Vitamin A Deficiency

Nutrition Department Medical Faculty of Sumatera Utara DKS09

Background
Nutrition Related Disease Nutrition problem in Indonesia Nutrition Status Survey 1998-2002, 10 million Indonesian children risk of Vit A deff >> (sub klinis) xeropthalmia blindness

What caused deficiency?

Primary (NUTRITION):
Protein energy malnutrition (defect on absorption)

Minimum daily vit A or -carotene intakes (long period)

No exclusive breast feeding for babies Imbalanced diet (less fat, protein, Zn, or other nutrients) help absorption and utilization
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Secondary (diseases related to absorption and metabolism )

Celiac disease Sprue Cystic fibrosis Pancreatic disease Congenital partial obstruction of duodenum

Giardiasis Cirrhosis Chronic hepatitis Chronic diarrhea

Other signs of defficiency

Frequent infections like measles, diarrhea, and malaria Stunted growth Anemia Malnutrition Thickened toad like skin, goose flesh

Skin Manifestation

Clinical signs of vit A deff

X1A XN: night blindness is the earliest symptom of vit A deff. Which is often reported by the mother as reduced visual acuity of the child in the evening and the night time X1A: conjungtival xerosis or drying of the conjungtiva X1B: bitos spot on the conjungtiva X2: corneal xerosis or dryness of the cornea with a granular looking swurface X3A: keratomalacia involving less than a third of the cornea X3B: Keratomalacia > 1/3 XF: funduscopy changes in visible in opthalmoscopy XS:Corneal scarring, compromising severly on visual acuity
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X1B

X2

X3A

X3B

XS

Vitamin A deff and toxicity

Toxicity
Excessive dietary intakes of vitamin A produce symptoms of acute and chronic toxicity including teratogenecity in developing fetuses Normally results from the indiscriminate use of pharmaceutical supplements, not from the consumption of usual diets Sign:
Serum vit A of 75-2000 RAE/100mL Bone pain & fragility Hydrochepalus and vomiting Dry, fissured skin Brittle nail Alopecia Gingivitis, cheilosis, anorexia, irritability, fatique Hepatomegaly and abnormal liver function Ascites and portal hypertention

How to diagnosed
Clinical sign Laboratorium: Serum retinol Retinol binding protein level

< 10 g/dL < 20 g/dL Sub clinic

Funduscopic examination

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Vitamin A

Vitamin A
Vitamin A-active compounds are represented by retinoids (designated as vitamin A) and their carotenoid precursors (provitamin A carotenoids) Structure:
Retinoids: retinol, retinaldehyde, and retinoic acids Provitamin A carotenoid (-carotene, -carotene, and -cryptoxanthin)
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Functions
Retinal is a structural component of the visual pigments of the rod and cone cells photoreception RA acts as hormon to affect gene expression Glycoprotein important for normal cell surface function such as cell aggregation and cell recognition Normal reproduction (retinol), bone development, immune function

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Absorption and convertion vitamin A and -carotene

-Carotene bile 2-50%

ENTEROCYTE

-carotene
Central cleavage

Retinaldehyde mixed micelle Retinyl ester Retinol INTESTINAL LUMEN

Sumber: Erdman dkk, 1993

Lymph
Chylomicron

Retinyl esters Retinol

Fatty acids

Retinoic acid

Portal blood flow (albumin)

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Stability (vitamin A)
In foods, the indigenous retinyl ester are dissolved in the lipid matrix, protected from the oxidizing action of oxygen by vitamin E and antioxidants Destructions of vitamin A compounds related to accelerated lipid oxidation, such as exposure to air, heat, traces of certain metals (Co and Fe), and storage time
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Stability (carotenoids)
Carotenoids in foods influenced by food processing and domestic cooking, such as nonenzymatic or enzymatic oxidation Cutting of fruits and vegetables into small pieces or maceration (non-enzymatic) increase exposure to carotenoids mix up carotenoid and lipoxygenase Lipoxygenase in plant tissues catalyzes lipid peroxidation hydroperoxides attack carotenoids (enzymatic)
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 Moderate heat, such as blanching and cooking denature carotenoid binding proteins releasing the carotenoid Optimal retention of carotene is obtained by steaming vegetables of cooking with minimal water until the vegetables are cooked

