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Vitamin A and Vitamin A
Deficiency Disorders
Dr. Moumita Pal
MBBS,DPH, MD
Dept. of Community Medicine
College of Medicine and Sagore Dutta Hospital
Vitamin A
• Active form-Retinol
• Proactive form (precursor)-Carotinoids
• Fat soluble
• Stable to heat at ordinary cooking
temperature.
• IU of Vit.A =0.3 mcg of Retinol
• RE: Retinol equivalent (Vit A activity)
• 1mcg of retinol=1 RE=3.33IU Vit A
2
Functions
• Formation of rhodopsin in Rods of retina. Helps
in dark adaptation
• Integrity of cellular structures specially
epithelial tissue ( respiratory, GI tract, GU tract,
skin)
• Role in immune defense mechanism
• Antioxidant property of free radical scavenging
• Skeletal growth
• Protects against certain cancers like bronchial
cancers 3
Sources
1. Animal Foods (retinol) : Liver, meat, kidney,
milk, fish, eggs. Richest source is fish liver oil.
4
Sources
2. Plant foods ( carotenoids):
coloured fruits and vegetables.
- green leafy vegetables (
spinach, amaranth)
-yellow orange vegetable and
fruits( pumpkin, mango,
papaya, apricots, carrots)
- Carotene converted to Vit A in
small intestine.
- Pigments with no vit A activity:
Lycopene in tomatoes
5
• Vit E protects it from oxidation
Destroyed by
• exposure to sunlight
• Heating for a long time
• Drying and dehydration
3. Fortified foods: vanaspati
margarine, milk
6
Storage
• Liver
• Retinol palmitate mostly
• Well fed person has sufficient reserve for 6-9
months
• Retinol ( free) highly toxic. Transported in
blood with retinol binding protein ( produced
in liver)
7
Requirements and recommendations
Groups Retinol RDA (mcg)
Adults ( Male/female)
Children >6 years
Adolescents
600
Children (1-6 years) 400
Infants (<12 months) 350
Pregnancy 800
Lactation 950
8
Toxicity
• Induced by single dose of >200mg ( 200000RE)
• Chronic - >4000 RE (infants) to 7000 RE (adults) consumed
daily
• Persistent large dose > 100 times of required dose daily
overwhelm liver storage capacity and produced
intoxication
• Skin/mucous membrane changes
• Dry lips, dryness of nasal mucosa and eyes, erythema,
scaling, peeling of skin, hair loss and nail fragility
• Headache, nausea vomiting
• Toxic to fetus (teratogenic): craniofacial, CNS,
cardiovascular, thymic malformation
9
Deficiency
Ocular
manifestations Extra ocular
manifestations
10
Signs and symptoms
Dryness, itching and redness of conjunctiva
Night blindness ( inability to see in dim light)
Others signs of xerophthalmia: Bitot spots, corneal xerosis, keratomalasia
Dry rough itchy skin: rash
Dry brittle hair and nail
Loss of acuity of senses : smell and taste
Loss of appetite
Fatigue
Poor growth
Low immunity/ vulnerability to infections
Increased risk of certain cancers
11
Vitamin A deficiency
• Leading cause of preventable blindness in
children
• Major cause of controllable public health and
nutrition problem in India
• 5.7 % children of India suffer from s/s
• Only 21 % children (12-35months age)
received Vit A supplementation
• Less than 10% coverage in Nagaland & UP
12
Etiological factors
• Most common in 1-3 years age group
Weaning and infections:
• Mothers not conversant with correct weaning practices
• Low vit A diet: diluted milk, poor starchy food, no fruits,
butter, vegetables or animal food
• Ignorance and economic reasons
• Repeated infection during teething, weaning, exposure
to the outer world  high demand
• PEM immunologically vulnerable
• High rate of diarrhoea, respiratory infections measles
compromised Vit A status
13
Social factors
• Cultural belief on BF and weaning
• Discarding colostrum, early or late weaning,
restrictions of food items, excessive dilution of
milk, vegetarianism, unscientific management
of infection, belief in quacks
• Poverty
14
Poor environmental sanitation Practices:
• Non availability of sanitary latrines
• Open air defecation
• Poor hygienic practices
• Lack of potable water
15
Other causes
• Vegetarians
• Prolonged dietary deprivation
• Chronic alcoholics
• Sprue
• Duodenal bypass
• Chronic diarrhea
• Cirrhosis
16
Xerophthalmia
• DEFINITION: “an abnormal dryness of the
eyeball produced usually by Long-continued
inflammation and subsequent atrophy of the
Conjunctiva and cornea.”
