light?, (iii) If (2)=yes:
Is this problem different from most other children/women in your
community?, (iv) Do you/Does your child have ‘Rataundhi’ ?
(The local term for XN).
Proxy reports from mothers were used for children. All
participants (including mothers) who complained of having a problem seeing
in low levels of light but no problem seeing during the day; and which
were different from most other children/women in their community were
considered to be having night blindness. They were asked to give examples
of the problem (spontaneous complaints). If no spontaneous complaints were
reported, they were asked whether, in low levels of light, they were able
to see something (eg food) that had been put in front of them, were able
to play or work, or were prone to walk into or to trip over objects
(prompted complaints). Standard methods and procedures for ophthalmic
examination were used to detect signs of xerophthalmia [7]. Ocular
examination was done with the help of a bright illuminant torch. WHO
classification [8] was adopted to grade the severity of xerophthalmia.
Conjunctival xerosis in isolation was not included as a marker but was
considered when accompanied with Bitot’s spots or a positive Kajal sign
[9]. Kajal is a formulation of lamp black mixed with oil used
as an ocular cosmetic. It stains the xerotic areas in the eye black which
makes XIA and XIB lesions stand out. Nutritional assessment was done using
CDC 2000 reference standards. Age and sex specific –2 Z-scores were
followed to define wasting and stunting. Statistical analysis was carried
out by chi-square test and odds ratio with its 95% confidence interval.
Binary logistic regression was used to do the multivariate analysis.
Results
Age and sex distribution of the study population is
shown in Table I. Mean age of the participants was 36±21
months. The urban and rural sex ratios were 0.83 each. Prevalence of
xerophthalmia in the present study was 9.1%. There was a rising trend in
the prevalence and severity of xerophthalmia with increasing age (Table
II). The difference in xerophthalmia prevalence among under two and
over two years age groups was statistically signi-ficant (P<0.001).
Table III depicts the socio demographic and maternal factors
in relation with xerophthalmia. Univariate analysis revealed lower
socioeconomic status, rural status, illiterate or working mother,
incomplete immunization and inappropriate care seeking behavior to be
signi-ficantly associated with xerophthalmia. A large number of children
were underweight (32%), stunted (65%) and wasted (72%) but xerophthalmia
was significantly associated with wasting alone (Table IV).
Other risk factors associated with xerophthalmia are also depicted in
Table IV. Multivariate binary logistic analysis obviated the
potential confounding factors that were statistically significant on
univariate analysis. An inadequate intake of proteins and vitamin A
containing foods as well as predominant maize diet emerged significant
dietary factors.
TABLE I Age and Sex Distribution of the Study Population
Age
group |
Rural(61) |
Urban(39) |
(months) |
Males (%) |
Females (%) |
Males (%) |
Females (%) |
0-12 |
265 (22.7) |
221 (22.3) |
141(18.4) |
162 (25.2) |
13-24 |
219 (18.7) |
213 (21.5) |
159 (20.7) |
151 (23.5) |
25-36 |
198 (16.9) |
192 (19.4) |
167 (21.7) |
109 (16.9) |
37-48 |
264 (22.6) |
215 (21.6) |
162 (21.2) |
121 (18.8) |
49-60 |
221 (18.9) |
152 (15.3) |
138 (17.9) |
101 (15.7) |
Total (n=3571) |
1167 (100) |