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Bioavailability
When meals containing natural amounts of vitamin A and provitamin A carotenoids consumed, efficiency vitamin A: 70-90% compared with 20-50% for the provitamins Present of fat in milk protects vitamin A from degradation Pulped better than pieces for carotene bioaccessibility (carrots), and addition of cooking oil is more effective
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 Host related factors affecting bioavailability:

Malnourished Presence of intestinal parasites Atrophic gastritis Elderly people with little or no acid in stomach Drug: Omeprazole pH>4.5 reduced carotene serum
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Medical Nutrition Therapy and Prevention

Therapy
Gejala
XN (buta senja), XIA (xerosis conjungtiva) tanpa pernah sakit campak 3 bulan terakhir Ada salah satu gejala X1B (bercak bitotnanah/radang-kornea keruh-ulkus korneapernah sakit campak

Hari 1
Beri kapsul vitamin A dengan dosis sesuai umur

Hari 2
-

Hari 15 (mgg II)

-

Beri kapsul vitamin A dengan dosis sesuai umur

Beri kapsul vitamin A dengan dosis sesuai umur

Beri kapsul vitamin A dengan dosis sesuai umur

Umur <6 bulan

Dosis 3 x 50.000 SI (1/2 kapsul biru)

6 bulan 1 tahun
1-5 tahun

100.000 SI (1 kapsul biru)

200.000 SI (1 kapsulmerah)
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(Sumber: Deteksi dan Tatalaksana Kasus Xeroftalmia,Depkes RI, 2003)

Prevention
Prevention:
< 6 months : 50.000 IU oral 6-12 months : 100.000 IU oral >1-5 year : 200.000 IU oral February and August

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Requirement

Not exceed 2 times the RDA (AKG 04)

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Medical Nutrition Therapy

Goals:
Provided an adequate food to reach normal nutrition status Provided high vitamin A food sources

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 Energy:
Adequate energy to prevent protein breakdown (energy supply and recovery) Malnutrition (poor nutrition status):
Stabilization phase: 80-100 cal/kg BW Trantition phase: 150 cal/kg BW Rehabilitation phase: 200 cal/kg BW
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 Protein
High protein To form Retinol Binding Protein and Rhodopsin Malnutrition (poor), step by step:
1-1.5 g/kg BW/ day 2-3 g/kg BW/day 3-4 g/kg BW/day

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 Fat
20-25% For optimal vit A absorption: 3-4 g per meal MCT PUFA>>SFA Palm oil (red), coconut oil
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 High vit A food sources How to cooked (fry or light fry) Food form: destructive gastrointestinal epitel condition easy to digest

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Vitamin A Sources
Sumber: Food Standard Agency(2002)

Vitamin A sources (retinol per 100 g edible portion) Cows milk Semi-skimmed 30 19

Skimmed
Cheese Egg Chicken Liver Sardines Butter

1
958 190 11 19,700 6 958
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Sumber -karoten
Sumber: Mangels dkk, 1993

-carotene sources (g/100g) Carrot (cooked): 9800 Sweet potatoes (cooked): 8800 Daun selada: 1200 Bawang prei: 1000

Carrot : 7900
Spinach (cooked): 5500 Tomato ketchup: 5000 Pumpkin : 3100 Blewah:3000 Daun singkong:3000 Bit: 2560

Tomato juice: 900

Celery : 710 Green beans: 630 Tomatoes: 520, sawi : 530 Watermelon : 230 Pickles : 180 Papaya: 99

Red pepper: 2200

Broccoli : 1300 Mango: 1300

Corn : 51
Avocado : 34 Apple: 26 and orange: 39
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Contoh makanan lunak kaya vitamin A

Pagi:
Bubur ayam + tomat cincang

Sore:
Kolak biji salak (ubi merah/oranye)

Selingan:
Kue sus isi wortel

Malam:
Lontong Telur bumbu opor Tumis buncis Pisang ambon

Siang:
Bubur/tim nasi Semur daging giling Oseng tempe Sayur lodeh (kcg pjg dan melinjo) Pepaya

Malam:
susu

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Contoh makanan biasa kaya vitamin A

Pagi:
Nasi goreng Telur ceplok

Sore:
Pastel isi sayuran

Malam:
Nasi Gulai ikan Tahu telur Tumis kangkung

Selingan:
Cake wortel

Siang:
Nasi Goreng ayam mentega Tumis kacang merah Cah wortel dan caisim Jeruk

Malam:
susu

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Thank you

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