sight and lifesight and life 2 newsletter 2/2006 sight and life is a humanitarian initiative of dsm...

SIGHT AND LIFE

INCORPORATING THE XEROPHTHALMIA CLUB BULLETIN

NEWSLETTER 2/2006

Correspondents: Bruno de Benoist, William S. Blaner, George Britton, Omar Dary, Frances R. Davidson, John W. Erdman, Jr., Tracey Goodman, Philip Harvey, Richard F. Hurrell, Rolf D. W. Klemm, Donald S. McLaren, Regina Moench-Pfanner, Christine Northrop-Clewes, Vinodini Reddy, Delia Rodriguez-Amaya, Ram Kumar Shrestha, Noel W. Solomons, Floren-tino S. Solon, Alfred Sommer, Andrew Tomkins, G. Venkataswamy, Emorn Wasantwisut, Keith P. West Jr., Yu Xiaodong, Michael B. Zimmermann. Editor: Klaus Kraemer

yyyyyy

Children in Madagascar, where the GRET program is running (see article on page 4).

School Feeding; CARIG 2006; Fat-Soluble Vitamins 2006; Micronutrient Premix in WFP Actions; Workshop Nutrition-al Anemia; Reports and Information from Benin, Burkina Faso, Dominican Republic, FSM Micronesia, Honduras, India, Kenya, Nepal, Sudan, Vietnam

SIGHT AND LIFE NEWSLETTER 2/20062

SIGHT AND LIFE is a humanitarian initiative of DSM

DSM Nutritional ProductsDSM Nutritional Products is the world’s leading supplier of vitamins, carotenoids and other fine chemicals to the feed, food, pharmaceutical and personal care industries. The company has a long tradition as a pioneer in the discovery of new products, new formulations and attractive applications for all industry segments. For further company information please visit www.dsmnutritionalproducts.com

DSMDSM is active in nutritional and pharma ingredients, performance materials and industrial chemicals. The company creates innovative products and services that help improve the quality of life. DSM’s products are used in a wide range of end markets and applications such as human and animal nutrition and health, cosmetics, pharmaceuticals, automotive and transport, coatings, housing and electrics & electronics (E&E). DSM’s strategy, named Vision 2010 – Building on Strengths, focuses on accelerating profitable and innovative growth of the company’s specialties portfolio. Market-driven growth, innovation and increased presence in emerging economies are key drivers of this strategy. The group has annual sales of over € 8 billion and employs some 22,000 people worldwide. DSM ranks among the global leaders in many of its fields. The company is headquar-tered in the Netherlands, with locations in Europe, Asia, Africa and the Americas.

Contents The Nutrimad school feeding program: Impact on failure rate and nutritional status of schoolchildren in Madagascar 4Reflections: Four decades with vitamin A and carotenoids; James Allen Olsen Memorial Lecture, CARIG, 2006 10Carotene Research Interaction Group (CARIG) Annual Conference 2006, San Francisco 1813th European Meeting on Fat-Soluble Vitamins 2006 in Jena 23Protecting nutritional status and the role of micro nutrient premix in the WFP’s response to the Indian Ocean Tsunami 25Distributing micronutrients and deworming medicine in hurricane-ravaged Honduras 27Eye care mission to the Dominican Republic, March 2006 29Update on the status of vitamin A deficiency and xerophthalmia in children under five treated at hospitals in Vietnam over a 27-year period (1979 – 2005) 30

Continuing nutrition education by the Youth Volunteer Group, Nepal 31The PACHE Trust health program and women’s empowerment 32An integrated nutrition, training and education program 33Knowledge and perception of vitamin A deficiency in the villages of Burkina Faso 35VAD and malnutrition among Sudanese children admitted to an urban hospital 36The fight against vitamin A deficiency at Ouassa-Beket, Benin 36Continued activity of the Ramala Women’s Group 37SIGHT AND LIFE visits Pohnpei, Micronesia, and films a nutrition documentary 39A digest of recent literature 41Letters to the editor 49Publications 51Micronutrient Forum 53SIGHT AND LIFE workshop Nutritional Anemia 54SIGHT AND LIFE, back cover

NEWSLETTER 2/2006 SIGHT AND LIFE3

Editorial

Reflections

On 29 May 2006, the 59th World Health Assembly, the govern-ing body of the World Health Organization (WHO), adopted a resolution on the ‘Prevention of avoidable blindness and visual impairment’. Given that still more than 161 million people world-wide are visually impaired, of whom 37 million are blind, and that about 75% of blindness is avoidable, the resolution is timely and is expected to strengthen the VISION 2020 plans. VISION 2020: The Right to Sight is a global initiative of the WHO and the International Agency for the Prevention of Blindness (IAPB). It comprises governments and NGOs committed to the preven-tion and treatment of blindness. Among other things, the reso-lution urges member states to include Vision 2020 in national development plans, and en-courages partnerships between the public and private sectors, NGOs and communities. Since its inception SIGHT AND LIFE has supported IAPB, and now it has also become a formal partner of Vision 2020. In this way SIGHT AND LIFE continues to take responsibility for the prevention of childhood blindness, as good vitamin A nutrition is pivotal for the eradication of this scourge.

As indicated in the previous edi-tion of the Newsletter, SIGHT AND LIFE’s 20th anniversary year

will be a year of action. But after 20 years of work committed to the fight against vitamin A and other micronutrient deficiencies, this should also be a time for re-flection. We think that we are on the right track with our mission and the services we provide, but I believe we could even do better. Therefore we are taking this occa-sion as an opportunity to examine our own activities. With the sup-port of an international consul-tancy group we are determining how we can fully leverage our capabilities. The consultants are undertaking this project on a pro bono basis. Your feedback from the questionnaire (see Newsletter 1/2006) and interviews with some of you are a valued contribution towards this goal.

Nutritional anemia remains an issue affecting more than two bil-lion people worldwide. We have decided to bring together leading experts to discuss approaches to controlling nutritional anemia. The program of a correspond-ing workshop on 27 September 2006 in Barcelona will be found on page 54 of this Newsletter. There is only limited capacity for the workshop and we are already almost fully booked. Should we, as we hope, succeed in moving the meeting to a larger room we will make an announcement to this effect on our website.

On 16 June 2006, at the invitation of SIGHT AND LIFE, experts of the United Nations World Food Programme (WFP) came to Swit-zerland to discuss school feed-ing activities with employees of DSM Nutritional Products. There was an enormous interest in this topic. Micronutrient-enhanced school feeding in Madagascar is also the topic of a contribution to this Newsletter by Arnaud Laillou and coworkers (page 4). On page 25 you can read about the role of high-energy nutri-ent dense biscuits in the WFP’s

tsunami response in South East Asia and school feeding. In April 2006 a team from SIGHT AND LIFE visited Micronesia to shoot a film documentary on what is called by the United Nations Standing Committee on Nutrition ‘the double burden of malnutri-tion’. Under- and overnutrition can no longer be regarded in isolation – and early intervention is key in implementing success-ful preventative strategies. The purpose of the film is to create awareness and suggest solu-tions for this worldwide nutrition problem. Please read the article on page 39 by Lois Englberger and Adelino Lorens. Finally, I would like to call your attention to Barbara Underwood’s article on four decades of intense vitamin A and carotenoid research (page 10). The article is based on the James Olson Memorial Lecture at this year’s Carotene Research Interaction Group (CARIG) annual conference (page 18). It is a very stimulating reflection on public health interventions to control vitamin A deficiency.

I am convinced that this year’s re-flections will provide us with clear directions for the future, and, more importantly, for the benefit of billions of people suffering from ‘hidden hunger’.


The Nutrimad school feeding program: Impact on failure rate and nutritional status of schoolchildren in MadagascarArnaud Laillou1, Luc Arnaud1, Menjaharimisa Ramaherisoa2, Charlotte Ralison2, Chantal Monvois1 and Serge Trèche31 The Research and Technological Exchange Group (GRET), Antananarivo and Paris. 2 The Laboratory of Bio-chemistry Applied to the Food Sciences and Nutrition (Labasan), University of Antananarivo, Madagascar3 UR106 “Nutrition, Food, Societies”, Institute of Research for Development (IRD), Montpellier, France

Introduction

The Nutrimad school feeding program (SFP), co-financed by SIGHT AND LIFE and the Ile de France regional council, is one of the three sections of the Nutrimad program, which is run by GRET (Research and Tech-nological Exchange Group), the IRD (Institute of Research for Development), and the Labasan (Laboratory of Biochemistry Ap-plied to the Food Sciences and Nutrition, of the University of Antananarivo, Madagascar) with the aim of contributing to the sus-tainable reduction of malnutrition in Madagascar. The objectives of the program are to counter immediate hunger and school failure rates, and to respond to the nutritional deficiencies of chil-dren from public primary schools within the framework of a sustain-

able system of school snacks, overseen by the local authorities. The approach of the Nutrimad SFP was to introduce a snack that was accessible to everyone, i.e. inexpensive, made from lo-cal raw materials, liked by the children, readily obtainable and reproducible, i.e. easy to prepare within schools, and of good nu-tritional value, i.e. designed so that one portion covers a share of nutritional requirements cor-responding to the level of defi-ciencies generally observed in schoolchildren in Madagascar. The Nutrimad SFP was imple-mented during the 2004 – 2005 school year in 15 public primary schools in underprivileged dis-tricts of Antananarivo, according to the methods described in a previous issue of the SIGHT AND LIFE Newsletter (1). The program comprised two parts.

The first consisted in provid-ing 12,893 children from the 15 schools with a snack in the form of a fortified and high-energy density gruel over an average of 110 days (between 101 and 119, depending on the school) spread over a period of approximately 6 months of the year.

This gruel, which was served dur-ing the first break for the price of 40 Ariary (approx 1.5 euro cents), was prepared in each school us-ing a corn meal powder called “Koba Tsinjo” (72.6%), peanut (8.5%), sugar (14.0%) and a vita-min and mineral mixture, to which 2.0% soybean oil was added dur-ing the preparation process. The quantities served (350 g of gruel containing 110 g of powder, or 380 kcal) were sufficient to cover 18% of the daily energy require-ments of a 10-year-old child,


as well as 75% of their RDA of micronutrients for which there is a major deficiency risk (iron, zinc and vitamin A), 60% of their RDA of calcium, 40% of their RDA of other minerals and vitamins, and 25% of their RDA of proteins, amino acids and essential fatty acids.

The second part consisted in nu-trition education activities, whose purpose was to communicate messages aimed at informing the pupils and encouraging them to adapt their diet to their nutri-tional requirements, and to lead a healthy lifestyle. These messages were delivered throughout the year by specially trained teach-ers, who were also provided with educational supports developed by the Nutrimad team.

A first, still incomplete appraisal (presented to a meeting of na-tional and international interest groups on 10 May 2006, at the in-vitation of Madagascar’s National Nutrition Office) of the operation and effects of the Nutrimad SFP during the 2004 – 2005 school year has now been drafted, and this forms the basis of the present article.

Methodological approach implemented for follow-up and evaluationThe follow-up and evaluation strategy implemented throughout the year 2004 – 2005 to check the relevance and effectiveness of the Nutrimad SFP consisted mainly in measuring:• pupils’ participation in the

scheme• the effect of nutrition education

activities on pupils’ nutrition knowledge

• the effect of gruel consumption on the frequency and nature of pupils’ meals, on their nu-tritional status, and on their school performance

In doing this, we had to take into account three main constraints. The first of these was the non-inclusion of control schools in our evaluation strategy, which meant that we were limited to comparing indicator values either recorded at the beginning and end of the year with the same pupils, or calculated for groups of pupils put together according to their gruel consumption. The second constraint was the insufficiency of financial resources allocated to the evaluation studies, which limited our choice of indicators for impact on nutritional status to those based on anthropometric measurements. The third con-straint was the impossibility of gathering, from the relevant serv-ices, previous years’ statistics on absenteeism and graduation into higher classes.

The analyses carried out can be divided into three categories:• those carried out on the en-

tire number (12,893) of pupils from 254 classes from the 15 schools, which consisted in creating a typology of schools and in recording information on the classes and teachers, as well as a self-administered questionnaire survey of the socio-economic situation of the families, a daily record of information on absenteeism and consumption of the snacks, anthropometric measurements and tests of nutrition knowledge taken at the beginning and end of the school year, and a record of results from the end-of-year exam determining whether pupils graduate into higher classes and which academic direction they should take;


• those carried out on reduced samples of pupils, in particular a measurement of food-intake which allowed us to check the adequacy of the consumption of gruel actually served (2,573 pupils from 64 classes in 5 schools), serial data-gathering intended to estimate, amongst other things, the effects of gruel consumption on the frequency and composition of meals (all pupils from 5 of the 15 schools), and the share of nutritional requirements cov-ered (a survey based on recall of the past 24 hours carried out on 480 children from 9 of the 15 schools);

• finally, studies concerning gruel preparation, which were car-ried out in 5 schools to ensure that preparation guidelines were being respected and to check the characteristics of the gruel being served.

Confirmation of the poor nutritional status and low spending power of pupilsIn the first place, the surveys and measurements taken allowed us to confirm the poor nutritional status of pupils at the start of the school year, before the Nutrimad SFP was launched.

Delayed growth and low weight affected 46.0% and 32.8% of

children respectively, although there was a low prevalence (2.2%) of wasting among children under 10 years (Figure 1).

Moreover, the nutritional status of boys is noticeably worse than that of girls (49.6% vs. 42.2% for delayed growth; 37.8% vs. 27.3% for low weight), and, while the prevalence of malnutrition re-mains relatively constant between ages 6 and 10, it increases con-siderably in older children. Fur-thermore, it seems that there is an important relationship between academic underachievement and nutritional status insofar as, of the total number of children, the prevalence of arrested size fits 38% of children who are one school year behind, and 55% of children who are two school years behind in their studies.

Regarding the sums of money the children could afford to spend on food each day, the 11,255 chil-dren who completed the ques-tionnaire had received an average of 67 Ariary from their parents on their most recent day at school. A third of the children received more than 50 Ariary, while 27% received less, of whom 5.1% received nothing at all.

A high rate of pupil participation in the scheme Over the entire gruel distribution period, the average rate of pupil participation in the scheme, i.e. the average percentage of days on which they consumed at least one serving of gruel during the operational period of the Nutri-mad SFP, was 68.4%. This rate was slightly higher in the second semester (71%) than in the other two (67% and 66%). The older the children, the more their participa-tion rate went up (from 60% at age 6 to 77% at age 13), or in other words, participation increased in direct proportion with the level of the school year (Figure 2).

Ultimately, despite having to pay 40 Ar for each serving of gruel, 34.3% of pupils took over 80% of the opportunities offered them to eat it throughout the year, which means that only 9.6% took 20% or less of these opportunities.

Figure 1. Prevalence of delayed growth, wasting, and low weight in children from the 15 schools (the figures for wasting are for children under 10 only).


Gruel prepared and consumed according to recommendationsThe observations and samples taken have shown that gruel prepared in the schools did in-deed contain on average the desired concentration of energy (108 kcal/100 g of gruel, which corresponds to 378 kcal for a 350 g serving) and, moreover, that 94.1% of children completely fin-ished their plate of gruel, with only 0.75% of children leaving more than 4 soup-spoonfuls, and 2.9% sharing their gruel with a friend.

Under these conditions, we can calculate that, over the 6 month period (from November 2004 to May 2005) during which the Nutrimad SFP was in operation, the snacks provided 23.8% of the children with over 40% of their RDA in micronutrients for which there is a major deficiency risk, between 20% and 40% of the RDA for 65% of them, and under 20% for only 11.2%.

A snack which does not take the place of regular mealsPending the processing of data from the survey based on recall of the past 24 hours, which should allow us to compare percent-ages of nutritional cover between children who ate the snacks and those who did not, the results provided here concern the effect of snack consumption on the frequency of daily meals.

The consumption of breakfasts (96.3%) and lunches (95.7%) at home by the children was just as frequent among those who ate the snacks as it was among those who did not. The consumption of dinners was even slightly, but significantly (98.1% vs. 96.1%; p<0.001), higher among children who ate the gruel than it was among the others. Furthermore, the comparison of snack con-

sumption in the morning (86.5% vs. 71.2% for the ch i ld ren who ate the gruel and those who didn’t re-s p e c t i v e l y ; p<0.01) and af-ternoon (69.8% vs . 57 .48%; p<0.05) shows that not only do the alternatives to the snacks offered by the Nutrimad SFP have considerably less nutritional value, but also that the children who did not eat the Nutrimad SFP snack did not necessarily eat anything else.

Notable effects on nutritional status

The information gathered over the course of the SFP’s 6-month operation period meant that the children could be divided into three groups according to wheth-er they consumed quantities of gruel covering averages of less than 20% (group 1), 20% to 40% (group 2) and over 40% (group 3) of their RDA in micronutrients for which there is a major deficiency risk; it also meant that the chil-dren’s growth in size and weight could be compared, taking into account a certain number of po-tentially confounding factors.

A comparison of the prevalence of delayed growth (Figure 3) shows that, for the raw values as well as for the adjusted values, there are highly significant differ-ences between the three groups of children: it can be estimated that differences in consumption are responsible for these differ-ences of prevalence to the order of 10% to 12% observed at the end of the school year.

The comparison of variations in children’s weight during the Nu-trimad SFP’s 6-month operation

period shows that gruel consump-tion had a favorably significant effect on the children’s weight (Figure 4): the children from group 3 gained 1.1 kg more than those from group 1. This effect was still significant after adjustment of all potentially confounding variables. Having taken these into account it can be estimated that, thanks to their greater consumption of gruel, the children from group 3 gained over 400 g more than group 1 children over 6 months.

Figure 2. Variation of children’s participation in the scheme as a function of their school year (CP–CM2 refers to primary school grades in French-speaking countries).

Figure 3. Effects of gruel consump-tion on the raw and adjusted* preva-lence of delayed growth at the end of the school year. Groups according to gruel consumption: 1) less than 20%; 2) 20% to 40%; 3) over 40%.* Adjusted by logistical regression for indicator variables of characteristics of the school, characteristics of the class (number of children, school year), of the participation level of teachers, of the children’s family group (index of pos-sessions, number of siblings, amount of pocket money given them by their parents) and of children’s characteristics (age, gender, number of days of ab-sence, academic underachievement.)


Improved nutrition knowledge and awarenessThe average marks obtained from nutrition knowledge tests taken before and after the Nu-trimad SFP’s 6-month operation period are given in Figure 5. For all the school years there was a significant improvement of nutri-tion knowledge during the year, although this improvement is apparently greater in years CP2, CP1 and CE than in CM1 and CM2.

The statistical analyses led to the identification of certain fac-tors influencing the variations in pupils’ nutrition knowledge throughout the school year. The most important of these, taking into account the essential role played by the communication of messages, was the teachers’ motivation.

Impact on school performance

An assessment of the effect of snack consumption on school performance of the total number of pupils from the 15 schools was based on the decision made at the end of the year as to whether they should graduate to the next class, and on the marks they obtained at the end-of-year ex-ams.

The children from group 3 were over 10% more likely to be al-lowed to graduate to the next class than those from group 1 (81% vs. 71%). Moreover, they were 6% less likely than group 1

to obtain below average marks at the end-of-year exams (27.1% vs. 33.2%). If we adjust, using logistical regression, the percent-age scores of children allowed to graduate to the next class for potentially confounding vari-ables, the differences between the groups still remain significant (72.6%, 75.6% and 82.5% for children from groups 1, 2 and 3 respectively; p<0.0001). It can therefore be estimated that the differences in consumption be-tween groups 1 and 3 helped to reduce the number of children having to repeat their school year by about a third.

The average marks obtained at the end-of-year exams by pupils from the three groups are given in Figure 6.

Prior to adjustment, there is only a slight gap between the marks obtained by children from group 3 and those of children from the other groups (from 0.10 to 0.15/10). After adjustment, how-ever, the gaps are larger and the improvement in marks attribut-able to regular consumption of the snacks can be estimated to within 0.4 points over 10.

It appears, then, that the imple-mentation of the Nutrimad SFP and the high rate of participation

Figure 4. Effects of gruel consump-tion on differences in weight, raw or adjusted*, between the beginning and end of the Nutrimad SFP’s 6-month operation period. Groups according to gruel consumption: 1) less than 20%; 2) 20% to 40%; 3) over 40%.*Adjusted by analysis of covariance for indicator variables of the characteristics of the school, characteristics of the class (number of children, school year), characteristics of the teachers, of the children’s family group (index of pos-sessions, number of siblings, amount of pocket money given them by their par-ents) and of children’s characteristics at the start of the year (age, size, Size/age and Weight/age Z-scores)

Figure 5. Comparison of average marks obtained by children in nutrition knowledge tests at the beginning and end of the school year (CP–CM2 refers to primary school grades in French-speaking countries).


by the pupils have considerably improved their school perform-ance.

