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Introduction
Vitamin A deficiency (VAD) is a major
nutritional concern in poor societies, especially in lower income countries like INDIA. Vitamin A is an essential nutrient needed in small amounts for the normal functioning of the visual system, and maintenance of cell function for growth, epithelial integrity, red blood cell production, immunity and reproduction.
Active forms are retinol, retinaldehyde, and retinoic acid Plants synthesize the more complex carotenoids which are cleaved to retinol by most animals and stored in the liver as retinyl palmitate N retinol plasma values: 15-30 mcg/dl in infants & 30-90 mcg/dl in adults Retinal is the prosthetic group of photosensitive pigment in both rods (rhodopsin) & cones (iodopsin), major difference lies in the nature of protein bound Needed in lysosomal membrane stability Plays a role in keratinization, cornification, bone development & cell growth & reproduction
Absorption of Vitamin A
Retinoids
Retinyl esters broken down to free retinol in small
intestine - requires bile, digestive enzymes, integration into micelles Once absorbed, retinyl esters reformed in intestinal cells 90% of retinoids can be absorbed
Carotenoids
Absorbed intact, absorption rate much lower
cells to the liver Transported from the liver to target tissue as retinol via retinol-binding protein, which is bound to transthyretin
Excretion of Vitamin A
Not readily excreted Some lost in urine Kidney disease and aging increase risk of
Functions of vitamin A
Vision (night, day, colour) Epithelial cell integrity against infections Immune response Haematopoiesis Skeletal growth Fertility (male and female) Embryogenesis
Functions of Vitamin A: Growth and Differentiation of Cells acid is necessary for cellular Retinoic
differentiation Important for embryo development, gene expression Retinoic acid influences production, structure, and function of epithelial cells that line the outside (skin) and external passages (mucus forming cells) within the body
Cancer prevention
Antioxidant capabilities Lung, oral, and prostate cancers Studies indicate that vitamin A-containing foods are more
Source of vitamin A
Colostrum foods containing either preformed vitamin A
esters - liver, milk,cheese,eggs or food products fortified with vitamin A or carotenoid precursors (mainly betacarotene), such as green leaves, carrots, ripe mangoes,eggs, and other orange-yellow vegetables and fruits.
Source of vitamin A
fruit carotenoid
sources(micrograms/100gm) Mango (golden) 307 Papaya (solo) 124 Cucurbita (mature pulp) 862 Buriti palm (pulp) 3,000 Red palm oil 30,000 Carrot 2,000 Dark green leafy vegetables 685 Tomato 100 Apricot 250 Sweet potato, red and yellow 670
Animal (micrograms/100gm) Fatty fish liver oils Halibut 900,000 Cod 18,000 Shark 180,000 Dairy produce Butter 830 Margarine, vitaminized 900 Eggs 140 Milk 40 Cheese, fatty type 320 Liver of sheep and ox 15,000 Beef, mutton, pork 04
Vitamin A requirement
7.11.2.1 Indias Undernourished Children: A Call For Reform and Action, World Bank Report:http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/2816271095698140167/IndiaUndernourishedChildrenFinal.pdf; last accessed on 24/09/07
Infancy Childhood Pregnancy Lactation Urban poor Older adults Alcoholism Liver disease (limits storage) Fat malabsorption Increased excretion as in cancer & UTI Low protein intake resulting in deficient carriers
Usually, VAD develops in an environment of ecological social and economical deprivation Synergism between deficient dietary intake of vitamin A coexists with severe infections, such as measles, and frequent infections causing
diarrhoea and respiratory diseases that can lower intake through depressed appetite and absorption, and deplete body stores of vitamin A through excessive metabolism and excretion
Health consequences
Xerophthalmia is the most specific VADD,and
is the leading preventable cause of blindness in children throughout the world Night blindness Anaemia can result from VAD in children and women,likely due to multiple apparent roles of vitamin A in supporting iron mobilization and transport, and hematopoiesis
VITAMIN A DEFICIENCY
1 clinically assessed eye signs. Term xerophthalmia encompasses the clinical spectrum of ocular manifestations of VAD, from milder stages of night blindness and Bitots spots, to potentially blinding stages of corneal xerosis, ulceration and necrosis (keratomalacia) 2 biochemically determined concentrations of retinol in plasma or serum
Classification of xerophthalmia
XNN ight blindness X1A Conjunctival xerosis X1BB itots spot X2 Corneal xerosis X3A Corneal ulceration/keratomalacia (< 1/3 corneal surface) X3BCorneal ulceration/keratomalacia ( 1/3 corneal surface) XSCorneal scar XFXerophthalmic fundus
constitutes the second major approach to assessing vitamin A status in a population, with values below a cut-off of 0.70 mol/l representing VAD , and below 0.35 mol/l representing severe VAD. a serum retinol concentration below a cutoff of 1.05 mol/l has been proposed to reflect low vitamin.
Criteria for assessing the public health significance of Clinical (primary) xerophthalmia 1.0% Night blindness (XN)*
Bitots spot (X1B) 0.5% Corneal xerosis and/or ulceration/keratomalacia (X2 + X3A + X3B) 0.01% Xerophthalmia-related corneal scars (XS) 0.05%
Biochemical (supportive) Serum retinol (vitaminA) < 0.35 mol/L (10 g/dL) 5.0%
200,000 IU of vitaminA orally every 36 months. Infants 611 months 100,000 IU of vitaminA orally every 36 months. Lactating mothers 200,000 IU of vitaminA orally once: at delivery or during the first 8 weeks postpartum if breastfeeding or during the first 6 weeks if not breast-feeding
Hypervitaminosis A
Acute Intoxication:
Results when excessively large single doses >300,000 IU ingested Infants: n/v, drowsiness or irritability w/signs of increased ICP Adults: drowsiness, irritability, headache & vomiting Serum vitamin A values = 200-1000 IU/dl (N: 50-100 IU/dl)
Toxicity of Vitamin A
Acute short-term megadose (100 x
Chronic Intoxication
Results when >50,000 IU/day ingested for several wks or more Signs & symptoms in infants: Early are anorexia, pruritus, irritability, tender swollen bones w/motion limitation Alopecia, seborrhea, cheilosis & peeling of palms & soles Hepatomegaly & hypercalcemia observed Craniotabes & hyperostosis of long bones Elevated serum vit A levels confirms diagnosis Reversible manifestations when vitamin A discontinued
damage
Bone and muscle pain Loss of appetite Skin disorders Headache Dry skin Hair loss Increased liver size Vomiting
Toxicity of Vitamin A
Teratogenic (may occur with as little as 3 x