• Ocular manifestation of Vit A deficiency in
various clinical forms
• Leads to blindness
but preventable
17
Xerophthalmia as a public health problem
WHO classification Clinical condition Prevalence among pre
school children
XN Night blindness >1%
X1A Conjunctival xerosis -
X1B Bitot’s spot >0.5%
X2 Corneal xerosis -
X3A Corneal ulceration/Keratomalacia (involving
<1/3 of cornea)
>0.01%
X3B Corneal ulceration/Keratomalacia (involving
>1/3 of cornea)
>0.01%
XS Corneal scar >0.05%
XF Xerophthalmic fundus -
Bio chemical Plasma retinol <0.35 micro mol/L >5% 18
Night blindness
• First symptom
• Inability to see in dim light
• Due to impaired dark adaptation
• Can be diagnosed by mother when- in the
evening child strikes against a stone and
while play and fall down/ unable to see the
content of food plate and gropes for food/ in
a dimly lit classroom can’t see blackboard
• Reversible with Vit A
19
Conjunctival Xerosis
• First clinical sign
• Cornea and tissue of the eye
become dry , wrinkled
(vertically folded) and
thickened
• Restricted to “exposed”
bulbar conjunctive
• Dryness looks like waxy paint
as lose of transparency and
shiny appearance
• loss of goblet cells /Less
mucin production Un
wettable cornea 20
Bitot’s Spot
• Triangular pearly
white/yellowish foamy spots
on bulbar conjunctiva
• Either side of cornea
• Due to hyper-keratinizing
metaplasia of epithelium &
accumulations of
seborrhoeic excretions.
• Diagnostic in children but
adult- inactive sequelae of
earlier disease. 21
Corneal xerosis
• Cornea appears dry dull and non wettable
• Serious condition
• May progress to corneal ulceration
• Ulcer may heal leaving a scar behind
• Affect vision
22
Keratomalacia
• Liquefaction of cornea
• Grave medical emergency-process is rapid
• Cornea becomes soft and burst open
• Through this content of eye may extrude out
• Eye collapses & vision lost
23
Extra ocular manifestations
• Follicular hyperkeratosis
• Growth retardation
• Anorexia
• Non specific & difficult to quantify
24
Treatment schedule for xerophthalmia
for all age groups except women of
reproductive age
Timing Vit A dosage
Immediately on diagnosis (day 1)
-<6 months of age
-6-12 months
->12 months
-50000 IU
-100000IU
-200000IU (110 mg)
Next day ( day 2) Same age specific dose
At least 2 weeks later Same age specific dose
Vit A in oil/ Retinol Palmitate
http://apps.who.int/iris/bitstream/10665/41947/1/9241545062.pdf
25
Women of reproductive age
• Daily oral dose of 5000-10000IU for 4 weeks
• Such daily dose should never exceed 10000IU
26
27
XEROPHATHALMIA FUNDUS:
• Pale yellow spots near the course of the
retinal vessels and in the retinal periphery
• Disappear with 2- 4 months of vitamin A
therapy
28
29
Prevention
1. Dietary modification
• Vit A or beta carotene rich food
2. Nutrition education
• Importance of vitamin rich diet, regular intake,
harmful effects of deficiency
• Fresh seasonal fruits and vegetables
• Healthy food preservation techniques
• Public meeting, schools and Mass media may be
used
30
3. Fortification
• Ghee, dalda, butter, margarine, dried skimmed milk
etc.
4. Periodic massive dosage
• NIS
• First dose- 100000 IU at 9th completed months along
with measles vaccine
• Then 200000IU at 16 months with DPT/OPV booster.