Conclusion

The follow-up and evaluation of the Nutrimad SFP during the 2004 – 2005 school year has es-sentially allowed us to highlight the poor nutritional status of chil-dren and to establish, or highlight, the adequacy of the type of snack provided:• over the 110 days of the pro-

gram, the children took 68% of opportunities offered them to eat the gruel;

• each portion consumed cov-ered 16% to 22% of their en-ergy requirements and 75% of their requirements of the main micronutrients;

• the snacks did not take the place of regular meals.

Furthermore, at the end of the year the most regular consum-ers had, in comparison with the

Figure 6. Effects of gruel consumption on average marks, raw and adjusted, obtained by pupils at the end-of-year exams (averages not accompanied by identical letters differ to the level of significance indicated). Groups according to gruel consumption: 1) less than 20%; 2) 20% to 40%; 3) over 40%.(1) Adjusted for indicator variables of the characteristics of the school, characteristics of the class (number of children, school year), characteristics of the teachers (ab-senteeism, mark given by monitors of participation in the scheme), of the children’s family group (index of possessions, parents’ level of education), and characteristics of the children (gender, age, Size/age Z-score at the start of the year).

others, a better nutritional status (40% vs. 50% delayed growth), were less likely to have to repeat their school year (20% vs. 30%), and did better at the end-of-year exams.

These very encouraging results are currently undergoing confir-mation in the 2005 – 2006 period at the same schools. The integra-tion of 8 control schools into the evaluation process should allow us to highlight not only the effect of snack consumption and nutri-tion education on the children’s nutritional status and school performance, but also the effec-tiveness of the present strategy within the context of the educa-tion system concerned.

References

1. Laillou A, de Sesmaisons A, Ralison R et al. (2005). Distributing fortified and high-energy density gruel to reduce the failure rate and improve nutritional status of Antananarivo schoolchildren. SIGHT AND LIFE Newsletter 2: 22–26.


Introduction

James Allen Olson was a bio-chemist/nutrition scientist, men-tor, colleague and friend to many of us. He was the father of VARIG (Vitamin A Research Interactive Group) and CARIG (Carotenoid Research Interactive Group) at the Experimental Biology meet-ings and one of the founding members of IVACG (International Vitamin A Consultative Group). At IVACG he was frequently request-ed to provide updates on vitamin A and carotenoid metabolism and he carried the torch for food-based approaches to vitamin A deficiency as a vital component of any micronutrient control pro-gram. For many years Jim and I worked together within IVACG and as research colleagues in vitamin A metabolism, assess-ment of status and promotion of sustainable intervention pro-grams. It is a privilege and an honor to be asked to speak at this memorial lecture and to reflect back to some of the significant years in vitamin A and carotenoid research and programs.

1960s: Where were we then?*2

In 1960, Hoffmann-LaRoche or-ganized a symposium convened in Switzerland on “Vitamin A and Metabolism” to honor Professor

P. Karrer (1). Karrer had isolated and elucidated the structure of vitamin A in 1931. The content of the symposium was meant to sum-up the situation with respect to vitamin A and provitamin A carotenoids. The “sum-up” re-vealed that there was yet lots to be learned, despite the fact that deficiency eye symptoms were described and a cure known (liver extract) from ancient times (2); that in the second decade of the 20th century these symp-toms were attributed to lack of a fat-soluble substance found in some animal foods and butterfat (3,4), which McCollum named vitamin A (3), or to a lack of caro-tenoids in some plant foods that Steenbock suggested in 1919 could be converted to the active component (5); that vitamin A was isolated and its structure elucidated by Karrer in 1931 (6); that Wald and colleagues in the latter part of the1930s had uncovered the functional role of the vitamin in vision (7,8); and in 1960, that Dowling and Wald (9) had reviewed the overt systemic signs of vitamin A deficiency and the role of vitamin A acid (retinoic acid) in maintaining growth and the health of epithelial tissues, though animals were deficient in retinol and were night-blind. And importantly, Stephenson and Clark*3 as early as 1920 re-ported that rats fed diets void of the active fat-soluble substances died at a higher rate even before eye signs occurred, but that eye symptoms in every case cleared when a petroleum ether extract of dried carrot was incorporated into their diet (10).

In spite of all that was known by 1960, much remained unknown. There was little knowledge of the global magnitude of the deficiency problem in humans. In part this was because there was no consensus on how best to assess vitamin A deficiency either clinically or biochemically given that clinical signs were not standardized and methodolo-gies available for biochemical assessment provided uncertain results. Detailed information on the metabolism of vitamin A was limited and the active form and

Reflections: Four decades with vitamin A and carotenoids; James Allen Olsen Memorial Lecture, CARIG, 2006

Barbara A Underwood*1, PhD, Adjunct Professor of Nutrition, Institute of Human Nutrition, Columbia University, New York

*1 E-mail: [email protected]*2 The photos of some of the people mentioned are taken from the SIGHT AND LIFE slides (02 HI History) on our website (http://sightandlife.org/slidesNEWppt/mainNEWsl.html) and can also be found on our CD; editor.

James A Olson (http://sight-andlife.org/PhotosAll/pic2000-4/NL400p21.jpg)

*3 The SIGHT AND LIFE slide P35 refers to the same publication (http://sightandlife.org/slidesSandP/E/Pslides.html)


function of vitamin A outside the visual cycle was still speculative (11). Analytical methods for quan-titative analysis existed for both the preformed vitamin and for provitamin carotenoids, but these methods were often tedious, diffi-cult to standardize, and frequently used toxic chemicals that failed to provide reproducible results in many laboratories (12–14). There were no large-scale intervention programs to combat vitamin A deficiency and even at the local level within hospitals there was little appreciation of how to treat or prevent the deficiency, which often accompanied protein-energy malnutrition (PEM). And notably, there was very little po-litical interest or will to eliminate vitamin A deficiency.

I saw my first cases of xeroph-thalmia in 1961, more than four decades ago, while conducting doctoral research among refugee children in what was then Je-rusalem, Jordan. I was midway through studies at Columbia University Institute of Nutrition Sciences, later renamed the In-stitute of Human Nutrition (IHN). I went there in 1959 because of a deep concern for problems of childhood malnutrition in the de-veloping world and the desire to become professionally involved in seeking appropriate solutions. The Institute had a newly created program led by William Henry Sebrell, one of the pioneer nutri-tionists of the 20th century. The

Institute’s objective was to train students to analyze, understand and seek solutions to malnutrition in the developing world in a ho-listic context (15). My academic training within this environment and the opportunity to do my thesis research in an international setting among malnourished chil-dren set the tone for the rest of my professional career.

2006: Where are we today – after 4½ decades?Prevalence No doubt, we have a greater appreciation of the magnitude of the global problem and the epidemiological factors, in ad-dition to diet, that contribute to its existence. The Micronutrient Report published in 2001(16) placed the magnitude of the problem among preschool-aged children at 75 – 140 million; earlier estimates by the WHO placed the prevalence as high as 230 million (17). These prevalence data are based on clinical eye signs and/or low blood vitamin A levels from a database that is far from repre-sentative and firm. Nonetheless, The Micronutrient Report also noted a trend toward improve-ment since 1980 in most regions of the world, particularly since 1990, a period when large-scale periodic vitamin A distribution pro-grams were expanding. Indeed, on the public health level, inter-vention by periodic distribution

of high-dose vitamin A supple-ments now covers an estimated 70% of preschool-aged children in 40 countries with at least one dose of vitamin A annually, and about 1/3 of these 40 countries have achieved 70% coverage with the required two doses (18). However, now we know that the problem extends beyond the pre-school years to pregnant women whose health and survival also are compromised in countries where deficiency is common (19). The magnitude of deficiency among pregnant women, however, is largely unknown and there are few targeted prevention programs in effect that reach these vulnerable women.

Metabolism and methods Knowledge of the metabolism of vitamin A and carotenoids has advanced dramatically since 1960. The active forms and func-tions of vitamin A are established: retinol in the visual system and retinoic acid in normal growth and development by modulation of gene actions. And new knowl-edge of non-provitamin A roles of carotenoids in the moderation of degenerative diseases is evolving as definitive analytical techniques allow for tracing the metabolism of individual carotenoids. Quan-titative analytical methods for retinoids are well advanced (20) and this has contributed to a variety of new field assessment methods, including a more ob-jective and reproducible meas-

EV McCollum Paul Karrer Otto Isler (left)


ure of night blindness (pupillary response) (21), subject-friendly collection of blood specimens (dry blood spots) for subsequent quantitative analysis either in the field or at a base laboratory (22) and assessing whole body stores (isotope dilution) (23). The appli-cation of new intrinsic carotenoid labeling methods offers greater ability to trace individual carote-noids from vegetables containing them in their natural matrices to their uptake from the gut and utili-zation: hence, to a more accurate measure of bioavailability (24).

Programs Intervention programs are mov-ing beyond strictly distributing nutrient supplements. These programs are becoming more integrated and viewed more holistically within the context of undernutrition, underdevelop-ment and poverty. Micronutrient fortified foods that can address both specific deficiencies and ca-loric undernutrition are available in many countries. They include vitamin A fortified sugar, oils, and some cereals, to name a few, but access by the poor at greatest risk still varies greatly, especially in rural areas with limited market access. And public health meas-ures including promotion and support for breastfeeding, ex-panded immunization coverage, parasite control programs, and home-based control of severe di-arrheal disease have contributed to decreased infectious morbid-ity and mortality and, hence, improved individual and national

development. Although improve-ments are occurring in availability of potable water and environ-mental sanitation, the UN reports (Los Angeles Times, March 10) that over 1.1 billion living in im-poverished communities remain without safe water. Yet in spite of all the progress made, including distribution of over 400 million vitamin A capsules annually (18), vitamin A deficiency remains a significant public health problem. A diet inadequate in vitamin A-containing food sources is the underlying cause of deficiency. Yet until recently food-based ap-proaches that impact on underly-ing causes of underdevelopment, undernutrition and micronutrient deficiencies were the step-child intervention least attractive to international funding agencies.

How did we get from there (1960) to here (2006)? Some significant decade milestones

1960–1970: Progress in understanding basic metabolism

The decade of the 1960s was the period that in my reflective view was noted mostly for advances in understanding the basic metabo-lism of vitamin A and provitamin A carotenoids. Central cleavage of beta-carotene in James Olson’s (25) and DeWitt Goodman’s (26) laboratories by enzymes isolated from the gut and liver of rats ad-vanced knowledge of bioconver-sion mechanisms. In humans,

efficient uptake of dietary retinol and conversion of β-carotene to retinal, esterification to retinyl esters, transport of the esterified product in lymph chylomicra and hepatic uptake from chylomicra remnants were demonstrated (27). Retinol binding protein (RBP) was isolated and partially character-ized in 1968, and subsequently its role in hepatic mobilization and transport of retinol as holo-RBP complexed with transthyretin was defined (28). Understanding of the reversible formation of single, bi- and trimolecular complex-ing clarified how the exchange of retinol from blood to tissues occurred without loss through kidney filtration. Furthermore, the concepts revealed in defining the metabolism of RBP provided the basis in the following two decades for a new indirect assessment of depleted hepatic stores, the rela-tive dose response (RDR) in my laboratory (29), its modification (MRDR) in James Olson’s labora-tory (30) and its current broad use in assessment of vitamin A status in human and animal studies.

On the public health front progress was slow. In 1964 the first ‘gues-timate’ of the global magnitude of deficiency was made. The ap-proximation of 20,000 to 100,000 affected children was based largely on interviews and subjec-tive information on the prevalence of eye signs (31), which did not generate political support for large intervention programs, even though severe vitamin A deficien-cy in children was very evident in developing countries, often as-sociated with PEM, and too often inappropriately managed leading to irreversible blindness, if the pa-tient survived. Many of us involved in international child health issues during the 1960s were appalled by the lack of attention to this preventable public health scourge, but there was no organized group to champion the cause at a politi-cal level and attract substantial funds for prevention.

George WaldRichard Kuhn HAPC Oomen


1970–1980: Breakthroughs in analytical methodology and public health

The decade of the 1970s is noteworthy for a major methodo-logical breakthrough in retinoid analyses, the application of high-pressure liquid chromatography (HPLC). Harold Furr recently commented that “Progress in nu-tritional biochemistry has always depended on progress in analysis of nutrients” (20). That is why the advent of HPLC in the mid-1970s was such an important addition to the analytical assessment arsenal (32,33), opening doors for progress in both basic and applied research. Although the instrument originally was too expensive to obtain and maintain in developing countries, it is now broadly available and the method of choice for most applications requiring quantitative retinoid analyses, especially for the analy-sis of vitamin A in blood.

On the public health platform during the 1970s, the most im-portant advance in vitamin A program applications occurred as the result of three seminal meet-ings. The first was a WHO/USAID sponsored meeting in Jakarta, Indonesia in 1974 (34). The Ja-karta meeting was notable for the heated controversy between ophthalmologists, epidemiolo-gists and nutritional biochemists on the appropriate classification criteria for xerophthalmia, cut-off

points to establish a public health problem, the health consequenc-es of deficiency beyond the eye, reliable assessment methodology and efficacy and effectiveness of different intervention programs. Tentative decisions on these issues were published in the meeting report but the science base was weak and few were satisfied. The scientists went from this meeting determined to provide the missing research data to resolve disagreements (35). The following year (1975) IVACG was formally established to maintain momentum toward the control of vitamin A defi-ciency diseases by providing an annual forum (later changed to biannual meetings) for informa-tion exchange among research-ers, public health professionals, international funding agencies, non-governmental agencies and private industry (36). Research activities did accelerate in subse-quent years as was obvious in the follow-up WHO/UNICEF/USAID/HKI/IVACG-sponsored meeting in Jakarta in 1980 (37). The meeting was less controversial because data were available from the considerable amount of research that had been completed in the previous six years. The result was consensus on earlier arguable issues, i.e. standardization and classification of xerophthalmia symptoms and signs, treatment and prophylaxis schedules and agreement to draw attention to the need for large-scale interven-tion programs.

Creation of IVACG deserves spe-cial mention. The USAID estab-lished and sponsored the group for 30 years. Administration of the program initially was through the Nutrition Foundation, which was later transformed into the International Life Science Insti-tute (ILSI). The group began with only 17 committed individuals and reached as many as 100 over the first decade (36). Individuals worked voluntarily in task forces

between the annual meetings to produce guidelines and state-of-the-art reviews, many of which remain useful even today. James Olson was a charter member of IVACG and co-authored many of the guidelines and reviews. He seldom missed a meeting. Frequently he provided the bio-chemical updates because his presentations were so lucid and understandable by all in the diverse group that assembled annually. In addition, he usually chaired sessions on carotenoid biochemistry and conducted fo-cus groups on carotenoids and food-based issues. The meetings grew during the three decades of IVACG’s existence to an attend-ance of about 800 delegates at the 22nd meeting held in Lima, Peru in 2004. The 2004 meeting was the last before disbandment and reorganization, which is currently in progress, to form a Micronutri-ent Forum. IVACG during its 30 years of existence gained respect throughout the international com-munity and played an influential role in international programs to control deficiency world-wide. Hopefully the reformed Forum will continue the momentum of IVACG in influencing scientific directions and political decisions, hence accelerating the elimina-tion of micronutrient deficiencies as public health problems.

Alfred SommerDonald S McLaren


1980–1990: Retinoid revolution in the lab and recognition that ocular signs were the tip of the iceberg in the field

Retinoid biochemistry experi-enced a renaissance late in the century when nuclear retinoid receptors were identified and their pleiotrophic effects recog-nized in 1987 (38). This was the beginning of research that has identified how retinoic acid influ-ences a multitude of gene actions that regulate differentiation and cellular growth and functions. This revolution is on-going with new effects on functions being reported regularly.

On the public health scene, though nutritional biochemists had argued vehemently at the 1974 meeting in Jakarta that health consequences went far beyond the eye-based on animal studies – ophthalmologists were unconvinced. The data system-atically collected in Indonesia by Alfred Sommer (an ophthal-mologist/epidemiologist) and colleagues during the decade of the 1980s documented the prev-alence of vitamin A deficiency in the country and provided a firmer basis for projecting the extent of the problem in four other Asian countries, i.e. 200,000–400,000 corneal cases and 4–8 million non-corneal cases (39). The team also elucidated the underlying epidemiological associations that led to clustering of deficiency in affected populations. The epide-miologic studies associated the lack of diversity in child diets, including lack of animal products and carotenoid-containing fruits and vegetables, with deficiency. The survey and epidemiological studies set the stage for the large randomly designed, controlled intervention trial that first estab-lished in humans the mortality risk associated with deficiency (40,41) that six decades earlier had been reported in animals

(10). The announcement at an IVACG meeting late in the 1980s of a 27% reduction in mortality was met with skepticism by the scientific community, including myself, who found it difficult to believe that such a large effect could occur from supplementa-tion without also addressing the prevalence of other diseases and unsanitary environmental conditions. Subsequently pre-school child mortality associated with deficiency was confirmed, though variable in magnitude, in Nepal (42), in Ghana (43), and in India (44), but not in Sudan (45), after administering high-dose vitamin A capsules every 4 or 6 months. Child mortality was also reduced in Indonesia (46) by regular intake of fortified monosodium glutamate, and in India (47) by providing a low-dose weekly supplement, potentially obtainable through food sources. Meta-analyses using data from the major trials concluded that on average, a 23–30% increase in mortality is associated with deficiency (48-50).

1990–2000: Progress on the political front

Political progress marked the decade of the 1990s. UNICEF’s World Summit for Children in 1990 was the ideal situation to call at-tention to the striking mortality re-duction benefit expected by cor-recting vitamin A deficiency. All the ingredients were assembled to launch a major international offensive against the deficiency as a public health scourge. The mortality risk was established and a short-term cost-effective intervention was available in the form of high-dose vitamin A supplements. A persuasive, pas-sionate, committed champion in the person of James Grant, then director of UNICEF, was poised to effectively mobilize the high-level political commitment needed from member states to launch a major international offensive.

This broad political commitment was achieved. The commitments were reinforced at subsequent international meetings in Canada in 1991, sponsored by several bilateral and international groups, at the International Conference on Nutrition in 1992, sponsored by WHO/FAO and in 1996 at the WHO/FAO World Food Summit in Rome. The emphasis from the beginning was on expanding the distribution of high-dose vitamin A supplements. Little support was available for alternative strate-gies. Supplement distribution was greatly facilitated when, in the latter part of 1990, distribution was linked to the WHO Expanded Program of Immunization’s (EPI) initiative of National Immuniza-tion Days (NID) for eradication of polio. This initiative provided a contact with preschool-aged children with minimal additional resources for delivery of the vi-tamin A capsule and is credited with success in greatly expanding coverage. NIDs have now ceased and countries are finding alterna-tive mechanisms for sustaining the high coverage rates.

Food fortification in developing countries received minor atten-tion until midway in the decade, in spite of the successful fortifica-tion of sugar in Central America (51). Primitive development of the food industry and absence of regulatory controls were consid-ered deterrents. But the need for a more sustainable intervention than periodic supplementation was recognized. The initiative for universal fortification of salt with iodine was making great inroads into relieving iodine de-ficiency disorders in developing countries, even in remote areas. Salt iodination advocates pushed their success as a model for vi-tamin A fortification, even though no comparable universally safe and acceptable food vehicle for vitamin A was available. Today, as noted earlier, there is momentum behind vitamin A fortification pro-


grams using several food vehicles adapted to cultural consumption habits, such as oils, cereals, condiments and dairy products. Because supplements in the form of vitamin A or β-carotene in dos-es similar to the RDA but given weekly reduced maternal mortal-ity by 40–50% (19), comparable results could be expected by appropriately fortifying commonly eaten foods incorporated into a diversified diet (52).