993 (100) |
767 (100) |
644 (100) |
TABLE II Prevalence of Xerophthalmia in Different Age Groups
Age-group |
Number |
Only night |
Only Bitot’s |
Corneal |
Corneal |
Kerato- |
Corneal |
Total number |
(months) |
|
blindness |
spots |
xerosis |
ulceration |
malacia |
scarring |
with |
|
|
(XN only) |
(XIB only) |
X2 |
X3A |
X3B |
XS |
xerophthalmia |
0-12 |
789 |
– |
6 (0.7) |
0 (0) |
0 (0) |
0(0) |
2 (0.3) |
8(1.1) |
13-24 |
742 |
– |
44 (5.9) |
1 (0.1) |
1 (0.2) |
0(0) |
1 (0.2) |
47(6.3) |
25-36 |
666 |
23 (3.5) |
47 (6.9) |
3 (0.4) |
1 (0.2) |
0(0) |
3 (0.4) |
77(11.6) |
37-48 |
762 |
43 (5.6) |
42 (5.5) |
3 (0.4) |
2 (0.2) |
0(0) |
6 (0.8) |
96(12.6) |
49-60 |
612 |
35 (5.7) |
54 (8.8) |
2 (0.3) |
1 (0.2) |
0(0) |
5 (0.8) |
97(15.8) |
Total |
3571 |
101 (2.8) |
193 (5.4) |
9 (0.3) |
5 (0.2) |
0(0) |
17 (0.5) |
325(9.1) |
Figures in parentheses indicate percentages. |
TABLE III Socio Demographic and Maternal Factors in Relation with Xerophthalmia
Variable |
Xerophthalmia |
|
Yes |
No |
OR ( 95%CI) |
Gender |
|
|
|
Male |
182 |
1752 |
0.9 |
Female |
143 |
1637 |
(0.7
to 1.2) |
Religion |
|
|
|
Hindus |
131 |
1460 |
0.8 |
Muslims |
194 |
1786 |
(0.6
to 1.1) |
Social class |
|
|
|
Upper |
9 |
277 |
0.3 |
Lower |
316 |
2969 |
(0.2
to 0.6) |
Family |
|
|
|
Nuclear |
49 |
542 |
0.8 |
Joint |
276 |
2704 |
(0.6
to 1.2) |
Dwellings |
Rural |
247 |
1913 |
2.2 |
Urban |
78 |
1333 |
(1.7 to 2.8) |
Working mother |
|
|
|
Yes |
319 |
136 |
3.9 |
No |
1160 |
1950 |
(3.2
to 4.8) |
Mother |
|
|
|
Literate |
23 |
354 |
0.05 |
Illiterate |
23 |
2912 |
(0.01
to 0.2) |
Immunization |
|
|
|
Complete |
32 |
1217 |
0.2 |
Incomplete |
293 |
2029 |
(0.12 to 0.3) |
Care seeking behavior* |
Appropriate |
4 |
291 |
0.2 |
Inappropriate |
321 |
2955 |
(0.04
to 0.4) |
Maternal xerophthalmia |
Present |
19 |
159 |
1.2 |
Absent |
306 |
3087 |
(0.7
to 1.9) |
*Appropriate care was care sought from qualified medical professionals in government
health facilities and private hospitals/clinics. Purchasing medicines from pharmacy, home
remedies, visiting pharmacies, temples and traditional healers was defined as inappropriate care.
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TABLE IV Nutritional and Comorbid Factors in Relation with Xerophthalmia
Variable |
|
Xerophthalmia |
|
Yes |
No |
OR( 95%CI) |
Breastfeeding |
Adequate |
134 |
2010 |
0.4 |
Inadequate |
191 |
1236 |
(0.3 to 0.5) |
Calories |
Adequate |
14 |
1057 |
0.09 |
Inadequate |
311 |
2189 |
(0.05 to 0.2) |
Proteins |
Adequate |
152 |
1847 |
0.6 |
Inadequate |
173 |
1399 |
(0.5 to 0.8) |
Staple |
Maize |
140 |
600 |
3.3 |
Wheat |
185 |
2646 |
(2.6 to 4.3) |
Vitamin A rich foods |
Adequate |
48 |
916 |
0.4 |
Inadequate |
277 |
2330 |
(0.3 to 0.6) |
Weight for Age |
Normal |
149 |
997 |
1.9 |
Underweight |
176 |
2249 |
(1.5 to 2.4) |
Height for Age |
Normal |
136 |
2186 |
0.3 |
Stunted |
189 |
1060 |
(0.2 to 0.4) |
Normal |
210 |
2370 |
0.7 |
Wasted |
115 |
876 |
(0.5 to 0.8) |
Pallor |
Present |
242 |
2471 |
0.9 |
Absent |
83 |
775 |
(0.7 to 1.2) |
Vitamin D deficiency |
Present |
10 |
265 |
0.5 |
Absent |
315 |
2981 |
(0.3 to 0.9) |
Yes |
69 |
95 |
8.9 |
No |
256 |
3151 |
(6.4 to 12.5) |
Diarrhoea |
Yes |
14 |
161 |
0.8 |
No |
311 |
3088 |
(0.5 to 1.5) |
Worms |
Present |
176 |
1216 |
1.9 |
Absent |
149 |
2030 |
(1.6 to 2.5) |
Development |
Normal |
8 |
236 |
0.3 |
Delayed |
317 |
3010 |
(0.2 to 0.6) |
Similarly, nutritional wasting and a preceding history
of measles were significant comorbid determinants.
