American Journal of Epidemiology
12
Copyright 1998 by The Johns Hopkins University School of Hygiene and Public Health
All rights reserved
BOOK REVIEW
Vitamin A Deficiency: Health, Survival and Vision
By Alfred Sommer and Keith P. West
ISBN 0-19-508824-7, Oxford University Press, New York, 1996, 456 pp., $75.00
Vitamin A deficiency is one of the most serious and
widespread nutritional disorders of children in devel-
oping countries. Knowledge about the important role
of vitamin A in human nutrition has progressed re-
markably in the past decade, and studies have con-
vincingly demonstrated that vitamin A deficiency,
even before it is clinically evident, contributes to high
fatality rates among young children.
Specialized agencies of the United Nations have
raised their level of commitment, and several interna-
tional forums have called for the virtual elimination of
vitamin A deficiency as a public health problem by the
end of this century.
In this clearly presented volume, Sommer and West
provide an overview of the main aspects of the vitamin
A deficiency problem with particular attention to epi-
demiology and public health management of deficient
populations. Historical development, relation of vita-
min A to child survival, infectious morbidity, anemia
and growth, biochemistry, immunology, and the
pathophysiology of xerophthalmia are also thoroughly
treated.
The first chapter retraces the vitamin A deficiency
problem from an historical point of view and further
raises questions about the late interest of researchers in
the significance of "mild deficiency" as an important
determinant of child survival and for the systemic
consequences of vitamin A deficiency.
Chapters 2-6 summarize very clearly and com-
pletely our present knowledge of the consequences of
vitamin A deficiency in child survival, infectious mor-
bidity (especially diarrhea, measles, and respiratory
disease), xerophthalmia, anemia, and growth. A large
number of published as well as unpublished studies are
discussed. Attention is drawn to the still unclear action
mechanisms of vitamin A and to important areas of
research for the future.
Chapters 7-9 deal with more physiologic aspects.
Chapter 7 reviews the many factors that contribute to
the appearance of vitamin A deficiency, the most
important of which are the systemic infections, diar-
rhea, respiratory disease, and measles, and protein-
energy malnutrition. However, the authors insist on
our still limited understanding of molecular mecha-
1175
Vol. 147, No.
Printed in U.S.A.
nisms by which protein status affects vitamin A-
dependent functions.
Chapter 8 describes the physiologic and biochemi-
cal processes that underly vitamin A activity and show
the recent progress and growing interest in this matter
since the identification in 1987 of nuclear receptors for
retinoic acid that induce gene expression.
Chapter 9 focuses on the relation between immuno-
competence and vitamin A status, an area of knowl-
edge that is rapidly expanding. Although the exact role
of vitamin A in maintaining immunocompetence has
yet to be made clear, there is strong evidence that
vitamin A plays an important part in maintaining the
lymphocyte pool, in T-cell-mediated responses and in
stimulating nonspecific immunity.
Chapter 10, which deals with treatment, reviews the
different patterns for the management of severely as
well as mildly vitamin A deficient children. Effective-
ness of vitamin A supplementation, dosage, and fre-
quencies are discussed. Efficacy of high-dose supple-
mentation in children with measles is highlighted and
response in children with various degrees of malnutri-
tion is debated.
Chapter 11 summarizes the different techniques for
assessing vitamin A status. Although considerable
progress has been made in the past 10 years to develop
field-applicable assessment methodologies, none of
the available indices are free of limitations that restrict
their interpretation in some settings.
The review of the epidemiology of vitamin A defi-
ciency reminds us of the magnitude of this public
health problem, particularly in the southern regions of
the world. Worldwide, 5 to 10 million children de-
velop xerophthalmia each year, and half of them go
blind, whereas 190 to 240 million children have been
estimated to be at risk of subclinical vitamin A defi-
ciency. Xerophthalmia particularly affects the most
vulnerable groups in the lower socioeconomic strata,
and it tends to cluster within provinces and even
households. This underlines the need to target com-
munities of greatest need in prevention programs.
Peak age often occurs from 2-4 years of age and the
protective effect of breastfeeding against clinical xe-
rophthalmia has been well demonstrated. Supplement-
1176 Book Review
ing mothers after birth with a large dose of vitamin A
improves maternal and infant vitamin A status. Even if
the vitamin A intakes of deficient children are regu-
larly found to be lower than those of children without
vitamin A deficiency, poor dietary intake of vitamin
A-rich foods does not always correlate with the lack of
availability of such foods in the household. These facts
have to be taken into account when implementing
prevention strategies to improve local diets and intakes
of deficient populations.
In chapters 13-15, the authors provide a detailed
review of dietary intervention, including supplemen-
tation and food fortification programs, and in the pro-
cess they discuss a large number of studies. Dietary
interventions to improve the vitamin A status of defi-
cient populations appear to be only partially effective,
and a host of factors that influence absorption and
utilization of dietary carotenoids remain unknown.
High dose supplements prove to be more effective,
and many of the reviewed studies do show improved
vitamin A status and reduction in xerophthalmia and
mortality with various doses and schedules at a very
low cost. The effects of supplementation of lactating
mothers on child mortality have still to be studied.
Food fortification with vitamin A can clearly be
effective, as shown by the improvement of children's
vitamin A status obtained in the vitamin A-fortified
monosodium glutamate program in Southeast Asia and
the vitamin A-fortified sugar program in Central
America. These programs are well described in chap-
ter 15. However, programs should be aggressively
pursued in order to maintain efficacy, and all potential
vehicles for fortification should be identified.
Other recent books on the topic, such as Vitamin A
in Health and Disease, edited by Blomhoff (1994) (1),
and The Retinoids: Biology, Chemistry, and Medicine,
edited by Sporn et al. (1994) (2), are more focused on
the physiopathologic aspects of vitamin A mecha-
nisms, and there is less emphasis on epidemiology and
strategies for prevention. Vitamin A Deficiency and Its
Control, edited by Bauernfeind (1986) (3), provides an
overview of the vitamin A deficiency problem but
some of the chapters are becoming out of date. Vita-
min A Deficiency: Health, Survival and Vision pro-
vides a synthesis of all the important aspects of the
vitamin A deficiency problem and highlights the link
between epidemiology and the biologic basis of vita-
min A action. This comprehensive volume thus allows
the reader to understand this major public health prob-
lem by providing a single source of reference.
REFERENCES
1. Blomhoff R, ed. Vitamin A in health and disease. New York:
Marcel Dekker, 1994.
2. Sporn MB, Roberts AB, Goodman DS, eds. The retinoids:
biology, chemistry, and medicine. New York: Raven Press,
1994.
3. Bauernfeind JC, ed. Vitamin A deficiency and its control.
Orlando, FL: Academic Press, 1986.
P. Hennart
P. Donnen
Laboratory of Epidemiology and Social
Medicine
School of Public Health
Free University of Brussels
Route de Lennik 808
1070 Brussels, Belgium
Am J Epidemiol Vol. 147, No. 7, 1998