Lip-service, but few resources, were devoted to food-based interventions through the 1990s, despite the fact that vitamin A deficiency as a public health problem is due to an inadequate diet. Horticultural or other ag-ricultural approaches attracted minimal international funding support and, therefore, potential for food-based approaches was not adequately evaluated (53). In part this can be attributed to the debate in recent years over bio-availabilty of provitamin-A caro-tenoid food sources, particularly green leafy vegetables that had been promoted for many years. The late Clive West introduced the controversy at a meeting of the Sub-Committee on Nutrition in Canada where he suggested that the 6:1 bioefficacy factor for beta-carotene used to evaluate food sources vastly overesti-mated its true value. Though the 6:1 factor was vigorously debated and defended, subsequent stud-ies by the West group (54) and others upheld the claim for a less efficient conversion factor and forced reevaluation of food sources of carotenoids, particu-larly as contenders for elimination of vitamin A deficiency. In my view, the debate virtually closed off international support for hor-ticultural-based intervention pro-grams in the decade of the1990s in spite of the success of the large-scale horticultural initiative in Bangladesh, sponsored initially by Helen Keller International, that has expanded in the number of

communities covered and has demonstrated an improvement in vitamin A status (52). Agricultural approaches through plant breed-ing came onto the horizon in the latter part of the decade (56) but did not receive substantial sup-port until the turn of the century.

2000 forward: Where are we going?

The end-of-decade goal for elimi-nation of vitamin A deficiency was widely promoted in the 1990s but, although progress was made, the goal was not met. To keep up the momentum, new goals for elimination of micronutrient deficiencies were set for 2010 at the 2001 UN “World Fit for Chil-dren” meeting at UNICEF in New York. The question for program implementers is how to adapt existing strategies to assure that the extended time frame is met in a timely manner and not just reset at the end of the decade. Supplementation undoubtedly will continue for several years in certain country situations, but it will take resources and an intense effort to reach the vulnerable 30% who are now missed even in the best country distribution sce-narios (18). Fortification efforts also will continue and undoubt-

edly will be increasingly effective in reaching rural communities and the poor as markets expand and economies develop. Public health measures through mas-sive immunization campaigns, particularly for polio and measles, have made great inroads into control of immunizable infectious diseases, but these gains need to be complemented by improved environmental sanitation and safe water to control non-immunizable disease. Fortunately, more than at any point in my experience with vitamin A interventions, in-tegrated approaches are gaining support, even food-based ap-proaches.

Indeed, the new kid on the food-based micronutrient intervention playing field is biofortification. Although introduced in the mid-1990s (55) and the potential of the approach reviewed in 2000 (56), substantial funding support only became available through the Bill and Melinda Gates Foun-dation in 2002. Biofortification is the cross-breeding of plants to increase the density of one or more nutrients, e.g. iron and/or zinc or provitamin β-carotene, and/or decrease inhibitors to absorption, e.g. phytates and/or polyphenols. At times, transgenic

Barbara Underwood during her presentation at the CARIG Meeting, see page 18.


methods may be used to intro-duce a nutrient otherwise absent, increase nutrient density above that achievable by cross-breed-ing, or insert favorable agronomic traits (e.g. disease resistance or increased yield). The advantage of biofortification is that staple crops grown and consumed by the poor can be enriched with mi-cronutrients and be available har-vest after harvest without added cost. β-carotene enriched crops currently being pursued include maize, cassava and sweet potato by traditional cross-breeding and rice by transgenic technology.

Golden Rice produced by Syn-genta (SGR1) is the most pub-licized example using genetic manipulations to introduce genes to overcome the impediment to synthesis of β-carotene. Caro-tene enrichment of the original product was not impressive. It was about 1.6 µg/g rice, which carried limited potential for mak-ing significant contributions to vitamin A requirements in spite of heroic claims to the con-trary. Announcement in 2005 of Golden Rice #2 (SGR2) changed the potential: SGR2 contains 31 µg/g β-carotene (57). This is equivalent to 1033 µg RAE in 400 g uncooked, milled rice (an adult male serving size of ~800 g cooked rice daily) and 516 µg RAE in 200 g uncooked, milled rice (an estimated serving size of 400 g cooked rice daily for a child > 3 years). These calculations as-sume 12:1 conversion efficiency for β-carotene to vitamin A. How-ever, feeding tests to estimate bioequivalence have not been reported to date. Nonetheless, factoring in an approximate 20% loss during cooking, 826 µg RAE would remain for an adult and 413 µg RAE for a child. SGR2, there-fore, could nearly meet the RDA across ages if the daily diet con-tained 800 g and 400g of cooked rice eaten by adults and children, respectively. SGR2 is an example of using transgenic technology to

introduce or improve carotenoids, particularly provitamin A, in staple crops grown and/or eaten by the poor, such as cassava and maize. There remains much research to be completed before such carotenoid enriched crops are available for public consumption. Bioavailability must be deter-mined from the biofortified crops prepared for consumption by traditional cooking procedures. Equally important is gaining ac-ceptance by consumers skepti-cal of transgenically produced food crops and of more intensely colored traditional crops.

Biofortification, however, is not restricted to use of transgenic technology. There is potential through traditional crossbreeding of germ plasma from varieties with higher nutrient density and other desired agronomic quali-ties. Perhaps the most advanced example in carotenoid-containing food plants is orange-fleshed sweet potato (OFSP) varieties. Although white sweet potato is the common staple eaten in many African countries, yellow-orange varieties do exist in many countries. One particular orange variety (Resisto) has already been evaluated in a feeding trial among primary school children in South Africa and found to be accept-able and to improve vitamin A status (58).

Some question whether vitamin A status can be maintained in a population using OFSP-based strategies. Jan Low recently com-pleted a community intervention trial that found OFSP an accept-able substitute for white-fleshed sweet potato in Mozambique (59). An integrated agriculture-demand creation-market devel-opment approach was imple-mented to introduce OFSP into intervention areas compared with a control community not provided OFSP vines. The 24-month study provided high-dose vitamin A capsules to all children at base-

line and six months, a placebo in the intervention areas at 12 months, and a high-dose capsule after specimen collection at 24 months. Hence, for 12 months, no children in either the interven-tion or control areas received a vitamin A capsule. The difference was that only children in the in-tervention areas were exposed to OFSP and an intensive campaign to promote its consumption. At the end of the 12 month period, a significant difference was seen in the percentage of children with a serum retinol level less than 0.7 µmol/l in the intervention groups, both before and after accounting for infection. Thus, vitamin A deficiency was reduced up to 24% among healthy chil-dren and 16% among those with evidence of infection. There were several other positive spin-offs from this integrated intervention, such as a substantial increase in knowledge of men and women, an increase in income for small-scale producers and an increase in daily caloric intake of the chil-dren, as well as the intake of other micronutrients in the OFSP.

Biofortification of staple crops with micronutrients, including provitamin carotenoids, is still early in development. Yellow cas-sava, maize and banana/plantain are in the developmental stages. There is much research remaining to pair the best nutrient content with most desirable agronomic traits, bioavailability from prod-ucts as consumed, consumer acceptance and economic ad-vantages among other outstand-ing issues. Nonetheless, a com-parison of bio-fortification with fortification and supplementation clearly shows the complementary benefits of each intervention and the potential in the long run of meeting the needs of the poor economically and safely through food, reserving high-dose sup-plementation for medical emer-gencies.


Conclusions

Advances in understanding ba-sic chemistry and functions of retinoids and carotenoids have been remarkable over the past four decades. This has paralleled progress in programs to control vitamin A deficiency through medical (supplement distribution) and market-based (food fortifica-tion) approaches. Progress has also occurred in public health programs to control immuniliza-ble infectious diseases that drain body nutrient reserves, although there remain an estimated 1.1 billion people without safe water. Whereas little attention was given to food-based approaches until recently, the future is promising due to breakthroughs that have occurred and are on the horizon for increasing carotenoids and other micronutrient densities in staple crops eaten by the poor and in improving other agronomic characteristics that enhance yields through biofortification. For carotenoid chemists and program enthusiasts, the research op-portunities are multiple to dem-onstrate, for example, bioavail-ability, cooking and preservation stability, acceptability, economic gains and biological effectiveness of these crops in contributing to control of micronutrient deficien-cies, especially among the poor.

References1. Proceedings of Symposium on Vitamin A

and Metabolism, Bürgenstock, Switzer-land, May, 1960. Vitamins and Hormones 18: 289, 1960. (Cited by Roels OA. The fifth decade of vitamin A research. Am J Clin Nutr 22:903–7, 1969)

2. Wolf G (1978). A historical note on the mode of administration of vitamin A for the cure of night blindness. J Clin Nutr 31:290–2.

3. McCollum EV & Davis M (1913). The ne-cessity of certain lipids in the diet during growth. J Biol Chem 15:167–75.

4. Osborne TB & Mendel LB (1913). The rela-tion of growth to the chemical constituents of the diet. J Biol Chem 15:311–26.

5. Steenbock H (1919). White corn vs yellow corn and a probable relationship between the fat soluble vitamins and yellow plant pigments. Science 50: 352.

6. Karrer P, Morf R, & Schöp K (1931). Helv Chim Acta 14: 1431–6.

7. Wald G (1939). The porphyropsin visual system. J. General Physiology 22:775–794.

8. Wolf G (2001). The discovery of the visual function of vitamin A. J Nutr 131:1647–1650.

9. Dowling JE & Wald G (1960). The bio-logical function of vitamin A acid. Proc. National Acad. Sci 56:587–608.

10. Stephenson M, Clark AB (1920). XLII. A contribution to the study of keratomalacia among rats. Biochem J 14: 502–521.

11. Roels OA (1968). The fifth decade of vitamin A research. Am J Clin Nutr 22:903–907.

12. Bessey OA, Lowry OH, Brock MJ & Lopez JA (1946). The determination of vitamin A and carotene in small quantities of blood serum. J Biol Chem 1:177–187l.

13. Neeld JB & Pearson WN (1963). Macro- and micromethods for the determination of serum vitamin A using trifluoroacetic acid. J Nutr 70: 454–462.

14. Carr FH & Price EA (1926). Colour reac-tions attributed to vitamin A. Biochem J 20:497–501.

15. Sebrell W H, Jr (1959). Program of the Columbia University Institute of Nutri-tion Sciences. J Am Med Assoc 170: 1928–9.

16. Mason JB, Lotfi M, Dalmiya N, et al. (2001). The Micronutrient Report. Mi-cronutrient Initiative, Ottawa, Ontario, Canada.

17. WHO (1995). Global Prevalence of Vita-min A Deficiency. MDIS Working Paper #2, World Health Organization, Geneva, Switzerland.

18. Micronutrient Initiative/UNICEF (2005). Vitamin/Mineral Deficiency. A Global Progress Report.

19. West KP, Jr. Katz J, Khatry SK, LeClerq SC, Pradhan EK, Shrestha SR, Connor PB, Dali SM, Parul C, Pokhrel RP, Som-mer A on behalf of the NNIPS-2 Study Group (1999). Double blind, cluster rand-omized trial of low dose supplementation with vitamin A or β-carotene on mortality related to pregnancy in Nepal. Brit Med J 318:570–5.

20. Furr HC (2004). Analysis of retinoids and carotenoids: problems resolved and un-solved. J Nutr 134:281S–285S.

21. Congdon N, Sommer A, Severns M. et al. (1995). Pupillary and visual thresholds in young children as an indicator of popu-lation vitamin A status. Am J Clin Nutr 61:1076–82.

22. Craft NE (2001). Innovative approaches to vitamin A assessment. J Nutr 131:1626S–1630S.

23. Haskell MJ, Mazumder RN, Peerson JM, Jones AD, Wahed MA, Mahalanabis D & Brown KH (1999). Use of the deuterated-retinol-dilution technique to assess total-body vitamin A stores of adult volunteers consuming different amounts of vitamin A. Am J Clin Nutr 70:874–80.

24. Tang G, Qin J, Dolnikowski G, Russell R, & Grusak MA (2005). Spinach or carrots can supply significant amounts of vitamin A as assessed by feeding with intrinsically deuterated vegetables. Am J Clin Nutr 82:821–8.

25. Olson JA & Hayaishi O (1965). The enzymatic cleavage of β-carotene into vitamin A by soluble enzymes of rat liver and intestine. Proc Natl Acad Sci, US 54:1364.

26. Goodman DS & Huang HS (1965). Bio-synthesis of vitamin A with rat intestinal enzymes. Science 149: 879.

27. Goodman DS & Blaner WS (1984). Bio-synthesis, absorption and hepatic me-tabolism of retinol. In: The Retinoids, Vol 2. Eds: Sporn MB, Roberts AB & Good-man DS, pp. 2–39. New York: Academic Press, Inc.,

28. Goodman DS, (1984). Plasma retinol-binding protein. In: The Retinoids, Vol. 2. Eds: Sporn MB, Roberts AB & Goodman DS. pp. 42–88. New York: Academic Press, Inc.

29. Loerch J, Underwood B & Lewis K (1979). Response of plasma levels of vitamin A to a dose of vitamin A as an indicator of hepatic vitamin A reserves in rats. J Nutr 109:778–86.

30. Tanumihardjo SA, Furr HC, Erdman JW, Jr & Olson JA (1990) Use of the modified relative dose response (MRDR) assay in rats and its application to humans for the measurement of vitamin A status. Eur J Clin Nutr 44:219–24.

31. Oomen HAPC, McLaren DS, Escapini H (1964). Epidemiology and public health aspects of hypovitaminosis A. A global survey on xerophthalmia. Trop Geograph Med 16:271–315.

32. McCormick AM, Napoli JL & DeLuca HF (1978). High-pressure liquid chro-matographic resolution of vitamin A compounds. Anal Biochem 86:25–33.

33. Roberts AB, Nichols MD, Frolik CA, Newton DL & Sporn MB (1978). Assay of retinoids in biological samples by reverse-phase high-pressure liquid chromatogra-phy. Cancer Res 38:3327–32.

34. Report of a Joint WHO/USAID meeting (1976). Vitamin A deficiency and xeroph-thalmia. Tech Rept Ser 590. World Health Org., Geneva.

35. Underwood B (2004). Vitamin A defi-ciency disorders: International efforts to control a preventable “pox”. J Nutr 134: 231S–236S.

36. McLaren DS (1987). A decade of achieve-ment: The International Vitamin A Con-sultative Group (IVACG) 1975–1985. In-ternational Life Science Institute-Nutrition Foundation, Washington, D.C.

37. WHO/UNICEF/USAID/Helen Keller Inter-national/IVACG (1982). Control of vitamin A deficiency and xerophthalmia. Tech Rept Ser 672, World Health Organization, Geneva.

38. Chambon P (1996). A decade of mo-lecular biology of retinoic acid receptors. FASEB J 10:940–54.

39. Sommer A (1982). Nutritional Blindness. New York: Oxford University Press, Inc.

40. Sommer A, Tarwotjo L, Djunadi E, West KP, Loeden AA, Tilden R, Mele L & Aced study group (1986). Impact of vitamin A supplementation on childhood mortality. A randomized controlled community trial. Lancet 327:1169–73.

41. Sommer A & West KP, Jr (1996). Vitamin A Deficiency Health, Survival, and Vision. New York: Oxford University Press, Inc., pp 438.

42. West KP, Jr, Pokhrel RP, Katz J, LeClercq SC, Khatry SK, Shrestha SR, Pradhan EK, Tielsch JM, Pandey MR, Sommer A (1991). Efficacy of vitamin A in reducing preschool child mortality in Nepal. Lancet 338:67–71.

43. Ghana Vast Study Team (1993). Vitamin


A supplementation in northern Ghana: effects on clinic attendance, hospital admissions, and child mortality. Lancet 342:7–12.

44. Vijayaraghavan K., Radhaiah G, Prakasam BS, Sarma KVR, Reddy V (1990). Effect of massive dose vitamin A on morbidity and mortality in Indian children. Lancet 336:1342–45.

45. Herrera MG, Nestel P, El Amin A, Fawzi WW, Mohamed KA, Weld L (1992). Vita-min A supplementation and child survival. Lancet 340:267–71.

46. Muhilal, Permeisih D, Idjradinata YR, Muherdiyantiningsih, Karyadi D (1988). Vitamin A-fortified monosodium gluta-mate and health, growth, and survival of children: a controlled field trial. Am J Clin Nutr 48:1271–6.

47. Rahmathullah L, Underwood BA, Thu-lasiraj RD, Milton RC, Ramaswamy K, Rahmathullah R, Babu G (1990). Reduced mortality among children in southern India receiving a small weekly dose of vitamin A. New Engl J Med 325:929–35.

48. Beaton GH, Martorell R, Aronson KJ, Edmonston B, McCabe G, Ross AC & Harvey B (1993). Effectiveness of vitamin A supplementation on childhood morbid-

ity and mortality in developing countries. ACC/SCN State-of-the-art series, Nutri-tion Policy Discussion Paper No. 13. ACC/SCN, Geneva.

49. Fawzi WW, Chalmers TC, Herrera G & Mosheller F (1993). Vitamin A supplemen-tation and child mortality. A meta-analy-sis. J Am Med Assoc 269: 896–903.

50. Glasziou PP & Mackerras DWM (1993). Vitamin A supplementation in infectious diseases: a meta-analysis. Brit Med J 306:366–70.

51. Pineda O (1998). Fortification of sugar with vitamin A. UNU Food Nutr Bull 19:131–6.

52. Bloem MW, Huq N, Gorstein J et al. (1996). Production of fruits and vegeta-bles on the homestead is an important source of vitamin A among women in rural Bangladesh. Eur J Clin Nutr 50 (Suppl 3):S62–S67.

53. Underwood BA (2001). Vitamin A-related childhood blindness, mortality, and mor-bidity. Interventions for prevention. In: Primary and Secondary Preventive Nutri-tion. Eds: A. Bendich & RJ Deckelbaum, Totowa, NJ: Humana Press Inc.

54. Castenmiller JM, West CE (1998). Bio-availability and bioconversion of carote-

noids. Ann Rev Nutr 18:19–38.55. CGIAR Micronutrients Project. Update

No. 1, October, 1996 and Update No. 2, October 1997, IFPRI, Washington D.C.

56. Bouis HS (Guest Editor) (2000). Special issue on improving human nutrition through agriculture. Food & Nutr Bull 21:252–567.

57. Paine JA, Shipton CA, Chaggar S, How-ells RM, Kennedy MJ, Vernon G, Weight SY, Hinchliffe E, Adams JL, Silverstone AL, Drake R (2005). Improving the nu-tritional value of Golden Rice through increased pro-vitamin A content. Nature Biotechnology 23:482–487.

58. Van Jaarsveid PJ, Faber M, Tanumi-hardjo SA, et al. (2005). β-carotene-rich orange-fleshed sweet potato improves the vitamin A status of primary school children assessed with the modified-rela-tive-dose response test. Am J Clin Nutr 81:1080–7.

59. Low J, Arimond M, Osman N, Osei AK et al. (2005). Towards sustainable nutri-tion improvement in rural Mozambique: Addressing macro- and micro-nutrient malnutrition through new cultivars and new behaviors. Project Report, December 2005.

Carotene Research Interaction Group (CARIG) Annual Conference 2006, San FranciscoNoel W Solomons, Center for Studies of Sensory Impairment, Aging and Metabolism, Guatemala City, Guatemala

The 2006 Carotene Research Interaction Group (CARIG) An-nual Conference was convened on Saturday, 1 April at the Argent Hotel in San Francisco. It accom-panied the Experimental Biol-ogy 2006 meetings. This year’s conference was organized and chaired by Dr. Elizabeth Johnson of Tufts University in Boston, a member of the CARIG Steering Committee. The proceedings began with the fifth annual James Allen Olson Perspective in Caro-tenoids lecture at CARIG, deliv-ered by Dr. Barbara Underwood. She was a close associate of the late Prof. Olson, including jointly working in Brazil and serving as colleagues on the International Vitamin A Consultative Group (IVACG). She spoke on the topic: Reflections: Four Decades with Vitamin A and Carotenoids. (the full text of the James Allen Olson

memorial lecture appears on page 10 of this issue). The sig-nificance of the talk was, in many ways, to show just how recent in emergence are the facts and principles that we hold in com-mon about assessing vitamin A status and on the necessity to develop public health intervention strategies against hypovitamino-sis A. Dr. Underwood, as well as Prof. Olson, a founding member of CARIG and the force behind VARIG (the Vitamin A Research Interaction Group), were part of vitamin A discovery and con-sensus development. This was inspired by a crucial meeting held in Basel, Switzerland in 1960, as-sessing the existing knowledge on vitamin A and pointing the way to the important next steps in the programmatic conquest of hy-povitaminosis A. Dr. Underwood recounted three decades of con-

tributions from IVACG, founded in 1975, with about 35 experts in the vitamin A field in attendance. The lecture highlighted the steady and solid accumulation of accurate biological and epidemiological knowledge about vitamin A de-ficiency. This would lead to the mobilization of a worldwide pub-lic health effort based primarily on high-dose supplement capsules or fortification of staple foods such as sugar or cooking oil.