Discussion
The prevalence of xerophthalmia in the present study
(9.1%) was far above the WHO threshold for classifying xerophthalmia as a
serious public health problem [10].
Nearly similar prevalence of 8.7% was also observed among
preschool children in urban slums of Nagpur [11]. A remarkably wide range
of prevalence (1.1% to 22.3%) noted in earlier studies [12,13] could be a
result of distinct study parameters and the fact that they were carried
out among different population groups with varying epidemio-logic
characteristics. Similarly, the results of the NNMB micronutrient survey
indicate a far low prevalence of Bitot’s spots and night blindness in
preschool children. (0.7% and 0.5%, respectively) [3]. This vast disparity
in prevalence again reflects the ‘focal and local’ nature of the disease.
Indeed, the prevalence of all stages of xerophthalmia including corneal
signs was alarmingly higher than acceptable in the present study.
Prevalence rates increased with age with peak at 4-5 years. This trend has
been confirmed by Curtale, et al. [14] in their large scale
community surveys. This is because of low dietary intake of vitamin A
foods and frequent exposure to intercurrent infections. Also, prolonged
breast feeding practice in the Indian scenario may have sufficient
prophylactic effect for vitamin A deficiency for preschool-age children
upto age 2 years. Corneal ulceration and keratomalacia are known to be
associated with high mortality and were less common than other signs as
observed by other Indian investigators [15]. Other variables like maternal
illiteracy, rural dwellings, poverty, poor care seeking behavior, etc.
observed significant in the present study were similar to those reported
earlier [15-19]. The present study, however, did not reveal any
significant association of maternal xerophthalmia with xerophthalmia in
children. Semba, et al. [20] had reported a relative risk of 9.08
for maternal xerophthalmia if her child had xerophthalmia. This is
probably because subclinical hypovitaminosis A is more common in adults
and also that females are reluctant to share their health concerns out of
hesitation and family pressures.
In a sub-economic society as in our study, a child is
likely to become deficient of protein and also not to retain an adequate
intake of carotenoids than to be deficient in either of the two alone.
This can be expected as the dietary questionnaire admininistered revealed
less than the recommended allowances of green leafy vegetables, yellow
fruits and animal proteins in a majority of the subjects. The second
repeat survey of the National Nutritional Monitoring Bureau (NNMB) also
revealed that the consumption of micronutrients was woefully inadequate
among individuals from all age groups including children. As many as
50-70% of individuals consumed less than 30% of RDI for vitamin A;
especially the pre-school children having higher deficits in their diets.
Schémann, et al. [21] also observed that weekly consumption
of vitamin A rich food was rare among xerophthalmic
preschool children in Mali. Association of wasting, measles, and worm
infestation with xerophthalmia has also been observed earlier [16,20,22].
An interesting observation made in the present study was a significantly
higher occurrence of xerophthalmia among children whose families consumed
maize as the staple cereal. The majority of maize consumed was white
maize, which is essentially devoid of yellow carotenoid pigments,
including those that serve as a source of provitamin A. In three of the
villages surveyed, maize was the most important staple food and supplied
more than 50% of the energy in local diets.Similar observation was made by
Harjes, et al. [23]. This could probably account for the reason
behind clustering of xerophthalmia cases in these villages.
We conclude that the undisputed long-term solution to
prevent this nutrition-related, avoidable blindness lies in changing the
dietary habits of the rural Indian population through behavior change
communication by nutritional education, nutritional supplementation, and
nutritional rehabilitation. Fortification of staple cereals like maize
through innovative food engineering technologies can go a long way towards
alleviation of the problem. Routine screening of ‘at risk’ children for
signs of xerophthalmia by peripheral health workers will help in early
detection and treatment. Prompt prophylaxis of contacts of affected
children would address the potential subclinical cases. Research is
required into factors responsible for clustering of cases in specific
areas.
Contributors: All authors were involved in all
aspects of the study and manuscript preparation.
Funding: Department of Community Medicine,
JN Medical College, AMU, Aligarh.
Competing interests: None stated.
What is Already Known?
• Vitamin A deficiency is an important cause of
preventable blindness due to xerophthalmia and high mortality
rates among under-five children in India.
What This Study Adds?
• Prevalence of xerophthalmia among children in
Aligarh district of Western UP region is considerably high to
warrant extra efforts to combat the same.
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