• Then same dose at 6 months interval up-to 5 years
• Total 9 mega-doses
31
5. Long term actions
• Continuous nutritional education
• Importance of immunization
• Environmental sanitation
• Breast feeding
• Early treatment of infection
• Good maternal and child health care
32
33

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Vit a and vit a deficiency disorders

  • 1. Vitamin A and Vitamin A Deficiency Disorders Dr. Moumita Pal MBBS,DPH, MD Dept. of Community Medicine College of Medicine and Sagore Dutta Hospital
  • 2. Vitamin A • Active form-Retinol • Proactive form (precursor)-Carotinoids • Fat soluble • Stable to heat at ordinary cooking temperature. • IU of Vit.A =0.3 mcg of Retinol • RE: Retinol equivalent (Vit A activity) • 1mcg of retinol=1 RE=3.33IU Vit A 2
  • 3. Functions • Formation of rhodopsin in Rods of retina. Helps in dark adaptation • Integrity of cellular structures specially epithelial tissue ( respiratory, GI tract, GU tract, skin) • Role in immune defense mechanism • Antioxidant property of free radical scavenging • Skeletal growth • Protects against certain cancers like bronchial cancers 3
  • 4. Sources 1. Animal Foods (retinol) : Liver, meat, kidney, milk, fish, eggs. Richest source is fish liver oil. 4
  • 5. Sources 2. Plant foods ( carotenoids): coloured fruits and vegetables. - green leafy vegetables ( spinach, amaranth) -yellow orange vegetable and fruits( pumpkin, mango, papaya, apricots, carrots) - Carotene converted to Vit A in small intestine. - Pigments with no vit A activity: Lycopene in tomatoes 5
  • 6. • Vit E protects it from oxidation Destroyed by • exposure to sunlight • Heating for a long time • Drying and dehydration 3. Fortified foods: vanaspati margarine, milk 6
  • 7. Storage • Liver • Retinol palmitate mostly • Well fed person has sufficient reserve for 6-9 months • Retinol ( free) highly toxic. Transported in blood with retinol binding protein ( produced in liver) 7
  • 8. Requirements and recommendations Groups Retinol RDA (mcg) Adults ( Male/female) Children >6 years Adolescents 600 Children (1-6 years) 400 Infants (<12 months) 350 Pregnancy 800 Lactation 950 8
  • 9. Toxicity • Induced by single dose of >200mg ( 200000RE) • Chronic - >4000 RE (infants) to 7000 RE (adults) consumed daily • Persistent large dose > 100 times of required dose daily overwhelm liver storage capacity and produced intoxication • Skin/mucous membrane changes • Dry lips, dryness of nasal mucosa and eyes, erythema, scaling, peeling of skin, hair loss and nail fragility • Headache, nausea vomiting • Toxic to fetus (teratogenic): craniofacial, CNS, cardiovascular, thymic malformation 9
  • 11. Signs and symptoms Dryness, itching and redness of conjunctiva Night blindness ( inability to see in dim light) Others signs of xerophthalmia: Bitot spots, corneal xerosis, keratomalasia Dry rough itchy skin: rash Dry brittle hair and nail Loss of acuity of senses : smell and taste Loss of appetite Fatigue Poor growth Low immunity/ vulnerability to infections Increased risk of certain cancers 11
  • 12. Vitamin A deficiency • Leading cause of preventable blindness in children • Major cause of controllable public health and nutrition problem in India • 5.7 % children of India suffer from s/s • Only 21 % children (12-35months age) received Vit A supplementation • Less than 10% coverage in Nagaland & UP 12
  • 13. Etiological factors • Most common in 1-3 years age group Weaning and infections: • Mothers not conversant with correct weaning practices • Low vit A diet: diluted milk, poor starchy food, no fruits, butter, vegetables or animal food • Ignorance and economic reasons • Repeated infection during teething, weaning, exposure to the outer world  high demand • PEM immunologically vulnerable • High rate of diarrhoea, respiratory infections measles compromised Vit A status 13
  • 14. Social factors • Cultural belief on BF and weaning • Discarding colostrum, early or late weaning, restrictions of food items, excessive dilution of milk, vegetarianism, unscientific management of infection, belief in quacks • Poverty 14