Of special interest for a caro-tenoid biology audience was Barbara Underwood’s particular point of view regarding public health interventions. She ac-cused the sometimes rancor-ous discussions in the 1990s concerning the true efficiency of bioconverting provitamin A to yield active vitamin A of retarding the progress toward developing


sustainable food-based alterna-tives to alleviate hypovitaminosis A. With that issue now resolved by a new consensus within the Dietary Reference Intakes of 2001, she pointed to gathering momentum in the area of bio-fortification, citing the founding of the Harvest Plus Project. The emphasis of biofortification is on staple crops of abundant and regular consumption by develop-ing-country populations. Cross-breeding for hybrid varieties of sweet potato (orange-fleshed varieties) and genetic modifica-tion in the second (high-carotene) generation of Golden Rice were examples in which daily individual vitamin A needs could be met from the abundant supplies of β-carotene in these biofortified tubers and grains.

An important and newsworthy note at the end of Dr. Underwood’s presentation was her announce-ment of the transformation of the IVACG. What began with its first meeting in 1975 ended with its 22nd meeting in Lima, Peru in 2004. A successor, the Micro-nutrient Forum, will be launched in Istanbul, Turkey, 16–18 April 2007, with a broader and inte-grated mandate involving vitamin A, iron, zinc, iodine and folic acid in a public health context.

Those of us who care about human vitamin A nutriture can derive lessons and standards in the message of Dr. Underwood’s

Reflections. Lessons relate to how to set an agenda for inquiry to rapidly advance basic and ap-plied knowledge, and standards to gauge the expectations for progress in redressing vitamin A deficiency problems. Should the interests of vitamin A get “lost in the shuffle” of multiple micro-nutrients and diluted scientific expertise and attention in the Forum, these Reflections may become the cudgel to demand the attention for vitamin A issues that were clearly championed by Underwood and Olson during the past four decades.

The second plenary lecture on the program was delivered by Dr. Earl Harrison, senior scientist at the USDA Human Nutrition Center at Beltsville, Maryland. He spoke on the topic of Mechanisms Involved in the Intestinal Absorption of Dietary Carotenoids. This was a fitting and complementary com-panion theme to Dr. Underwood’s presentation with her emphasis on provitamin A carotenes from foods to supply vitamin A to de-prived populations. To orient the audience, Dr. Harrison reviewed the conventional schematic as-pects of dietary carotene uptake from the intestinal lumen into intestinal cells (enterocytes) and the options for its further passage either as the intact carotenoid or as a derivative retinoid. Dr. Harrison and his co-worker have advanced evidence that both simple diffusion and a receptor-mediated transport (carotene transporters) are involved in the usual absorptive physiology of carotenoids.

The laboratory at Beltsville has used a novel, in-vitro cell culture model, that of the Caco cell mon-olayer in a directional absorption chamber, to explore the mecha-nisms of absorption of dietary carotenoids. The absorption chamber experiments revealed an 11% fractional absorption for β-carotene, which is not so far

from the rate documented for the intact human intestine. Kinetic experiments showing saturation kinetics under certain conditions, however, are a strong argument that a “facilitated transport” is operating, and this is in line with a receptor involvement. A clever set of experiments in Caco cell cultures, stellate (Ito) cell (hepatic fat storage cells) cultures, and cell-free microsomes (membrane envelopes) add credence to a transporter basis by showing stereo-specificity in uptake. In all three systems, different isomers of β-carotene were taken up to different extents. In descending order of uptake, affinity in the sys-tems was revealed to be: all-trans β-carotene; 9-cis-β-carotene; and 13-cis-β-carotene.

Bolstered by the coming together of cell-system evidence support-ing a transported mechanism, Dr. Harrison’s research group has turned to identifying enzymes known to be located in the apical membrane of intact enterocytes, as candidates for involvement in the transporter mechanism. Their search has centered on so-called class-B scavenger receptors, extensively studied for their in-volvement in cholesterol uptake. This has led pharmacologists to develop inhibitory agents for receptor uptake. This laboratory has also used mouse models with deletion of genes of specific

A slide from Barbara Underwood advocating a holistic approach.

Earl Harrison


enzymes (the so-called “knock out” mouse) to draw inferences about pathways in carotene metabolism. Geneticist created knock-out animals, deprived of or suppressed regarding one or another receptor. These proved to be strong investigative tools to use in pursuing the role of transporters in carotene uptake. In concluding his talk, Dr Harrison summarized a series of Beltsville laboratory experiments using receptor inhibitors, knock-out mice and their combination, to illustrate a partial dependency of carotene uptake on this class of membrane-associated enzyme as the basis for facilitated cel-lular uptake of carotenoids in the intestine.

Dr Kathleen C Ellwood, of the Center for Food Safety and Ap-plied Nutrition (CFSAN) of the Food and Drug Administration (FDA) of the United States pre-sented the topical theme Review-ing the Scientific Evidence for Health Claims. Dr. Ellwood is as-signed to the Division of Nutrition Programs and Labeling, Office of Nutritional Products Labeling and Dietary Supplements of the CFSAN. She provided a lucid exposition of the United States government’s oversight and regu-lation in the food-labeling area, and participated in a lively and interactive question and answer period thereafter. Need for labe-ling rules came about with the expansion of knowledge about bioactive substances in foods (of which the various carotenoids are examples). There came an effort by manufacturers of foods and supplements in the United States to transform findings into claims of beneficial effects. This led producers and marketers to seek to make claims about the benefits of consumption of the substances, the food containing the substances or both. To the extent that foods and substances are offered as remedies and therapies, a specific regulatory

handling comes into play. Dr. Ellwood correctly presented this as a case example of the merger of science with policy.

Claim statements for a product are a form of “speech”; within the United States of America, freedom of speech is protected by the First Amendment to the Constitution. Provisions for mak-ing claims for health regarding a retail product are now covered by legislation (statutes) and the ju-dicial precedents (case law). The FDA considered disease therapy claims for foods in the 1970s and 1980s, and concluded that food must be treated by the same standards as any drug.

Since that era, however, emerging scientific discovery has shown a series of more subtle diet-health relationships including protection and preservation of wellbeing and function. U.S. consumers were interested in seeking the potential benefits from dietary factors, and there was market-ing pressure to deliver what the consumer demanded. This led to the passage in 1990 of the Nutri-tion Labeling and Educational Act, which governs the nature of claims that could be attached to edible products. It was not about treating established disease, i.e. the drug action, but rather about “Health Claims”. The act regu-lated claims of causal relation-

ships between a food substance and a disease or health-related condition in the general US population or sub-population, in which consumption could reduce their risk. For the Health Claim to be approved the standard was “significant scientific agreement”, that is a strong consensus of a causal relationship.

The speaker recounted how manufacturers felt constrained by having to get over such a high bar; they brought suits in court claiming that the Act infringed upon the First Amendment guar-antee of freedom of speech. This has led, since 1999, to a second-ary level of regulation for labeling, the so-called Qualified Health Claim (QHC). These claims in-clude qualifying language in order to prevent the consumer from be-ing misled. QHCs are applied for relationships such as that relating lycopene or lycopene-containing foods to reduced risk of prostate cancer and similar assertions.

The process of evaluation by the FDA for a QHC has a defined set of steps. The first is literature review and selection. Animal studies are not relevant. Insofar as observational studies can indicate association, but not cau-sality, the most relevant literature is considered to be that from in-tervention trials. The interventions can have outcomes of reduced incidence of disease/condition or favorable modification of a validated modifiable risk factor related to ill health.

Kathleen C Ellwood

San Francisco’s famous cable cars.


Once the trial studies are assem-bled and sorted, those that meet inclusion criteria are rated for quality in terms of design, inclu-sion/exclusion criteria, balance of population characteristics across groups, verification of compliance with the intervention and appropriateness of statistical analysis. This is done for each study. The CARIG audience was particularly intrigued to learn that any study without a “validated” dietary intake method would be excluded from consideration. For those who know the limitations of dietary method validation/cali-bration, this seems fraught with arbitrary possibilities.

The pre-final step is to rate the overall strength of the body of evidence in terms of type, quality, quantity and studies’ sample size, consistency and replication of findings, and the relevance to the US general population or target subgroups. Finally, the claim can have three degrees of ranking: 1. conclusive; 2. limited; or 3. very limited.

The modifications in the FDA procedures derive from the ten-sion among consumers’ desire to preserve health, producers’ and retailers’ desire to exercise free speech, and the government’s duty to protect the citizenry from consumer fraud. Dr. Ellwood’s message had shown that the role of the scientific community lies in how well they design and execute studies on causal relationships between a dietary substance and a beneficial outcome.

Prof. John Erdman of the Univer-sity of Illinois also spoke in the second session of the program with a talk entitled: Tomato, Lyco-pene and the Risk of Prostate Cancer. He was also awarded this year’s Wilbur O. Atwater Memorial Lecture, sponsored by the United States Department of Agriculture on 4 April, which had the theme of carotenes at its center. His award’s lecture topic was Colors, Critters, and Cancer. As he explained, the colors refer to carotenoid pigments; the crit-ters refer to the selection (limits and possibilities) with different animal models for investigation of carotenoid metabolism and effects; and cancer is specifically prostate cancer. The context is the epidemiological evidence that suggests that tomato consump-tion is protective against prostate cancer.

The world of colorful carotenoids contains over 650 compounds. Phytoene and phytofluene are simple colorless precursor caro-tenoids. All known members of this family of compounds are ini-tially synthesized in plant tissues; animals cannot form carotenoids. Prof. Erdman reminded his audi-ences that the ripeness of fruits

and vegetables is reflected in their carotenoid content. Caro-tenes contribute to the hues of birds’ feathers and insects’ coloring. Moreover, carotenes are important to aroma compounds in nature that have importance for interspecies signaling.

Not all animals handle caro-tenoids in a uniform fashion. It has been found for instance that, for studies of carotenoid metabolism related to human physiology, gerbils, ferrets and pre-ruminant calves provide the best in likeness to human absorp-tive systems. They are capable of absorbing the compounds both intact and metabolized. As herbivores, rats and mice are ef-ficient converters of provitamin A carotenoids. They are poor at absorbing intact carotenoids; thus, high feed levels are needed for these rodents to replicate the tissue concentrations achieved in humans. In Prof. Erdman’s view, the armamentarium of animal models for cancer studies with carotenoids includes rats, mice, and again ferrets.

The prostate gland and caro-tenoid-containing foods came together in the observations of vastly different spontaneous inci-dence rates for prostatic cancer with 70 times greater incidence rates in North American blacks and 50-fold increased rates

John Erdman

Prof. Erdman’s collaborators.


in North American whites, as compared to peers in Shanghai, China. The Physicians’ Health Study implicated higher intakes of tomato sauce, tomatoes, pizza and strawberries, all sources of lycopene (a non-provitamin A carotenoid), with reduced pros-tate cancer occurrence. Prof. Erdman summarized the science findings of his group in pursuing the bases of these epidemiologi-cal observations. Using a pros-tatic cancer murine tumor model, the combination of broccoli and tomato proved to be superior to tomato alone, and both were superior to isolated lycopene in terms of anti-cancer activity in the mouse tumors. The conclusion is that lycopene is not the only preventive substance in broccoli or tomatoes.

The other basic pursuit involved the potential bioactivity of meta-bolic derivatives of lycopene. Analogous to the format by which retinoids and apo-carotenals of different carbon lengths are produced by central or eccentric cleavage of provitamin A caro-tenes, the search has been joined for generation of apo-lycopenals. The carotene monoxygenase I (CMO I), responsible for central cleavage of β-carotene (formerly known as 15,15’ monoxygenase) is inactive in cleaving lycopene. However, the carotene monoxyge-nase II (CMO II), which produces eccentric cleavage of β-carotene, can also generate apo-lycopenals in in-vitro systems. These prod-ucts have recently been detected with sensitive assay techniques in human plasma and breast milk in concentrations over 100 times lower than that of lycopene itself. Studies documenting the bioactiv-ity of lycopene split-products have yet to appear, but the fundamen-tals of carotene biology for retin-oids are a template for inquiry into potential anti-cancer mechanisms for lycopene.

The final wisdom from Prof. Erdman is not to ignore other compounds, even phytoene and phytofluene precursors. In the ripe tomato, the sum of these two compounds is equivalent by weight to that of lycopene, and these non-aromatic forms are 10 times more abundant than alpha- and beta-carotenes combined.

Other awards were involved in the CARIG meeting arena in San Francisco. These included travel-awards based on the scientific merit of the abstracts submitted by graduate students for pres-entation in Experimental Biology on carotenoids. The winner was Francesca Alvarez-Calderon, from Florida International Univer-sity, for her free-paper entitled: A computational study of end-group conformational barriers in carote-noids. In addition, a new element was brought in for the benefit of encouraging and recognizing the talent of young trainees this year. This was a poster competition as part of the VARIG/CARIG social, held following the Conference. A total of 12 contestants exhibited their free-paper posters, brought for display in the mini-symposia of the EB 2006. Heather Mernitz, from the USDA Human Nutrition Research Center at Tufts Univer-sity was judged as best in the competition with her poster on Inhibition of lung carcinogenesis by 9-cis retinoic acid and 1,25 dihydroxyvitamin D3 in the A/J mouse model. Finally, the Steer-ing Committee of CARIG made a “surprise award”, in the form of a recognition-of-merit plaque, to Maria Stacewicz-Sapuntzakis, the tireless and undaunted editor of the CARIG Newsletter, who has undertaken its semi-annual publication since the founding of the Group.

Heather Mernitz in front of her awarded poster.

Maria Stacewicz-Sapuntzakis receives award from Wendy White.

At the VARIG/CARIG social event.


13th European Meeting on Fat-Soluble Vitamins 2006 in Jena Volker Böhm, PD, Institut für Ernährungswissenschaften, Friedrich-Schiller-Universität Jena, Germany

This year, for the first time, this European Conference took place in Germany. Fat-soluble vitamins (FSV) offer a wide field of research and have brought together Euro-pean scientists and students eve-ry three to four years since 1960, first in the UK and then touring Europe. After Arcachon (1996) and Toulouse (2000) in France and Rieti (2003) in Italy, this year Jena in Germany provided an op-portunity to listen and to lecture, to discuss and to develop state-of-the-art and new approaches, illuminating the role of these compounds for human health and more. A very efficient interchange of knowledge took place due to the traditionally small number of around 50 participants. Students, in particular, took this opportunity to present their work on a Euro-pean level and to talk to experts in the field.

The 13th FSV meeting was hosted by the Institute of Nutrition at the renowned Friedrich Schiller University in Jena. It took place in the Old Castle in Dornburg (10 km from Jena), that has just

been completely refurbished to meet the demands of a modern meeting place while keeping its beautiful historical ambience. Accommodation was in Jena, a city of 100,000 inhabitants and also famous for its optical trade (Zeiss, Jenoptik).

The conference started with a plenary lecture by the interna-tionally known carotenoid expert Steven J Schwartz from the Ohio State University in Columbus, Ohio, USA. He presented some of the results of his group on bio-availability of different caroten-oids, talking also on bioactivity of these secondary plant products being able to reduce the risks for some degenerative diseases. The first session followed, re-porting results with carotenoids. Catherine Caris-Veyrat from INRA Avignon, France, mainly focused on oxidation products of carote-noids, discussing some possible effects of these metabolites. Yoav Sharoni from Beer-Sheva, Israel, presented new results on mecha-nisms for cancer prevention by carotenoids, while Gordon Lowe

from Liverpool, UK, explained investigations on interactions between cigarette smoke and β-carotene.

The second session focussed on vitamin E. David Muller, London, UK, presented analytical details on separation and quantification of conjugated vitamin E metabo-lites in sepsis. Andreas Wagner from Jena, Germany, showed how intervention with α-toco-pherol and folic acid affected 8-oxodG, a biomarker of oxidative stress in leukocytes and urine in humans. Stefano Manfredini, Ferrara, Italy, finished the ses-sion, comparing the antioxidant activity of novel vitamin E based antioxidants within several assay systems. Afterwards most del-egates enjoyed typical Thuringian sausages, beer and jazz music.

The second day started with results on the structure-activity relationship of carotenoid deriva-tives in activation of the antioxi-dant response element transcrip-tion system, presented by Joseph Levy, Beer-Sheva, Israel. Paola


Palozza, Rome, Italy, discussed experiments with β-carotene in vascular cells exposed to oxysterols. Investigations on carotenoid metabolism in animals were presented by Johannes von Lintig, Freiburg, Germany. A round-table discussion on perspectives for fat-soluble vita-mins led to an intense exchange between the experts, showing a lot of interesting tasks to be in-vestigated in the next years. The discussion closed with the deci-sion to continue the meetings in the future. Two colleagues offered to invite the scientists in 2009 to Potsdam, Germany, and in 2012 to Greece.

After lunch, Diana Bellovino, Rome, Italy, presented investiga-tions on the effect of the matrix on the bioavailability of carote-noids. Anna Iannone, Modena, Italy, discussed new results from electron spin resonance experi-ments investigating the antioxi-dant potential of α-tocopherol and lycopene. After an official reception by the Mayor of Jena all delegates used the time to have a look at the posters. Some del-egates spent the afternoon break walking through the gardens of the castle grounds; others en-joyed discussing and relaxing in small groups. A dinner and music event was the highlight of the second evening. European food prepared by local cooks was combined with local wines of the most Northern vineyard in Germany and European music played by mandolins and guitars of the group “Lautengilde Jena”, conducted by the organizer of the meeting – the large hall of the castle provided a good ambience for the event.

The last half-day of the confer-ence started with an update on isomerization of lycopene pre-sented by Volker Böhm, Jena, Germany. Emmanuelle Reboul, Marseille, France, explained which transporters are involved

in the uptake of lycopene and β-carotene. Wilhelm Stahl, Düs-seldorf, Germany, finished the carotenoid session with experi-ments showing photoprotective effects of carotenoids. In the last session of the meeting Hülya Sagmanligil Özdemir, Van, Turkey, presented results on fat-solu-ble antioxidant vitamin levels in newborn babies and their relation to the maternal vitamin status. Patrick Borel, Marseille, France, talked about different lipases be-ing responsible for hydrolysis of retinyl palmitate.

Three awards for the best post-ers, elected by all delegates, some concluding remarks and a farewell finished two very efficient days within the old walls of Dorn-burg Castle. All delegates left the conference venue more relaxed than when they arrived, which could well be an additional effect of the charming atmosphere and the small number of delegates. All were invited to come to the 14th European Meeting on Fat-Soluble Vitamins that will take place in 2009 in Potsdam, Germany, or-ganized by Florian J. Schweigert and his team.


Protecting nutritional status and the role of micro-nutrient premix in the United Nations World Food Programme’s response to the Indian Ocean TsunamiWorld Food Programme, Regional Bureau for Asia, Wave Place Building, 7th Floor, 55 Wireless Road, Pathumwan, Bangkok 10330, Thailand

Immediate relief

The Indian Ocean Tsunami of 26 December 2004 presented the humanitarian community with one of the largest challenges it had ever faced. The United Na-tions World Food Programme re-sponded with an immediate and massive relief effort that eventu-ally became one of the most com-plex operations the organization had ever undertaken, spanning six countries, two continents, and millions of beneficiaries.

While the primary focus of the im-mediate response was providing life-sustaining food aid to those whose houses, fields, crops and livelihoods had been washed away, WFP also sought to shore up the nutritional status of groups made vulnerable by the tsunami – in particular children, new moth-ers and the elderly.

In such situations, ready-to-eat or easy-to-prepare fortified foods play a key role. Within days of

the tsunami, WFP found itself required to deliver large quantities of such foods to the crisis zone in record time. In Aceh and Nias, WFP had not been providing for-tified foods prior to the tsunami, so it turned to countries in the re-gion, such as Bangladesh, where WFP was producing such foods in large quantities .

DSM, which is one of WFP’s primary private-sector partners in nutrition, responded quickly through SIGHT AND LIFE to WFP’s requests for assistance by donating micronutrient premix – enough to fortify over 5,000 metric tons of high-energy bis-cuits. Such biscuits are used primarily in WFP’s school feed-ing programs, as a mid-morning snack designed to help prevent micronutrient deficiencies among school children. They are also extremely useful in emergencies, as they are lightweight and easy to transport, yet provide high nu-tritional and caloric value.

SIGHT AND LIFE’s donation was delivered to factories in Bang-ladesh that produce fortified biscuits for WFP. The donation allowed WFP to release large quantities of fortified biscuits in Bangladesh and send them to countries across the crisis zone. Planes filled with biscuits started leaving Dhaka on 13 January.

By the end of January, 700 metric tons of biscuits had been shipped to Aceh, Indonesia, by both air and sea. This was a major dona-tion, representing 15% of the total amount of biscuits used in the entire tsunami operation in 2005. The biscuits sent to Indo-nesia were enough to provide nutritional supplementation to over 300,000 children aged 3 to 12 years for three months.

Mid- and long-term relief

By May 2005, WFP was providing daily food rations to 2.25 million people across the tsunami zone – in Aceh and Nias in Indonesia,

School feeding in Banda Aceh. WFP/ Barry Came. Girls with high-energy biscuits, Aceh, Indonesia. WFP/ A K Kimoto.


Sri Lanka, the Maldives, Thailand, Myanmar and Somalia. As the acute crisis passed, the focus of operations shifted from averting wide-scale hunger to protect-ing groups left vulnerable by the disaster. These groups included displaced people, farmers whose land had been inundated, and fishing families who had lost their boats or other means of fishing.

In many cases, these communi-ties had had relatively stable food security prior to the tsunami. In other cases, the waves had made difficult conditions much worse. Across the board, however, the emphasis was not so much on raising pre-existing nutritional levels as making sure that nu-tritional levels did not decline as a result of the tsunami and its after-effects.

As a recent joint statement by WFP, UNICEF and the WHO on “Preventing and Control-ling Micronutrient Deficiencies in Populations Affected by an Emergency” puts it: “The aim is to avert micronutrient deficien-cies or prevent them from get-ting worse among the affected population. Such foods must be appropriately fortified, taking into account the fact that other unfor-tified foods will meet a share of micronutrient needs.”

Adults who were displaced or part of otherwise vulnerable groups received daily rations for their entire families (generally rice, canned fish, fortified noodles and oil in Indonesia; rice, pulses, sugar and oil in Sri Lanka). Chil-dren in school received either the fortified biscuits (Indonesia and Maldives) or a mid-day meal (Sri Lanka). New mothers and young children received fortified food and nutrition education through Mother and Child Nutrition (MCN) programs.

By December 2005, school feed-ing programs covered 330,000 children in Indonesia and 102,000 in Sri Lanka. Over 143,000 moth-ers and young children were enrolled in MCN programmes in Sri Lanka, along with 33,000 in Indonesia, with plans to expand the programs in both countries. At the same time, the number of beneficiaries receiving general food rations was decreasing, as homes were built and people re-turned to their old livelihoods.

Fortified foods such as high-energy biscuits played a critical role in the early days of the re-sponse, and in the future-oriented programs such as school feeding which aimed to shore up the nu-tritional status of communities. However, fortified biscuits were not used as emergency rations in the early stages to the degree originally planned. The relatively rapid re-opening of land routes – in Aceh in particular – meant that communities could receive standard rations by truck trans-port, rather than having to rely on flown-in fortified foods. In the end, WFP used approximately half of the amount of fortified bis-cuits that it had originally planned for the entire tsunami operation.

Following the initial shipments of 700 metric tons of fortified biscuits to Indonesia, as well as

Boys at school in Banda Aceh. WFP/ Barry Came.

other shipments to the Maldives and Sri Lanka, WFP was able to source the remaining biscuits that it needed locally. As a result, the remainder of the SIGHT AND LIFE donation was used to produce biscuits in Bangladesh for use in WFP school feeding programs in that country.

The rapid response of SIGHT AND LIFE and other WFP part-ners to the tsunami was critical, allowing WFP to provide large quantities of fortified foods to the affected areas. Without it, certain communities might have faced a drop in children’s nutritional levels, along with all the other challenges brought in the wake of the waves.

Additionally, the donation pro-vided much-needed support for school feeding in Bangladesh. WFP plans to provide fortified meals or supplementary snacks to 300,000 children in Bangla-desh in 2006. While these pro-grams may not be as dramatic as the tsunami response, in terms of the impact on children’s lives they can be more widespread and longer-lasting. Long after the reconstruction of the tsunami-hit areas is over, the world will still face the ongoing “silent emergen-cies” of malnourished children, and children who are denied an education due to poverty.


Distributing micronutrients and deworming medicine in hurricane-ravaged HondurasHoward B Schiffer, Executive Director, Vitamin Angels Alliance, Santa Barbara, CA, USA

Background

Hurricane Mitch struck north-western Honduras with devastat-ing effects in 1998, setting back the remarkable progress that the country had been making in ad-dressing their problems of health care, education and poverty. Honduras now faces daunting issues as it attempts to address serious health conditions such as malnutrition, child mortality, den-gue fever, respiratory infections, HIV/AIDS and rapid population growth. Malnutrition, coupled with infestations of parasites, is a serious problem for children. Unfortunately, micronutrient de-ficiencies are found at high levels in the north and west rural regions of Honduras and were made worse by the hurricane and its aftermath.

While it is widely understood that vitamin A and other micro-nutrient deficiencies are a major cause of disease and blindness among children, parasites are also a leading cause of diseases among children and adults in the world today. Worms consume macro- and micronutrients in the

gut before children can absorb them, and hence impair children’s growth and developement. This can lead to physical stunting, learning problems, illness and death. Deworming these children is essential for their health and well-being and is an essential component of a micronutrient campaign.

As was reported in SIGHT AND LIFE Newsletter 2/2005 (pp. 20–21), Vitamin Angel Alliance (VAA) and Cristo Salva are running a project to provide basic medical services and combat malnutrition in Honduras. Now, with the sup-port of SIGHT AND LIFE, these efforts are continuing in the form of the Honduras Micronutrient Project. This campaign, which is commencing this year, will al-leviate micronutrient deficiency and VAD (vitamin A deficiency), and reduce the parasitic worm load for 30,000 children from two to ten years old in northwestern Honduras. We are working with local school districts to distrib-ute chewable multivitamin and micronutrient supplements and educate parents to have their children take one daily, and we

are distributing mebendazole (500 mg) once every 6 months to eliminate parasitic worms.

The project sites

The project sites are rural villages in northwestern Honduras near the Guatemalan border. These are the little villages around the central village of Macuelizo. Hacienda Cristo Salva is located in one of the small neighboring villages – Las Varas – and the Clinica de Cristo Salva is located in the center of Macuelizo with central access to all the villages. Specifically, Cristo Salva dis-tributes the micronutrients and mebendazole in the towns and villages in and surrounding the Valley of Macuelizo.

The villages have no medical care whatsoever. The poverty in the region is endemic and extreme. Many of these children literally eat a root on their way to school in the morning for their breakfast. Professor Oscar Mendoza, the former District Officer and cur-rent head teacher in a local mid-dle school, agreed to work with Cristo Salva to help mitigate in part the sickness and hunger of the children. In addition, Cristo Salva has a network of people on the school boards, village officials and even translators who have offered to assist us.

The campaign

Cristo Salva distributes the prod-ucts to the schools, with school officials helping to oversee the process. Cristo Salva plans a teachers’ meeting in each com-munity to educate teachers and health workers on how to distrib-


ute the parasitic medicines (along with an education program on basic hygiene and sanitation) and how to educate the parents about the daily supplements for their children. The periodic, organ-ized distribution of mebendazole supplements has worked suc-cessfully in our past experience and we are confident about the progress of this project. Dur-ing the first year it is planned to reach 30,000 children and in the second and third year others not yet reached will be included.

A grant to run the project and the micronutrients are being donated by SIGHT AND LIFE. The tableting is being contributed by Anabolic Labs with excipient contributions from Domino Foods and Mutual Foods. The mebendazole is being purchased from (and partially do-nated by) MedPharm. PAHO (Pan American Health Organization) is supplying the Kato Katz test kits for the baseline study. Support on the baseline study is being provided by George Washington University and the Ministry of Health (MOH) in Honduras. The distribution of the products follows strict guidelines. The in-country partners of the me-bendazole part of the campaign receive WHO survey materials and guidelines for administering safe and appropriate doses of mebendazole to children. Only trained healthcare workers or volunteers administer the doses and maintain accurate record

sheets about children receiving supplements and mebendazole. They ascertain the child’s age – through discussion with care-giver, or by observing the am-bulatory ability of the child. The caregivers are instructed to give the children one micronutrient vitamin/mineral chewable tablet each day. Based on the records of individual children an evaluation and follow up of the campaign is possible.

Partners

Vitamin Angel Alliance is the lead agency for the program. Our mission is to provide basic nutrition to people in need. Our vision is far reaching. We believe that every person has a right to basic nutrition; that malnutrition linked diseases are preventable and that education in addition to supplementation is essential for long-term health. A more detailed scope of the mission of VAA was given in SIGHT AND LIFE News-letter 2/2005 (pp. 20–21).

Cristo Salva is implementing the program in Honduras. It is a non-profit NGO consisting of lay people, doctors, nurses, teachers, and missionaries. For 15 years it has been serving the people of Honduras, focused primarily in the State of Santa Barbara. The vision of Cristo Salva is to provide basic needs in the form of vitamins, clean water, hygienic education, agricultural education, nutritional education

and support, medical and dental clinics, pre-natal education, eye glasses, clothing, and shoes.

Goals, outcomes and reportsThe records kept, using WHO survey materials, will give infor-mation on:• Number of community meet-

ings held• Number of micronutrient sup-

plements distributed• Number of worm tablets dis-

tributed• Number and ages of children

reached

It is expected that the benefits gained will be reduced blindness, morbidity, mortality and clinic visits as well as improved general health. Some of the benefits may be difficult to quantify. However, there is no doubt that these re-ductions in health problems will enable health workers and facilities to redirect a substantial portion of their resources to other public health and socio-economic concerns.

The Honduran Micronutrient Campaign will be monitored and evaluated by VAA with full partici-pation by Cristo Salva and other in-country partner organizations. The primary emphasis will be on the coverage of the program, with results largely based on the sup-plements and medication reach-ing the intended beneficiaries.


Eye care mission to the Dominican Republic, March 2006Sade Kosoko-Lasaki, MD, MSPH, MBA, Creighton University, Omaha, NE, USA

Introduction

During our previous trip to the Dominican Republic (DR), we demonstrated that VAD is a pub-lic health problem in this country. This was reported in SIGHT AND LIFE Newsletter 2/2005 (pp. 35–36) with more details given in the 3/2005 issue (pp. 21–23).

In March 2006, Creighton Univer-sity realized a similar mission with the same partners. In addition to the screening of children and the administration of vitamin A cap-sules, adults were examined for glaucoma. Glaucoma is also the commonest cause of blindness in African-American and Hispanic populations.

The primary health care workers (Cooperadores) received a half-day review and training session on the clinical signs and symp-toms of vitamin A deficiency, its effects on childhood morbidity and mortality and preventative strategies. Dr. Kosoko-Lasa-ki emphasized the benefits of breast-feeding and encouraged the consumption of foods rich in vitamin A, such as green leafy vegetables, carrots, mangoes, papaya, etc. The Cooperadores also received lectures on the

importance of adults having their eyes screened for glaucoma. All the Cooperadores received eye exams and screening. Two new cases of glaucoma were identi-fied amongst the group.

Other trip activities included screening children for the eye signs of vitamin A deficiency, distributing vitamin A capsules, and providing screening and ocular examination and treat-ment for adults, specifically for glaucoma. In addition, a lecture to the Ophthalmology Society on the importance of screening for glaucoma was delivered by Dr. Kosoko-Lasaki.

Results

Approximately 200 children, ages 3 months to 10 years, were screened and received vitamin A. A total of 178 adults received visu-al acuity, visual field (using the FDT Visual Field Analyzer), slit lamp, tonometry and fundus exams. Ninety-four patients had complete ophthalmologic exams. Thirty new cases and 44 existing cases of glaucoma were diagnosed, and six glaucoma surgeries were per-formed. Follow-up referrals were sent to Dr. Sebastian Guzman and to the ILAC clinic in Santiago.


proach reaches the poor and marginalized residents in the remote, underserved areas of the Dominican Republic.

Acknowledgement

Much-appreciated support was provided by:SIGHT AND LIFE, New World Medical, Inc. (Rancho Cuca-monga, California), Creighton

Conclusion

The children, adults, and health care personnel in the DR ben-efited from the efforts of the Eye Care team and its collaborative approach with the local Santiago ophthalmologist and ILAC family practice physicians. The ILAC Cooperadores (health care work-ers) use the “teach-the-teacher” strategy. This grass-roots ap-

The following article is based on a complete report sent to SIGHT AND LIFE. Earlier Newletters (1/1999, pp. 15–17; 1/2002 pp.12–14) reported previous findings and survey results, as well as detailed recommendations: therefore only the most recent comments are given here (editor).

Update on the status of vitamin A deficiency and xerophthalmia in children under five treated at hospitals in Vietnam over a 27-year period (1979 – 2005) Nguyen Chi Dzung MD, PhD, Hanoi National Institute of Ophthalmology, Tran Minh Tan MD, Hanoi National Children’s Hospital, Vietnam

In 2005 cases with eye signs of vitamin A deficiency (125 cases with XN) were still seen in many hospitals in Vietnam, especially in remote and mountainous areas. Similar findings were published in previous issues (see SIGHT AND LIFE Newsletter 1/2002 pp. 12–14). Due to the sporadic cas-es of VAD still found, not only in the community but also in some hospitals, and the persistent risk of blindness for children in some remote and mountainous areas,

the VAD prevention and control program needs to be continued, with the focus on mountainous, remote and economically impov-erished areas in order to totally eliminate xerophthalmia by the year 2010.

Therefore we hope to continue to receive support from SIGHT AND LIFE in the form of vitamin A capsules in order to achieve this goal of eliminating xerophthalmia and VAD in Vietnam.

We always highly appreciate in-ternational assistance, which is very valuable. On this occasion, we would like to express the sincere thanks of our people and colleagues to all UN agencies, in-ternational NGO’s such as CBM, FHF, HKI, Orbis, SF, SIGHT AND LIFE , and our good friends, who have given Vietnam such valuable and effective assistance in our Blindness Prevention Program for so many years.

University Institute for Latin American Connection (ILAC) Of-fice, (Omaha, Nebraska, USA), Creighton University Office of Health Sciences–Multicultural and Community Affairs (HS-MACA) (Omaha, Nebraska, USA). Dr. Sebastian Guzman and staff (Santiago, Dominican Republic), ILAC Mission staff (Santiago, Dominican Republic).

Left: The MOH Deputy Minister gives high-dose vitamin A capsules to children. On the right is Dr. Jama Gulaid, Head of Health and Nutrition, UNICEF, Hanoi. Right: Dr. Nguyen Cong Khan, Director of National Institute of Nutri-tion (NIN) speaks at the launch of a National Micronutrients Day campaign.


Continuing nutrition education by the Youth Volunteer Group, NepalAshish Sharma, Youth Volunteer Group (YVG), Banepa, Kavrepalanchok, Kathmandu, Nepal

In SIGHT AND LIFE Newsletter 3/2005 (pp. 27–29) we reported on the nutrition education pro-gram made possible by financial and logistical support from SIGHT AND LIFE. We were very pleased when SIGHT AND LIFE gave us the opportunity to continue a similar program in another area of Nepal.

About 43% of Nepal’s total popu-lation of 23.8 million is under the age of 16. Of these, 3% suffer from vitamin A deficiency xeroph-thalmia. Eye diseases are consid-ered to be a vast problem which has adverse effects in the mental as well as physical development of children. This gave us the in-centive to continue this Nutrition Education Campaign.

Despite the fact that the National Vitamin A Program for the preven-tion of vitamin A deficiency has been ongoing for many years now (editor: see SIGHT AND LIFE Newsletter 3/1995 pp. 12–13), it seems that knowledge in the population is still not sufficient. Therefore the YVG started this education effort in various areas to make people aware of their own nutrition situation and that of their children.

From January to March 2006 this “Nutrition Education Campaign” was carried out in the area of the Kavrepalanchok district. The direct beneficiaries were 559 chil-dren and 275 pregnant and nurs-ing mothers and their families.

Objectives, methods and pro-cedures were very similar to the previous program, with improve-ments where possible (see News-letter 3/2005)

Children’s eye screening

The eyes of a total of 559 children were examined by a senior oph-thalmic assistant for any signs or symptoms of VAD. All affected children were given a vitamin A capsule and some of them were referred to the Nepal Eye Hos-pital. Twenty-six children (4.6%) aged 5 months to 5 years were found to have eye symptoms (XN 6; X1B 10: XN+X1B 7; X2+X3 3).

Conclusions and recommendation

There has been an increase in knowledge about vitamin A rich food, vitamin A deficiency dis-eases, blindness etc. amongst mothers and caretakers, and those identified with eye symp-toms received appropriate care.

The evaluation showed a very positive impact on the people with regard to knowledge.

Although there has been a posi-tive response to the program in the areas where it is running – with an increase in knowledge of vitamin A rich food and ways of consuming it, as well as more in-formation about VAD – this short

program of three months cannot solve the problem completely. If the people do not take the initia-tive themselves the problem will never be solved.

Outsiders like us are ever ready to work in this field to increase people’s awareness, but there are many reasons why we cannot do this work for very long. So if we support and prepare some peer groups among the local people then they can work in a better and more sustainable way.


The PACHE Trust health program and women’s empowermentP Manoharan, Project Director, Pache Trust, Madurai, Tamil Nadu, India

Introduction

The People’s Association for Community Health Education Trust (PACHE Trust) is a grass-roots level non-profit and non-governmental organization func-tioning for the dedicated cause of uplifting the rural poor with due emphasis on the betterment of women and children. The or-ganization is also involved in a considerable number of HIV/AIDS prevention projects among the highly vulnerable groups. The organization has been involved in many projects involving com-munity health, women’s empow-erment etc.

PACHE Trust, in joint venture with SIGHT AND LIFE, has been en-gaged in the prevention of vitamin A deficiency disorders (VADD) in recent years. The SIGHT AND LIFE Newsletter 1/2002 contained an article from PACHE Trust (pp. 20–21), and pictures of program activities were included in News-letter 3/2004, p. 48. The project was launched in districts where children were found to be prone to deficiency diseases. It is one of the most significant projects in Tamil Nadu addressing the needs of children below 10 years of age. VADD are a major health concern among children, especially the rural poor. The project has been attaining increasing success with every passing year. The commu-nity has been sensitized and there is visibly increased awareness on the prevention of VADD.

The goals, to treat and prevent VADD, have not changed over the years. The methods of com-munication, training and of raising attention for precautionary meas-

ures have been developed and refined. More attention is now given to pregnant and lactating mothers.

Achievements include reaching more children, the orientation of school teachers, regular school visits, regular vitamin A supple-mentation (vitamin A capsules), health camps, giving attention to people with other diseases and a strong collaboration with authorities.

Awareness of self-help groups (SHG)

The SHGs play a major role in the effective implementation of project activities because women are highly involved. It is the SHGs who disseminate the new mes-sages and developmental meas-ures to the community, especially to the women. Besides dissemi-nation of information regarding vitamin A, other micronutrients,


macronutrients and the impor-tance of a balanced diet were emphasized.

During the past year 30 orienta-tion seminars were conducted for SHG leaders (many of them are women) representing about 900 groups. The training had a wholesome effect and served its purpose. The members of the SHGs are trained well and the success of the project relies on them as they have to bring the group together and to pass on the messages.

Conclusions

The program is going well and developing in the right direc-tion. There are more people to reach and resources are never enough. We thank all those who contributed to the success of the program especially all the active participants, school children, women and SHG leaders, but also organizations like SIGHT AND LIFE, whose contributions are essential. We hope to be able to continue our work with the help of all.

Kitchen gardening

This proved to be an interesting and suitable approach. Besides the general public, school children showed much interest in planting saplings beside the school and in other places. It was demonstrated how to collect seeds and how to handle them to grow plants.

Cultural programs

The street plays and other activities have their own impact on the pro-gram. In this way even illiterate peo-ple can understand the concept.

An integrated nutrition, training and education programR Ratna Swamy, State Health Coordinator, Population and Environmental Education Centre (PEEC), Velgode, Kurnool District, Andhra Pradesh, India.

Introduction

PEEC considers itself privileged to work hand in hand with SIGHT AND LIFE. The support of SIGHT AND LIFE over the past years has made it possible to develop a significant health program cov-ering most of the state of Andhra Pradesh. Reports about PEEC activities were included in SIGHT AND LIFE Newsletters 3/2001 (pp. 34–35) and 1/2004 (p. 17). The program is a continuation from previous years and it is key to sustainability through educa-tion, counseling and distribution of vitamin A capsules. The main target groups are community and grass-roots people who are given adequate knowledge to make use of the available natural resources to overcome nutritional problems in growing children.