  • 15. Poor environmental sanitation Practices: • Non availability of sanitary latrines • Open air defecation • Poor hygienic practices • Lack of potable water 15
  • 16. Other causes • Vegetarians • Prolonged dietary deprivation • Chronic alcoholics • Sprue • Duodenal bypass • Chronic diarrhea • Cirrhosis 16
  • 17. Xerophthalmia • DEFINITION: “an abnormal dryness of the eyeball produced usually by Long-continued inflammation and subsequent atrophy of the Conjunctiva and cornea.” • Ocular manifestation of Vit A deficiency in various clinical forms • Leads to blindness but preventable 17
  • 18. Xerophthalmia as a public health problem WHO classification Clinical condition Prevalence among pre school children XN Night blindness >1% X1A Conjunctival xerosis - X1B Bitot’s spot >0.5% X2 Corneal xerosis - X3A Corneal ulceration/Keratomalacia (involving <1/3 of cornea) >0.01% X3B Corneal ulceration/Keratomalacia (involving >1/3 of cornea) >0.01% XS Corneal scar >0.05% XF Xerophthalmic fundus - Bio chemical Plasma retinol <0.35 micro mol/L >5% 18
  • 19. Night blindness • First symptom • Inability to see in dim light • Due to impaired dark adaptation • Can be diagnosed by mother when- in the evening child strikes against a stone and while play and fall down/ unable to see the content of food plate and gropes for food/ in a dimly lit classroom can’t see blackboard • Reversible with Vit A 19
  • 20. Conjunctival Xerosis • First clinical sign • Cornea and tissue of the eye become dry , wrinkled (vertically folded) and thickened • Restricted to “exposed” bulbar conjunctive • Dryness looks like waxy paint as lose of transparency and shiny appearance • loss of goblet cells /Less mucin production Un wettable cornea 20
  • 21. Bitot’s Spot • Triangular pearly white/yellowish foamy spots on bulbar conjunctiva • Either side of cornea • Due to hyper-keratinizing metaplasia of epithelium & accumulations of seborrhoeic excretions. • Diagnostic in children but adult- inactive sequelae of earlier disease. 21
  • 22. Corneal xerosis • Cornea appears dry dull and non wettable • Serious condition • May progress to corneal ulceration • Ulcer may heal leaving a scar behind • Affect vision 22
  • 23. Keratomalacia • Liquefaction of cornea • Grave medical emergency-process is rapid • Cornea becomes soft and burst open • Through this content of eye may extrude out • Eye collapses & vision lost 23
  • 24. Extra ocular manifestations • Follicular hyperkeratosis • Growth retardation • Anorexia • Non specific & difficult to quantify 24
  • 25. Treatment schedule for xerophthalmia for all age groups except women of reproductive age Timing Vit A dosage Immediately on diagnosis (day 1) -<6 months of age -6-12 months ->12 months -50000 IU -100000IU -200000IU (110 mg) Next day ( day 2) Same age specific dose At least 2 weeks later Same age specific dose Vit A in oil/ Retinol Palmitate http://apps.who.int/iris/bitstream/10665/41947/1/9241545062.pdf 25
  • 26. Women of reproductive age • Daily oral dose of 5000-10000IU for 4 weeks • Such daily dose should never exceed 10000IU 26
  • 27. 27
  • 28. XEROPHATHALMIA FUNDUS: • Pale yellow spots near the course of the retinal vessels and in the retinal periphery • Disappear with 2- 4 months of vitamin A therapy 28
  • 29. 29
  • 30. Prevention 1. Dietary modification • Vit A or beta carotene rich food 2. Nutrition education • Importance of vitamin rich diet, regular intake, harmful effects of deficiency • Fresh seasonal fruits and vegetables • Healthy food preservation techniques • Public meeting, schools and Mass media may be used 30
  • 31. 3. Fortification • Ghee, dalda, butter, margarine, dried skimmed milk etc. 4. Periodic massive dosage • NIS • First dose- 100000 IU at 9th completed months along with measles vaccine • Then 200000IU at 16 months with DPT/OPV booster. • Then same dose at 6 months interval up-to 5 years • Total 9 mega-doses 31
  • 32. 5. Long term actions • Continuous nutritional education • Importance of immunization • Environmental sanitation • Breast feeding • Early treatment of infection • Good maternal and child health care 32
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