Main activities

PEEC is a center for the coor-dination of activities for more than 110 local NGOs, and even

more NGOs attend information meetings. Orientation and train-ing programs for NGO leaders on the importance of vitamin A deficiency (VAD) are offered, as well as awareness camps on eye care for schoolchildren, slum children and their parents. The vitamin A capsules from SIGHT AND LIFE are not only important for the immediate prevention of deficiency, they are also an im-portant tool to raise awareness and to reach people and finally to communicate the message about the importance of the vitamin A and the various kinds of fruits, vegetables and other foods con-taining vitamin A and provitamin A carotenoids.

The financial support from SIGHT AND LIFE allows us to give small financial contributions to some NGOs for their activities and to start vegetable gardens. PEEC prepares and prints resource ma-terials like wall posters, handbills, stickers and booklets etc. in the local language. Assistance was

offered to tsunami victim families using a special grant from SIGHT AND LIFE.

Training programs

During 2005 only three training programs were conducted. They were attended by representatives from 85, 90 and 66 NGOs.

Awareness programs

Some of the partner NGOs are se-lected for this program to spread the message on the need for vitamin A and its relation to eye care. These NGOs visit schools, slum areas, integrated child de-velopment schools and women’s groups, and enlighten them about the importance of healthy nutri-tion. Also they inform the chil-dren, their parents and neighbors about the various vegetables and fruits. These NGOs also distribute resource materials like wall post-ers, handbills, UNICEF materials and booklets, and they paste wall posters on the walls of important


public places in the villages. It is very effective and people are interested in participating in such meetings.

A new method of awareness campaigning is carried on in the districts of Guntur and Krishna. In this the local NGOs have formed into a committee and engaged a motor vehicle with all our slogans, symbols of vitamin A deficiency and eye care which moves from village to village. The local lead-ers in the villages have taken on the responsibility of spreading the messages.

Vegetable gardens

This is an innovative method to ensure that vegetables with a rich carotenoid content, including green leafy vegetables, are made available to people in the local markets. For this we have given some assistance to women farm-ers and women’s self-help groups

to grow vegetables with more provitamin A. This is a revolving fund and the partner NGOs will be revolving this money among the women’s groups. This has proved very successful in some districts, like Chittoor, Prakasam and Guntur.

PEEC’s sister organization, the Rural Development Society, dis-tributes vegetable seeds as part of the kitchen gardens scheme for better nutrition among chil-dren. This program is linked with vitamin A deficiency prevention. Thousands of families are given the vegetable seeds which they plant in kitchen gardens around their houses and use for food. So this is also indirectly support-ing the eradication of vitamin A deficiency.

Resource materials

Wall posters are prepared and printed. These are distributed to the partner NGOs for display on the walls of public places to highlight the message. This is very informative and people are very enthusiastic about it.

Handbills are distributed to the public in the villages during fes-tivals, holidays etc. They are very effective. Social workers, doctors and paramedical staff appreciate them as they are another form of information material.

The “SIGHT AND LIFE Guide-book on Vitamin A in Health and Disease” was translated into the local language (Telugu), printed and distributed to local leaders, teachers, social workers etc. through NGOs. This book has been well received and needs to be reprinted to meet demand.

Tsunami assistance

Emergency relief measures were carried out in four districts. The relief materials distributed dur-ing the disaster period consisted of food grains like rice and dhal; aluminum pots for selling fish; dress materials for saris and dhotis; towels, blankets and utensils; and educational materi-als like note books, slates etc. for schoolchildren. The aid included calcium tables and safe drinking water containers. This covered 440 families altogether and 420 children benefited. The tsunami victims expressed their gratitude to SIGHT AND LIFE for the help in the emergency.

Conclusion

On the whole, the program is continuing successfully and no major difficulties are faced. Many NGOs are interested in participat-ing and they are asking us to hold meetings every three months. The vitamin A capsules are very attractive and many NGOs want to receive more, but we are not able to supply them because the stock is very limited. The govern-ment is not issuing the permis-sion necessary to import the vitamin A capsules donated by SIGHT AND LIFE. The products available in the medical stores are not comparable and are very expensive. PEEC wants to reach even more people in Andhra Pradesh but due to financial and resource restrictions this is not always possible.


Knowledge and perception of vitamin A deficiency in the villages of Burkina FasoRosemary Fleury Téchoueyres, Youzondo Association, Bordeaux-Caudéran, France

During missions to the north of Burkina Faso, we noticed cases of night blindness. This led us to found the Youzondo Association, whose name, in the Moré lan-guage, refers to this condition.

Operation

In many areas we chose to create village associations consisting of a committee of eight people and two delegates per district. They meet every quarter to discuss a topic related to nutrition, com-munication or agriculture. Their activities are coordinated with the national Burkinabé Association for the Prevention of Youzondo.

It all began under the palabras tree at Petit Samba. As usual between 1pm and 4pm we were discussing everyone’s concerns, particularly with regard to chil-dren’s health, and this was how we heard about Youzondo sick-ness.

Action taken

With the help of a student phar-macist from Ouagadougou, we studied the average composi-tion of the diets of 80 mothers and their children by means of a questionnaire. This evaluative work also took into account levels of plasma retinol and conjunctival impression tests. The extent of vi-tamin A deficiency at Petit Samba was found to be a serious public health problem.

The second stage was to organ-ize a day of festive and sporting events, including a bicycle race, a football match, and a theatre performance given by Hippolyte Ouangrawa’s troupe. This show

portrays a village family whose son suffers from night blindness. It describes the intervention of members of his family, the woman next door, the marabout, and the nurse at the Centre of Health and Social Advancement. The subject (i.e. the dangers of vitamin A de-ficiency, the way to deal with it, the kinds of food which contain it etc.) is treated both accurately and humorously. Afterwards, a fo-rum allows the audience to react, to ask questions, and to give their point of view.

The third part of our approach was training. Thanks to subsidies, we were able to create health broadcasts for local radio. We also organized 3 days of training with a medical nutritionist and a sociologist, aimed at nurses, district delegates, and teachers. We stressed the importance of a varied diet. We recommended orange fruits and vegetables (mangoes, papayas, carrots, and orange sweet potatoes) and vegetables with dark green leaves (leaves of sorrel, niebe and baobab). Other foods, however, are not so readily available: eggs, liver, milk and related products, and red palm oil, the supply of which has been stopped from Ivory Coast.

Results

Three hundred and sixty-five mango trees have been planted in Petit Samba. At Bonou, we have a one-hectare market garden. Two other villages are about to begin growing for the market. At Tiogo, a dispensary has been built. Schools are circulating health information thanks to the educational materials sent by SIGHT AND LIFE.

Conclusions

We are preparing a 5-year sci-entific evaluation of the effect of awareness-raising at the village of Petit Samba for 2007.

We would like to thank the many people who help us to do our job, whether through work, donations, or in other ways.


Vitamin A deficiency and malnutrition among Sudanese children admitted to an urban hospitalHassan Mohamed Ahmed, Professor of Pediatrics and Dean of the Faculty of Medicine, Academy of Medical Sciences and Technology, Khartoum, Sudan

Protein energy malnutrition (PEM) constituted about 10% of total admissions to the Academy Charity Teaching Hospital (ACTH) during the period between De-cember 2004 and December 2005. Xerophthalmia was found more often in children with malnu-trition or after measles infection, and in children from displaced families, among nomads and in orphans.

During the above period a total number of 1,420 children under five years were admitted to the nutrition ward of ACTH, 13 of whom had different degrees of xerophthalmia. Two children de-veloped keratomalacia, which in one was bilateral and left the child totally blind. The second child lost one eye, which had ruptured at home before admission. All children admitted were given 2

doses of vitamin A in dosages recommended by the WHO. This was adopted as a routine on the PEM ward. We thank SIGHT AND LIFE for providing the vitamin A capsules.

The initial vitamin A level in Su-danese children showed wide variation, but the important fact was that about 42% of them were below 40 µg/100ml, and 20% were well below 20 µg/100ml. This is a level which predisposes children to xerophthalmia and blindness. 10 days after vitamin A supplementation all children showed a significant rise in serum vitamin A to protective levels of above 40 µg/100ml.

The National Nutritional Programs maintain supplementation of vita-min A at a community level. They conduct home-to-home visits as

The fight against vitamin A deficiency at Ouassa-Beket, BeninJeremie Orou, Fondation pour l’Aide et l’Autopromotion à la Base en Matière de Santé et Développement (FAABA), Bembereke, Bénin

part of an EPI team for immuni-zation to eradicate poliomyelitis. Vitamin A is supplemented twice a year in doses recommended by the WHO.

In 2005 FAABA, in collabora-tion with the Ouassa community centre, completed three major projects to combat vitamin A deficiency:• A campaign to distribute

vitamin A• Nutritional education of moth-

ers and caregivers• Cultivation of vegetables by the

women

Campaign to distribute vitamin AThis campaign was announced by the town crier, and publicized on local radio. On 14 October 2005, over 500 children aged between 6 months and 5 years were seen, and each received a capsule.

Nutritional training

We organized two training ses-sions for mothers, and especially grandmothers who take care of the children after weaning. The latter are often illiterate and the guardians of traditional taboos surrounding food. We showed these women the various foods (for growth, energy and protec-tion) using posters which stress


the importance of yellow and red-colored foods rich in vitamin A.

Cultivation of vegetables

After the training sessions by our agents, the women of Beket decided to start a garden for the cultivation of vegetables, espe-cially leafy vegetables. This initia-tive will allow the enrichment of children’s diets, and will provide them with a good source of vita-mins and minerals.

Conclusion

The success of our operation has encouraged us to continue in 2006. We even plan to bring in an ophthalmic specialist to diagnose the population in our local area.

We would like to thank SIGHT AND LIFE for their help with re-gard to the capsules and educa-tional materials.

Continued activity of the Ramala Women’s GroupMargaret Anyango, Rongo 40404, PO Box 119, Kenya

Introduction

We are glad to be able to continue our work in mitigating micronu-trient deficiencies and related dangers as well as to contribute to the improved nutrition of all those participating in our ac-tivities. The continued support of SIGHT AND LIFE in the form of financial assistance, as well as with educational materials and the links opened to other organisations were essential for our work within Rongo and its neighboring regions, which is timely and relevant. Thus it is in keeping with the overall mission of the group, i.e. to holistically enhance, foster, promote, and strengthen socio-economic op-portunities of rural women and children. Health-related issues including nutrition remain the top priority of the group. We strongly believe that health is not only the absence of ills but also the fight for the fullness of life, a life free from micronutrient deficiencies.

Nutrition activities

Vitamin A capsules received from SIGHT AND LIFE were adminis-tered to 3,673 children below five

years of age. About 27 days were spent on this exercise. The envis-aged outcome of this exercise was to improve retinol levels in children under five and to reduce episodes of night blindness, acute VAD and related disorders, and other VAD-related ailments among children. Rongo and its neighboring regions, such as Sakwa, Kamagambo, Randung, Opapo, Migori, etc. benefited.

On various occasions RWG distributed about 5.58 tons of foodstuffs rich in vitamin A. Such vegetables as cabbage, sukuma-wiki (kale), carrots, kiukamba,

etc. were distributed to women of childbearing age and children of five years and under. Approxi-mately 1,500 persons benefited from this program. Many of the women reached were also trained in how to prepare vegetables without destroying their nutritious value.

About 63 persons have been trained so far. During such train-ing, participants are taught how to prepare foods without destroy-ing vital micronutrients. Demon-strations on how to prepare such foods were also conducted. Most women at the time of the training


were at least breast-feeding their babies. It was quite encouraging to see some of these women tak-ing notes very seriously during the demonstrations.

A wide range of training tech-niques and tools were used, such as group-focused discussions, roleplay, case study, brainstorm-ing, demonstrations, lectures, etc. The training emphasized the involvement of schoolchildren as key informants and educators both at family and community levels. Participants were informed about strategies to involve chil-dren, such as drawing competi-tions, debates, poems, etc.

Eye health training and door-to-door eye screening

Due to ever-increasing complaints about eye-health-related prob-lems by community members, and childhood blindness due to VAD, this training was a neces-sary part of the effort of RWG. Five individuals were selected for further training on the basis of their ability to deliver services to the communities, reputation and working relationship within the communities. They were fully

aware of the people and their needs. Two resource persons in-vited from Tanzania facilitated the one-week intensive training.

Training on poultry keeping

The training was intended to in-crease local participation in direct production of locally available foods rich in vitamin A. To attend the training it was required that participants were able to start and sustain chicken-rearing to re-quired standards which would be overseen by a qualified veterinary officer. From the local communi-ties 56 women were trained by veterinary officers from the Minis-try of Livestock Development on how to start and manage a small poultry farm for family and other domestic purposes. The training included visits to commercial poultry farmers.

Conclusions

We are convinced that our efforts are going in the right direction. However, more is necessary in training and communication as well as in local production of healthy food through food pro-duction initiatives and encour-agement of agro-business.

We cannot finish this report with-out noting that at present the ef-forts are not sufficient to manage VAD and other micronutrient de-ficiencies. In this sense we have to say the struggle continues and we hope for further support, including continuing support from SIGHT AND LIFE.


SIGHT AND LIFE visits Pohnpei, Micronesia, and films a nutrition documentaryLois Englberger and Adelino Lorens, Island Food Community of Pohnpei, PO Box 2299, Kolonia, Pohnpei, Federated States of Micronesia

SIGHT AND LIFE visited Pohnpei in April 2006 to film a documen-tary about nutrition problems in Micronesia and the efforts un-derway for alleviating these prob-lems. Their visit was coordinated by the Island Food Community of Pohnpei.

Klaus Kraemer, Head of SIGHT AND LIFE, and Thomas Breisach, Deputy Head of the DSM Nutri-tional Products Communications Section, made up the SIGHT AND LIFE team. They were in Pohnpei from 21 to 27 April, 2006. Ulla Lohmann, filmmaker, and her camera assistant Markus Hain were engaged as consultants and were in Pohnpei from 10 to 27 April, 2006.

The purpose of the film is to pro-duce a documentary about global nutrition problems, including mi-cronutrient deficiencies and nutri-tion- and lifestyle-related chronic diseases such as diabetes, heart disease and cancer. Dr. Kraemer pointed out that Pohnpei is an example of a country having a double burden of malnutrition: the problem of micronutrient deficien-cies such as vitamin A deficiency, and the problem of overweight and chronic diseases. He said,

“No one would expect an island in the Pacific to have the nutrition problems of both developing and industrialized countries.” Over half of Pohnpei’s children have vitamin A deficiency, a dis-order leading to increased infec-tion and mortality. Coupled with this, there are serious problems of obesity and chronic diseases such as diabetes, heart disease and cancer in Pohnpei, leading to higher rates of mortality and great suffering among families and individuals.

The group filmed the beauty spots of Pohnpei, including the

lush Pohnpei landscape, the his-torical site of Nan Madol, water scenes, and cultural events, first portraying aspects of the para-dise concept that many people in other parts of the world have about life on a Pacific island.

The team then filmed aspects of the real-life situation relating to food, nutrition and health, and efforts to improve the nutri-tional situation. These included the Pilot Farm in Madolenihmw led by Pohnpei Agriculture of the Department of Economic Affairs, the Pohnpei Traditional Foods for Health project led by IFCP in collaboration with Mand

The SIGHT AND LIFE team (from left): Markus Hain, Ulla Lohmann, Klaus Kraemer, Thomas Breisach.


Community and the Centre for Indigenous Peoples’ Nutrition and Environment (CINE); Mr. Sei Uemoto and his plans to develop increased marketing of Karat banana and other local foods; the Youth to Youth project with Class 4 of Mand Elementary School in collaboration with the Conservation Society of Pohnpei; Pohnpei Library Week along their theme of “GO LOCAL”; and the vitamin A supplementation pro-gram led by the Pohnpei Depart-ment of Health/FSM Department of Health, Education and Social Affairs.

SIGHT AND LIFE has provided on-going assistance for many years to the Federated States of Micronesia, including research on the nutrient content of local island foods and vitamin A awareness materials, such as posters and the recent video titled GOING YELLOW, which has often been

shown on Pohnpei local television. This video was prepared last year (2005) as a project initiated and sup-ported by SIGHT AND LIFE in con-junction with the Island Food Com-munity of Pohnpei and produced by Micronesian Sem-inar (see SIGHT AND LIFE News-letter 1/2006, pp. 31–33).

At a farewell luncheon for the SIGHT AND LIFE team, Dr. Krae-mer was invited to give a few words of advice to IFCP and their efforts to improve health and nu-trition in Pohnpei. The IFCP board members and all present were very touched by his insight. His three points were as follows:

• Think about quantities of food eaten. There is a serious prob-lem of overweight and obes-ity in Micronesia. Fresh local foods are generally good, but even local foods can lead to overweight if eaten in excess or if prepared in unhealthy ways (adding sugar, frying or using excess fat).

• Focus on the youth. They are the future. Their habits are not yet fully set.

• Remember that not all im-ported foods are unhealthy.

There are some imported foods available that are fortified with micronutrients. Remember to read the labels!!

IFCP has already started work-ing on this advice, talking about quantities eaten and working with the youth. Also, an email message was sent out to the IFCP email network to share in-formation about fortified instant noodles. Although many instant noodles sold in Pohnpei contain no vitamin A, there are some brands that have been fortified and contain up to 30% of the estimated daily requirements. If consumers plan to eat instant noodles, they could choose the fortified brands in order to get a more nutritious food. The same message is now being relayed to community members in small workshops, showing actual ex-amples of the fortified and non-fortified brands.

Thanks are again extended to SIGHT AND LIFE for their visit to Pohnpei, making the documen-tary and providing helpful advice. The IFCP also thanks their partner agencies including Pohnpei Agri-culture of the Department of Eco-nomic Affairs, College of Micro-nesia-FSM Land Grant Program, Pohnpei Departments of Health and Education, and the Pacific German Regional Forestry Project, for providing transport.

The Governeur of Pohnpei, Johnny P David with Klaus Kraemer.

At the farewell luncheon.

Nutrition education (left) and Lois Englberger weighing and measuring a woman.


A digest of recent literatureDonald S McLaren*

Introduction

Community research“Vitamin A supplementation for re-ducing the risk of mother-to-child transmission of HIV infection” by Wiysonge CS, Shey MS, Sterne JAC et al. Cochrane Database Syst Rev 2005, No 4, p. CD003648 (Ministry of Public Health, Central Technical Group, EPI c/o BP 25125 Messa, Yaounde, Cameroon. Email: [email protected])Results of this review did not find evidence to support vitamin A sup-plementation of HIV-infected preg-nant women to reduce mother-to-child transmission of HIV, although there was evidence of birth weight improvement.Results of the large trial in Zimba-bwe (see below) were awaited at this time.

“Effects of a single large dose of vitamin A, given during the post-partum period to HIV-positive women and their infants, on child HIV infection, HIV-free survival, and mortality” by Humphrey JH, Iliff PJ, Marinda ET et al. J Infec Dis 2006; 193: 960–971 (JH Hum-phrey, 1 Borrowdale Road, Bor-rowdale, Harare, Zimbabwe. Email: [email protected])14,110 mother-infant pairs were en-rolled. Neither maternal nor neona-tal vitamin A supplementation sig-nificantly affected postnatal MTCT or overall mortality. For several reasons the results of this trial raises concern about universal maternal or neonatal vitamin A supplementation in HIV-endemic areas. (This would include large areas in the third world where maternal vitamin A supple-mentation programs are currently recommended by WHO).The above concerns are echoed by WW Fawzi in an accompany-ing editorial – “The benefits and concerns related to vitamin A supplementation” J Infec Dis 2006;193: 756–759

“Effects of postpartum maternal or neonatal vitamin A supple-mentation on infant mortality among infants born to HIV-nega-tive mothers in Zimbabwe” by Malaba LC, Iliff PJ, Nathoo KJ et al. Am J Clin Nutr 2005; 81: 454–460 (JH Humphrey, ZVITAMBO Project, 1 Borrowdale Road, Bor-rowdale, Harare, Zimbabwe. Email: [email protected])This study was part of the large trial described in the previous abstract. Mothers who received vitamin A received 400,000 IU and infants 50,000 IU. Over 12 months of fol-low up there was no effect on infant mortality in either case.

“Some dietary and adipose tis-sue carotenoids are associated with the risk of nonfatal acute myocardial infarction in Costa Rica” by Kabagambe EK, Furtado J, Baylin A et al. J Nutr 2005; 135: 1763–1769 (Hannia Campos, Email: [email protected])1456 cases of first acute MI were matched with the same number of healthy controls. Subjects were distributed into quintiles of dietary intake or adipose tissue concentra-tion of carotenoids or tocopherols. Adipose tissue β-carotene content was inversely related to MI risk, as was intake of fruits and vegetables rich in β-carotene. Lutein + zeaxan-thin content of adipose tissue was directly associated with MI risk.

“Antioxidant vitamins reduce oxidative stress and ventricu-lar remodeling in patients with acute myocardial infarction” by Gasparetto C, Malinvorno A, Culac-ciati D et al. Int J Immunopathol-Pharmacol 2005; 18: 487–496 (Dept of Int Med and Therapy, University of Pavia, Italy)Various parameters of the antioxi-dant system were monitored from shortly after the onset of the acute MI until one month later. Vitamin treatment improved the antioxidant system, reduced the oxidative stress, inflammatory process and left ventricular modeling.

“Effect of vitamin A on fracture risk” by Jackson HA, Sheehan AH. Ann Pharmacother 2005; 39: 2086–2090 (HA Jackson, Clarian Health

Mention has been made in several recent issues of the Newsletter of the shift in topic that has gradually taken place in the retinoid and caro-tenoid literature. Basic laboratory research has far outstripped human community and clinical studies which are clearly of more concern to most readers of the literature digest. As a result, abstracts of basic stud-ies have had to be strictly limited because of restricted space. An attempt has been made to include those basic studies that seem to be of greatest relevance, but this has hitherto left a large number of cho-sen, relevant papers excluded.A number of readers have ex-pressed their appreciation of the way in which their attention has been drawn by a quick scan of the literature digest to topics of special interest to them. This would clearly be all the more valuable if the cover-age of the new literature could be made more complete. Consequent-ly, this issue contains an Appendix after the main abstracts. This has been compressed to provide only essential information on the papers it covers in order to include as many as possible. The title (sometimes abbreviated) is in bold as usual, followed by the name and initials of the first author and finally the journal reference. Abbreviated abstracts have been grouped according to topic as this seemed the best way for readers, if they so wish, to make some selection. With use of the Internet this should give access to more complete information. It would be helpful to the editor to learn if this change is appreciated.

* Address for correspondence: Prof. Donald S. McLaren12 Offington Avenue, Worthing,West Sussex BN14 9PE, [email protected]


Partners Pharmacy Dept, 1-65 21st St., Indianapolis, IN 46202-1367, USA. Email: hjackson@clarianorg)This literature search from 1966 to March 2005, using vitamin A consumption and fracture risk fails to provide definitive evidence for a causal association.

“Vitamin supplementation of HIV-infected women improves postnatal child growth” by Vil-lamor E, Saathoff E, Bosch RJ et al. Am J Clin Nutr 2005; 81: 880–888 (Department of Nutrition, Harvard School of Public Health, 665 Hunt-ington Avenue, Boston, MA 02115, USA. Email: [email protected])Multivitamins (thiamin, riboflavin, vitamin B6, niacin, vitamin B12, vitamin C, vitamin E and folic acid) were tested against vitamin A or β-carotene. Multivitamins gave significant improvement in attained weight, weight for age, and weight for length. Vitamin A or β-carotene had no such effect, indeed vitamins and β-carotene mix seemed to re-duce benefits on these outcomes.

“Vitamin A, mastitis, and mother-to-child transmission of HIV-1 through breast-feeding” by Dorosko SM. Nutr Rev 2005; 63: 332–346Mastitis is an increased mammary permeability and is frequently ac-companied by bacterial infection. Supplementation with vitamin A reduces the prevalence of bacte-rial mastitis and the inflamma-tory response. However, studies of mother-to-child transmission in HIV-positive women have shown no reduction with vitamin A sup-plementation. One study in Tanza-nia reported an increase. Possible mechanisms for this unexpected result are being investigated. One way may be the paracellular entry of leukocytes affected by retinoic acid into breast milk.

“Diarrhoea and malnutrition in children” by Baqui AH, Ahmed T. Brit Med J 2006; 332: 378 (Dept Int Hlth, Johns Hopkins University, Bloomberg School of Public Health, Baltimore MD 21205, USA. Email:[email protected])This review follows an international

meeting in Bangladesh on this subject. Oral rehydration has been successfully pursued for more than three decades and now WHO and UNICEF have introduced a new reduced osmolarity formulation (WHO/UNICEF Joint Statement. Clinical management of acute diar-rhoea. 2004). In addition they rec-ommend the therapeutic use of zinc for 10–14 days at a dose of 10 mg daily in infants under 6 months and 20 mg daily in older children. There is no mention of vitamin A. Before the beneficial effect of zinc sup-plementation in acute diarrhea was discovered there were many reports of the efficacy of vitamin A. A recent reappraisal (see two abstracts be-low) reported even greater benefit of vitamin A than when analysis was made previously. Furthermore, there is growing acceptance of the concept that diarrhea is often an integral part of vitamin A deficiency and the need for vitamin A replace-ment is evident. Other recent docu-ments, especially in connection with achievement of some of the Millen-nium Goals have always bracketed together vitamin A and zinc in this context. This issue requires urgent attention; data supporting vitamin A supplementation for treatment and prevention of diarrheal diseases are available.

“Maternal vitamin A supplemen-tation and immunity to malaria in pregnancy in Ghanaian primi-gravids” by Cox SE, Staalsoe T, Arthur P et al. Trop Med Int Hlth 2005;10:1286–1297 (Dept Epide-miology and Population Health, London Sch Hyg & Trop Med, Lon-don, UK. Email:[email protected])The pathological effects of malaria in pregnancy are believed to be due to the sequestration of parasites in the placenta, mediated by binding of variant surface antigens (VSA) expressed on the surface of P. falciparum-infected red blood cells to placental chondroitin sulfate A (CSA). Vitamin A supplementation was accompanied by reduced levels of anti-VSACSA antibodies and may reflect reduced placental parasitemia.

“Random-effects models in in-vestigating the effect of vita-min A in childhood diarrhea” by Andreozzi VL, Bailey TC, Nobre FF et al. Ann Epidemiol 2006;16: 241–247 (VL Andreozzi, Avenida Humberto Delgado 33, Alhos Ve-dros, 2860-021, Portugal. Email: [email protected])Enhanced statistical analysis meth-ods were applied to previous stud-ies on vitamin A and diarrhea in childhood. Levels of significant beneficial effects were reached that were not attained previously – see also comments on WHO/UNICEF recommendations that include zinc but exclude vitamin A two abstracts above.

“The concentration of free holo-retinol-binding protein is higher in vitamin A-sufficient than in deficient Nepalese women in late pregnancy” by Sankanarayanan S, Suarez M, Taren D et al. J Nutr 2005;135: 2817–2822 (Penn State Univ, Huck Inst Life Sci, Univer-sity Park, PA 16802, USA. Email: [email protected])The RBP/TTR index (< 0.36 or se-rum retinol < 1.05 µmol/l indicative of vitamin A deficiency), introduced by FJ Rosales of this group, was shown to be a useful proxy for free holo-RBP concentration and that vitamin A status affects its distri-bution.

“Serum carotenoids, vitamins A and E, and 8-year lung function decline in a general population” by Guenegou A, Leynaert B, Pin I et al. Thorax 2006; 61: 320–326 (Dept Epidemiology, INSERM Unit 700, University of Medicine Bichat, 16 rue Henry Huchard, 75018 Paris, France. Email: [email protected])1194 French subjects aged 20–44 years were examined in 1992 and followed up in 2000. Serum β-caro-tene underwent a steady increase in that period and along with this there was a similar slower decline in FEV1 (forced expiratory volume in 1 sec-ond) – an indicator of lung function. In heavy smokers both β-carotene and vitamin E were protective.

“Dietary β-cryptoxanthin and inflammatory polyarthritis: re-


sults from a population-based prospective study” by Pattison DJ, Symmons DPM, Lunt M et al. Am J Clin Nutr 2005; 82: 451–455 (Arthritis Research Campaign, Epidemiology Unit, University of Manchester, UK)A modest increase in β-cryptoxan-thin intake, equivalent to one glass of freshly squeezed orange juice per day, is associated with a reduced risk of developing inflammatory disorders such as rheumatoid ar-thritis.

“Serum retinol and total carotene concentrations in obese pre-school children” by Saccardo-Sar-ni RO, De Souza FIS, Ramalho RA et al. Med Sci Monit 2005; 11: 510–514 (RO Saccardo-Sarni, R Zamlutti 94, Sao Paulo, CEP: 04116-260, Brazil. Email: [email protected])It was found that there was an association between obesity and hyperlipidemia and low serum level of carotenoids; possibly affording some antioxidant protection. (It is doubtful if total carotenoid levels are meaningful; fractionation would appear essential.)

“Momordica cochinchinensis, Rosa roxburghii, wolfberry, and sea buckthorn – highly nutritional fruits supported by tradition and science” by Burke DS, Smidt CR, Vuong LT. Curr Top Nutraceut Res 2005; 3: 259–266 (Pharmanex Research Institute, LLC, 75 West Center Street, Provo, UT 84601, USA. Email:[email protected])Fruits such as these originate from Southeast Asia where their value as healthy fruits has been recognized for many years. Analysis has shown that they are rich in antioxidant vitamins, especially lycopene and β-carotene.

“Modification of lymphocyte DNA damage by carotenoid sup-plementation in postmenopau-sal women” by Zhao X, Aldini G, Johnson EJ et al. Am J Clin Nutr 2006;83:163–169 (KJ Yeum, Mayer-USDA-Human Nutrition Research Center on Aging, Tufts University, Boston, MA 02111, USA. Email:[email protected])Al l carotenoid-supplemented

groups showed a significant de-cline in endogenous DNA damage. 4 mg each of lutein, β-carotene and lycopene daily, an effective amount, can be readily taken orally.

“Improving the nutritional value of Golden Rice through increased pro-vitamin A content” by Paine JA, Shipton CA, Chaggar S et al. Nature Biotech 2005; 23: 482–487 (Syngenta, Jealott’s Hill Int Res Cent, Bracknell, Berkshire, RG42 6EY, UK)It was discovered that the daffodil gene that encoded phytoene syn-thase (psy), one of the two genes used to develop Golden Rice, was the limiting step in β-carotene accumulation. A psy from maize was substituted. Total carotenoids increased up to 23-fold maximum with a preferential accumulation of β-carotene.

Multimicronutrient research“Micronutrients in childhood and the influence of subclinical inflammation” by Thurnham DI, Mburu ASW, De Wagt A. Proc Nutr Soc 2005; 64: 502–509 (Univ Ulster, Ctr Food & Hlth, Sch Biomed Sci, 47 Knocknougher Rd, Coleraine BT51 4LA, Londonderry, Northern Ireland. Email:[email protected])Attention is drawn in this review to the neglected importance of the acute phase response (APR) in the assessment of nutritional status of a number of micronutrients. Vitamin A, iron and zinc have been most exten-sively studied in this regard but other vitamins and elements are likely to be implicated. The phenomenon is widespread, especially in childhood, as even subclinical infection and in-flammation are capable of reducing the concentration of the nutrient in the serum and the effect is evident within as little as 24 hours. The overall effect is to give the impres-sion that deficiency levels are more widespread than they really are. Attempts are being made to devise and introduce correction values for routine application.

“Prevalence of iron deficiency and its association with vitamin A deficiency in preschool children”

by Ferraz IS, Daneluzzi JC, Van-nucchi H et al. J Pediatr 2005; 81: 169–174 (IS Ferraz, ER Preto/Bon-firm Paulista, km 308, CEP 14110-000 Ribeiro Preto, SP, Brazil. Email: [email protected])179 children aged 24–72 months without diarrhea or fever at the time of the study were examined for vitamin A (30-day dose response test) and iron (HB, serum iron, and unsaturated iron-binding capacity assays) status. 135 had vitamin A deficiency and 64 had iron defi-ciency but there was no association between the two.

“Anemia, iron status and vitamin A deficiency among adolescent refugees in Kenya and Nepal” by Woodruff BA, Blanck HM, Slutsker L et al. Publ Hlth Nutr 2006; 9: 26–34 (Ctr Dis Control & Prevent, Ntl Ctr Chron Dis Prevent & Hlth Promot, Maternal & Child Nutr Branch, 4770 Buford Highway NE, Mailstop K-25, Atlanta, GA 30341, USA. Email: [email protected])Anemia (hemoglobin <11.0 to 13.0 depending on age and sex); iron deficiency (transferrin receptor conc > 8.3 µg/ml) and vitamin A defi-ciency (serum retinol < 0.7 µmol/l) had the following levels of preva-lence: anemia 46% in Kenya, 24% in Nepal; 43% iron deficiency in each country; vitamin A deficiency 15% in Kenya and 30% in Nepal. Adolescents tend to be a neglected group in refugee situations and merit greater care.

“Only a small proportion of ane-mia in northeast Thai school-children is associated with iron deficiency” by Thurlow RA, Win-ichagoon P, Green T et al. Am J Clin Nutr 2005; 82: 380–387 (Institute of Nutrition, Mahidol University, Salaya, Thailand)567 children aged 6–12.9 years were tested for anemia, hemoglobin type, iron and vitamin A status. The prevalence of anemia overall was 31%, only 16% of these were iron deficient. Hemoglobinopathy and vitamin A deficiency played larger parts. (The data were not presented in a way that showed a relation-ship between iron deficiency and vitamin A deficiency. However, the study suggests that there is still


much to learn about this area. It is interesting to note that those with C-reactive concentration ≥10 mg/l (n=12) were excluded from the study, indicating an understanding of the APR problem with vitamin A – see above.)

“Anaemia, iron deficiency and vitamin A status among school-aged children in rural Kazakh-stan” by Hashizume M, Chiba M, Shinohara A et al. Publ Hlth Nutr 2005; 8: 564–571 (Univ Tokyo, Dept Int Community Hlth, Grad Sch Med, Tokyo, Japan. Email: [email protected])Among 159 school-age children 1) anemia, 2) iron deficiency and 3) vitamin A deficiency were as-sessed. Indicators (but not criteria) used were: (1 and 2) HB, serum iron, serum ferritin, transferring saturation and erythrocyte protoporphyrin; and (3) serum retinol <1.05 µmol/L. Anemia prevalence was 27%, iron deficiency 13%, vitamin A deficiency 21%. Serum iron and retinol concen-trations were significantly correlated. (Very many small studies like this without an intervention element are now being undertaken, but are prob-ably not valid in statistical terms.)

“Anemia and deficiency of vita-min A in children evaluated in a nutritional attention center from Caracas” by De Abreu J, Borno S, Montilla M et al. Arch Latinoamer Nutr 2005; 55: 226–234 (CANIA, Caracas, Venezuela)124 moderately malnourished chil-dren < 10 years were compared with 98 healthy children. For vitamin A status plasma retinol, RDR and CIC were used. For anemia and iron status hemoglobin, transfer-ring saturation and serum iron were used. Anemia was significantly higher in malnourished (34.2%) than in healthy (19.2%) children. Vitamin A deficiency was about 10% in both groups. (APR or vitamin A/iron status were not investigated in this small study.)

“Vitamin A deficiency and anae-mia in young children living in a malaria endemic district of west-ern Kenya” by Nabakwe EC, Lich-tenbelt W van M, Ngare DK et al. East Afr Med J 2005; 82: 300–306

(Dept Child Hlth and Paediatrics, Moi University, PO Box 4606, El-doret, Kenya)303 children aged 1–3 years were studied. 29% had severe vitamin A deficiency, 92% had anemia and 76% malarial parasitemia. Reti-nol levels were significantly lower among those with high C-reactive protein (p< 0.001).(This is a larger study in a narrower age range of children. APR was in-cluded and shown to be related to vitamin A status. Iron/vitamin A rela-tionship was not included. There is a need for an international protocol and standards to be promulgated if reliable and comparable data are to be produced.)

“Effect of zinc and vitamin A supplementation on antibody re-sponses to a pneumococcal con-jugate vaccine in HIV-positive in-jection drug users: a randomized trial” by Deloria-Knoll M, Steinhoff M, Semba RD et al. Vaccine 2006; 4: 1670–1679 (Deloria-Knoll M, Johns Hopkins University, Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore MD 21205, USA. Email: [email protected])118 HIV+ injection drug users were randomized to oral 400,000 IU vi-tamin A, 300 mg zinc, vitamin A + zinc, or placebo. Geometric mean titer increased 1.3 – 3.3-fold for all pneumococcal serotypes. Neither vitamin A nor zinc altered the im-munogenicity of the evaluated vaccines.

“Prevalence of infant vitamin A deficiency and undernutrition in the Republic of Congo” by Samba C, Tchibindat F, Houze P et al. Acta Trop 2006; 97: 270–283 (B Gourmel, Laboratoire de Biochimie A, Hôpi-tal Saint Louis, 1 Avenue Claude Vellefaux, F-75011, Paris, France. Email: [email protected])5,722 preschool children, 190 clusters of 30 children each, were studied between July and Septem-ber 1999. Each was examined for clinical xerophthalmia (XN and/or X1B) and dietary intake of vitamin A-rich foods. Serum retinol was estimated on a subsample of 300 in one area.Night blindness was detected in

0.7%, Bitot’s spot in 7.7%. Serum retinol was deficient (< 10µg/dl) in 18% and low (<20µg/dl) in 49%. It is concluded that “vitamin A defi-ciency is still a serious public health problem”. (The sample size is large and the examinations took place in a single season, but there are other difficulties. The subsample for se-rum retinol may not be representa-tive, coming from a single area. There is a discrepancy between XN (0.7%, below WHO criterion of >1.0%) and X1B (7.7% well above WHO criterion of >0.5%). The usual ratio XN>X1B is reversed. No ac-count was taken of APR.)

“A double-blind, randomized, clinical trial of the effect of vita-min A and zinc supplementation on diarrheal disease and respira-tory tract infections in children in Mexico City, Mexico” by Long KZ, Montoya Y, Hertzmark E et al. Am J Clin Nutr 2006; 83: 693–700 (Dept Nutrition, Harvard School of Public Health, Boston MA, USA)736 children, aged 6–15 months, were assigned to receive 1) vitamin A every 2 months, 2) zinc daily, 3) vita-min A and zinc, or 4) placebo. Over-all vitamin A supplementation was associated with a 27% increase in diarrheal disease and 23% increase in cough with fever. Zinc had no ef-fect on these outcomes.Rates were stratified by household and personal characteristics and the following results obtained: vitamin A decreased diarrhea in children from households with dirt floors but in-creased diarrhea in children from households with non-dirt floors, piped water, and indoor bathrooms. Zinc decreased diarrhea in children from households with dirt floors and whose mothers were more educat-ed. Vitamin A increased cough with fever in children from less-crowded households that lacked indoor bath-rooms and children of less-edu-cated mothers. (The findings have been quoted almost word-for-word but these complex results are still very difficult to interpret. However, they should have a bearing on the recent UNICEF recommendations for the treatment and prevention of diarrheal diseases –see above under community research.)


“Vitamin A and zinc status in patients on maintenance haemo-dialysis” by Cabral PC, Diniz A da S, de Arruda IK. Nephrology 2005; 10: 459–463 (Dept of Nutrition, Federal University of Pernambuco, Brazil)55 patients and 28 healthy con-trols were compared. The mean serum retinol concentration was significantly (p<0.0001) greater in patients than in controls. Zinc in serum was similar in patients and controls. The higher serum retinol is compatible with kidney tubular damage reported previously.

Experimental studies“Retinoic acid metabolism and signaling pathways in the adult and developing mouse testis” by Vernet N, Dennefeld C, Rochette EC et al. Endocrinology 2006; 147: 96–110 (M Mark, Institut de Géné-tique et de Biologie Moléculaire et Cellulaire (IGBMC), Institut Clini-que de la Souris (ICS), Collège de France, BP10142, 67404 Illkirch Ce-dex, France. Email: [email protected])These workers determined the dis-tribution in adult and fetal mouse testis of enzymes and other factors involved in retinoic acid metabo-lism. Correlating these results with pathological phenotypes generated by RAR and RXR mutations and vi-tamin A deficiency suggested that 1) spermiation requires RXR beta/RAR alpha heterodimers in Sertoli cells, and 2) spermatogonia proliferation involves two distinct RAR-mediated signaling pathways in both Sertoli cells and spermatogonia.

“Retinol improves bovine em-bryonic development in vitro” by Livingston T, Eberhardt D, Edwards JL et al. Reprod Biol Endocrinol 2004; 2: 83 (Dept Animal Science, University of Tennessee, Knoxville, TN 37996, USA. Email: [email protected])Previous studies indicated that retinoids influence several repro-ductive events, including follicular development, oocyte maturation and early embryonic development. This study showed that addition of 5 micromolar retinol treatment during embryo culture improved embry-onic development by increasing

blastocyst rate of bovine oocytes, suggesting a beneficial antioxidant effect during embryo culture.

“β-carotene conversion into vita-min A in human retinal pigment epithelial cells” by Chichili GR, No-hr D, Schaeffer M et al. Invest Oph-thalmol Vis Sci 2005; 46: 3562–3569 (Institute of Biological Chemistry and Nutrition, University of Hohen-heim, Stuttgart, Germany)It was shown that BCO (β,β-car-otene-15,15’-monoxygenase, the enzyme that converts β-carotene into retinal by oxidative cleavage in the small intestine) is expressed in the RPE (retinal pigment epithe-lium) and that β-carotene can be converted into retinol. This may be an alternative pathway that would ensure the retinoid supply to pho-toreceptor cells.

“Disruption of the lecithin:retinol acyltransferase gene makes mice more susceptible to vitamin A de-ficiency” by Liu L, Gudas LJ . J Biol Chem 2005; 280: 40226–40234 ( LJ Gudas, Dept Pharmacology, Weill Medical College, Cornell University, 1300 York Avenue, New York, NY 10021, USA. Email: [email protected])Lecithin:retinol acyltransferase (LRAT) catalyzes the esterification of retinol in the liver and some other tissues. It was shown that LRAT (-/-) knock-out mice were very respon-sive to vitamin A deficiency, almost no vitamin A being stored through-out the body after a few weeks on a deficient diet. They would form an excellent experimental model for quantitative manipulation of dietary retinol.

“Are fat-soluble vitamins effec-tive in enhancing tumoricidal cell activity?” by Meydani SN. J Nutr 2005; 135: 2918S (Jean Meyer U.S. Department of Agriculture Human Nutrition Research Center, Tufts University, Boston, MA, USA. Email: [email protected])The cancer immunoediting hypoth-esis proposes three ways in which the immune system might help to defend the body against cancer. Some studies suggest how the im-mune system might be an important determinant of host resistance to

cancer. Other work shows how enhancing the effector function of innate and adaptive immunity and their interaction might be beneficial. Some research suggests a similar effect might result from reduced production of immunosuppressive factors by tumors.Fat-soluble vitamins, in particular vitamins A and E, have been shown to play a part in some of these processes but much more work is needed.

“Vitamin A status in mice affects the histone code of the phospho-enolpyruvate carboxykinase gene in liver” by Scribner KB, Odom DP, McGrane MM. J Nutr 2005; 135: 2774–2779 (MM McGrane, Depts of Nutritional Sciences and Molecular and Cellular Biology, University of Connecticut, Storrs, CT 06269 USA. Email: [email protected])Vitamin A deficiency decreases PEPCK gene expression in mice, and expression is restored with retinoic acid (RA). This study dem-onstrated associated changes that occur in nuclear receptor binding, coactivator recruitment, and histone acetylation in response to vitamin A status.

“Accumulation of retinol in the liver after prolonged hyporetinol-emia in the vitamin A-sufficient rat” by Gieng SH, Raila J, Rosales FJ. J Lipid Res 2005; 46: 641–649 (FJ Rosales, Dept Nutritional Sci-ences, Pennsylvania State Uni-versity, University Park, PA, USA. Email: [email protected])Inflammation was induced by continuous recombinant human interleukin-6 infusion. The results showed that instead of being lost, retinol accumulated in the liver and that hyporetinolemia was attribut-able to a decrease in the availability of hepatic RBP. There are important implications for the understanding the mechanism by which measles infection induces hyporetinolemia and vitamin A deficiency of extra-hepatic tissues.


Clinical studies“Effects of retinoid therapy on insulin sensitivity, lipid profile and circulating adipocytokines” by Corbetta S, Angioni R, Cattaneo A et al. Eur J Endocrin 2006; 154: 83–86 (Univ Milan, Osped Mag-giore, IRCCS, Inst Endocrine Sci, Via F Storza 25, 1-20122 Milan, Italy. Email: [email protected])Patients with psoriasis who were being treated long-term with the retinoid acitretin were studied. The treatment resulted in a mild, tran-sient reduction of insulin sensitivity and HDL-cholesterol levels that were not related to modifications of adiponectin, resistin and tumor necrosis factor alpha levels. Al-though the role of resistin in humans remains elusive, the levels of this adipocytokine seem to be affected, at least in part, by retinoids.

“Synergism of desbutyl-ben-flumetol and retinol against Plas-modium falciparum in vitro” by Samal D, Rojanawatsirivet C, Wernsdorfer G et al. Wien Klin Wo-chenschr 2005; 117: Suppl 4, 39–44 (Dept of Neurology, Medical Uni-versity of Vienna, Vienna, Austria. Email: [email protected].)This in vitro study demonstrates that addition of retinol to DBB resulted in a strong inhibition of schizont maturation.

“In vitro activity of artemisinin alone and in combination with retinol against Plasmodium falci-parum” by Thriemer K, Wernsdorfer G, Rojanawatsirivet C et al. Wien Klin Wochenschr 2005; 117: Suppl 4, 45–48A similarly positive result to that outlined in the abstract above in work by the same experimental team. Both studies suggest that retinol may be a promising partner for antimalarial therapy.

“Renal pathology and retinol status in multiple myeloma” by Gavrilov V, Yermiahu T, Goro-discher R. Kidney Int 2006; 69: 173–177 (Biochemistry Laboratory, Soroka Medical Center, PO Box 151, Beer Sheva, Israel. Email: [email protected])

Renal dysfunction is a common and serious complication in multiple my-eloma. This group showed: 1) uri-nary retinol is a more reliable marker of renal dysfunction than elevated serum creatinine; 2) serum retinol is decreased with normal or mildly elevated serum creatinine, but not in patients with moderate/severe renal failure; and 3) urinary retinol may serve as a diagnostic marker of renal proximal tubule dysfunction in multiple myeloma.

“Reductions in serum vitamin A arrest accumulation of toxic retinal fluorophores: a potential therapy for treatment of lipo-fuscin-based retinal diseases” by Radu RA, Han Y, Bui TV et al. Invest Ophthalmol Vis Sci 2005; 46: 4393–4401 (Jules Stein Eye In-stitute, University of California, Los Angeles, California, USA)A toxic vitamin A-based fluorophore (A2E) present within lipofuscin has been implicated in the death of retinal pigment epithelium (RPE) and photoreceptor cells in many degenerative retinal diseases. In an animal model it was shown that HPR (N-4-hydroxyphenyl) retinamide po-tently and reversibly reduced serum retinol. Accumulation of A2E and lipofuscin autofluorescence were also reduced.

“Effect of short-term, high-dose retinol on dark adaptation in ag-ing and early age-related macu-lopathy” by Owsley C, McGwin G, Jackson GR et al. Invest Ophthal-mol Vis Sci 2006;47:1310–1318 (C Owsley, Dept Ophthalmology, School of Medicine, University of Alabama at Birmingham, 700 South 18th Street, Suite 609, Birming-ham, AL 35294-0009, USA. Email: [email protected])Baseline variables were similar in placebo and high-dose retinol groups. Those who received retinol had an increased rate of rod-medi-ated dark adaptation in older pa-tients who were in the early stages of ARM (same as AMD). The authors suggest these results are consistent with the hypothesis that a local de-ficiency of retinol is responsible for the disease. (In view of the results presented in the abstract above it seems unlikely that this alone is

responsible and much more work is needed.)

“Retinol-binding protein, trans-thyretin, and C-reactive protein in extremely low birth weight (ELBW) infants” by Ambalavanan N, Ross AC, Carlo WA. J Perinatol 2005; 25: 714–719 (N Ambalavanan, University of Alabama at Birmingham, 619 South 20th Street, Birmingham, AL, USA)This highly significant research is based, as is so often the case, on a simple idea developed in one area and neglected in another. Vitamin A deficiency reduces RBP (retinol-binding protein) but not TTR (trans-thyretin). Inflammation, even at a sub-clinical level, reduces both RBP and TTR and increases C-reactive protein, an acute phase response component. In 79 ELBW infants higher CRP and RBP/TTR molar ra-tio on day 28 were associated with death/bronchopulmonary dysplasia (a common association with ELBW) at 36 weeks. It was concluded that inflammation, rather than vitamin A deficiency, was the cause of low serum retinol levels. (In other words, this suggests that the considerable amount of research leading to the current practice of administering routinely intramuscular vitamin A to ELBW infants is fallacious in that no true state of vitamin A deficiency exists, but only a misleadingly low serum retinol attributable to inflam-mation).

“Vitamin A and E deficiency and lung disease in infants with cystic fibrosis” by Bines JE, Truby HD, Armstrong DS et al. J Pediatr Child Health 2005; 41: 663–668 (Dept Gastroenterology and Clinical Nu-trition, Royal Children’s Hospital, Melbourne, Victoria, Australia)In this cohort of 39 newly diagnosed infants with cystic fibrosis no asso-ciation was found between serum vitamin levels at diagnosis and air-way inflammatory indices at either diagnosis or 12 months later.

“Vitamin A levels in patients with CF are influenced by the inflam-matory response” by Greer RM, Buntain HM, Lewindon PJ et al. J Cyst Fibros 2004; 3: 143–149 (Dept Paediatrics and Child Health, Uni-


versity of Queensland, Brisbane, Australia. Email: [email protected])These authors were aware that inflammation increases C-reactive protein and is associated with de-pression of serum vitamin A in nor-mal subjects. They found a similar relation to occur in their cystic fibro-sis patients. This was also found in the ELBW infants described in the abstract two above. Again, under these circumstances it is erroneous to assume that vitamin A deficiency is present.

“Vitamin A for treating measles in children” by Huiming Y, Chaomin W, Meng M. Cochrane Database Syst Rev 2005 No 4, p. CD001479 (West China Second University Hos-pital, Third Section of the People’s South Street, Chengdu, Sichuan, China 610041. Email: [email protected])There was no significant reduction in the risk of mortality in the vitamin A group overall. There was evidence that when two doses of vitamin A were given there was associated reduced risk of mortality in children under the age of two years.

“Plasma vitamin A levels in de-prived children with pneumonia during the acute phase and after recovery” by Da Silva R, Lopes Jr E, Sarni ROS et al. J Pediatr 2005; 81: 162–168 (JADAC Taddei, Uni-versidade Federal de Sao Paulo, Brazil. Email:[email protected])Plasma retinol was measured dur-ing the acute phase of pneumonia and after recovery in 40 deprived children aged 6 months to 5 years. Mean plasma levels were signifi-cantly higher after recovery, thus demonstrating the effect of the acute phase response (APR) on vitamin A status. (It is encouraging to learn from this and other papers that recognition of the occurrence and significance of the APR effect is beginning to be appreciated by research workers in this area around the world. Efforts are being made by Thurnham and his group (see Multimicronutrient research above) and others to produce cor-rection tables. Another approach to the problem is to promote tests that are not subject to this difficulty.

The pupillary threshold test and conjunctival impression cytology come to mind.)

Appendix

Experimental research

Hypervitaminosis in the catPolizopoulou ZS, J Fel Med Surg 2005; 7: 363

All-trans-retinoic acid acceler-ates the differentiation of human B lymphocytes matur ing into plasma cellsMorikawa K, Int Immunopharma 2005: 5: 13–14

The C-terminal region of cis-reti-nol /androgen dehydrogenase 1 (CRAD1) confers ER localization and in vivo enzymatic functionLiden M, McCarroll JA; Exp Cell Res 2005: 311; 205–217Vitamin A inhibits pancreatic stel-late cell activationMcCarroll JA, Gut; 2006; 55: 79–89Reductions in serum vitamin A ar-rest accumulation of toxic retinal fluorophoresRadu RA, Invest Ophthalmol Vis Sci 2005; 46: 4393–4401

Complexes of carbon nanotu-bules with selected carotenoidsStobinski, L, J Nanosci Nanotech 2005; 5: 2121–7

Selective distribution of β-caro-tene stereoisomers in rat tissueBen-Amotz A, Nutr Res 2005; 25: 1005–12

Analysis of ALDH1A2, CYP26A1, CYP26B1, and CRABP2 in human neural tube defectsDeak KL, Birth Def Res 2005; 73: 868–75

Protective effects of increasing vitamin E and A doses on cispla-tin-induced oxidative damage to kidney tissue in ratsDillioglugil MO; Urol Int 2005; 75: 340–44

Enhanced UV-mediated free radi-cal generationKlamt F, Photochem Photobiol Sci 2003; 2: 856–860

Rapid measurement of retinol, retinal, 13-cis-retinoic acid and

all-trans-retinoic acid by high performance liquid chromatog-raphyTatum V, J Food Drug Anal 2005; 13: 256–9

The enhancing role of vitamin A deficiency on chemically induced nephroblastoma in ratsLi K, J Pediatr Surg 2005; 40: 1951–6

Lecithin:retinol acyltransfer ase is responsible for amida tion of retinylamineGolczak M; J Biol Chem 2005; 280: 42263–73

Retinoid X receptor agonists in-crease Bc12a1 expression and decrease apoptosis of naïve T lymphocytesRasooly R, J Immunol 2005; 175: 7916–29

Diet-related variation in cellular retinol-binding protein type II gene expression in rat jejunumSuruga K, Br J Nutr 2005; 94: 890–5

Acetaldehyde inhibits the forma-tion of retinoic acid from retinal in the rat oesophagusYokoyama S, Scand J Gastro 2006; 41: 80–6

Effect of administration of eti-dro nate and retinol on bone mechanical properties in ovariec-tomized ratsKaczmarczyk SI, Pharmacol Rep 2005; 57: 203–11

Retinoids and steroids in bovine mammary gland immunobiologyMeyer E, Livestock Prod Sci 2005; 98: 33–46

Dietary vitamin A has both chron-ic and acute effects on vitamin A indices in lactating rats and their offspringAkohoue SA, J Nutr 2006; 136: 128–32

The effect of vitamin A on CC1(4)-induced hepatic injuries in ratsNoyan S, Acta Histochem 2006; 107: 421–34

The effect of cholesterol in the liposome bilayer on the stabiliza-tion of incorporated retinolCheo LS, J Liposome Res 2005; 15: 157–66


Megalin-mediated reuptake of retinol in the kidneys of mice is essential for homeostasisRaila J, J Nutr 2005; 135: 2512–6

Clinical significance of altered expression of retinoid receptors in oral precancerous and cancer-ous lesionsRalhan R, Int J Cancer 2006; 118: 1077–89

TBX1, a DiGeorge syndrome candidate gene, is inhibi ted by retinoic acidZhang LF, Int J Devel Biol 2006; 50: 55–61

Retinoic acid amplifies the host immune response to LPS through increased T lympho cytes number and LPS bin ding protein expres-sionDevaux S, Mol Cell Endocrin 2005; 245: 67–76

Non-classical action of retinoic acid on the activation of the cAMP response element-binding protein in normal human bron-chial epithelial cellsAgarwal S, Mol Biol Cell 2006; 17: 566–575

Role of retinoic acid receptors al-pha 1 and gamma in the response of murine limbs to retinol in vitroGaldones E, Birth Def Res 2006; 76: 39–45

Inhibitory effects of retinoic ac-id metabolism blocking agents (RAMBAs) on the growth of human prostate cancer cellsHuynh CK, Br J Cancer 2006; 94: 513–23

Growth stimulation of human pulmonary adenocarcinoma cells and small airway epithelial cells by β-caroteneAl-Wadei HAN, Int J Cancer 2006; 118: 1370–80

Retinoid receptor antagonists after the pattern of apoptosis in organogenesis stage mouse limbs

Ali-Khan SE, Toxicol Sci 2006; 90: 208–20

Retinaldehyde dehydrogenase 2 (RALDH2)-mediated retinoic acid synthesis regulates early mouse embryonic forebrain develop-mentRibes V, Development 2006; 133: 351–61

Expression of nuclear receptor and target genes in liver and intestine of neonatal calves fed colostrum and vitamin AKrueger KA, J Dairy Sci 2005; 88: 3971–81

Differential teratogenesis of all-trans-retinoic acid administered on gestational day 9.5 to SWV and C57BL/6N miceCollins MD, Birth Defec Res 2006; 76: 96–106

Impairment of spermatogenesis and enhancement of testicular germ cell apoptosisComitao R, J Exp Zool 2006; 305A: 288–298

Function of retinoid nuclear re-ceptorsMark M, Ann Rev Pharmaol Toxicol 2006; 46: 451–480

Chronic dietary vitamin A sup-plementation regulates obesity in an obese mutant WNIN/Ob rat modelJeyakumar SM, Obes Res 2006; 14: 52–59.

Community research Plasma lycopene, other carote-noids, and retinol and the risk of cardiovascular disease in menSesso HD, Am J Clin Nutr 2005; 81: 990–7

Intakes of vitamins A, C and E and folate and multivitamins and lung cancerCho E, Int J Cancer 2006; 118: 970–8

Effect of micronutrient supple-ment on health and nutritional status of schoolchildrenSivakumar B, Nutr 2006; 22: S15-S25

Low levels of carotenoids and ret inol in involu t ional osteoporosisMaggio D, Bone 2006; 38: 244–8

Hypo- and hyperresponse to egg cholesterol predicts plasma lutein and β-carotene concentrations in men and womenClark RM, J Nutr 2006; 136: 601–7

GLV supplements increased plasma β-carotene, vit amin C, zinc and hemoglobin in young healthy adultsAgte V, Eur J Nutr 2006; 45: 29–36

Clinical research

Changes in conjugated linoleic acid and palmitoleic acid are cor-related to retinol levels in chronic renal failureLucchi L, Artif Organs 2005; 29: 413–8

Serum and CSF vitamin A con-centrations in idiopathic intrac-ranial hypertensionTabassi A, Neurology 2005; 64: 1893–6

Hypervitaminosis A-induced liver fibrosisNollevaux MC, Liver Int 2006; 26: 182–6

Serum retinoic acid, retinol and retinyl palmitate levels in patients with lung cancerMoulas AN, Respirology 2006; 11: 169–74

Zinc and vitamin A supplemen-tation in Indigenous Australian children hospitalized with lower respiratory tract infectionChang AB, Med J Aust 2006; 184: 107–12

www.sightandlife.org


Letters to the editor

Fortification of edible oil with vitamin A and carotene

Dear Sir

Your SIGHT AND LIFE Newslet-ter 1/2006 included a paper on vitamin A fortification of edible oil as a cost-effective and sustain-able intervention program to sup-ply vitamin A to the population. It was good to know that vitamin A fortification of edible soybean oil was voluntarily implemented in Bangladesh: I hope the same will happen in other countries. In the 1990s our Brazilian nutrition group started to study and to put together scientific data to support the utilization of cooking oil as a vitamin A and carotene carrier to prevent vitamin A deficiency. One of the main obstacles for its use was the prestige of other ve-hicles like wheat flour and sugar, and the fact that vitamin A, be-ing heat-sensitive, could not be added to a cooking ingredient. Our first published paper (1991) on the subject studied the stabil-ity of vitamin A added to refined soybean oil during cooking and storage. It was shown that, after 6 – 9 months of storing the oil in sealed metal cans at room tem-perature, the content of the vita-min A was still 99% of the original value. In open cans stored in a light environment the vitamin A content starts to decrease after 6 months. When the same fortified oil was used for the preparation of local rice and bean foods, boiling or under pressure, levels from 88% to 99% of the original vitamin A values were found. Levels of vitamin A in potatoes deep fried in vitamin A-fortified cooking oil at high temperature decreased slightly. Repeated frying of the same fortified oil at high temperature decreased the

amount of vitamin A incorporated into the potatoes (1). Standard biological trials on vitamin A depleted rats fed non-fortified and A-fortified cooking oil con-firmed its bioavailability based on plasma and liver vitamin A levels (2). A final confirmation of the bio-utilization of the vitamin A fortified oil was obtained in nor-mal human subjects by adding fortified oil to salad or to cooked food and measuring the post-absorption plasma peak rise and the area under the A-serum test curve. A control group receiving non-fortified oil did not show changes in comparison to their fasting plasma serum A levels, but the postprandial A plasma level increased threefold in sub-jects who received fortified oil (3). With these scientific studies we have provided a background of necessary scientific support for the use of cooking oil as a vitamin A carrier. Other similar studies were carried out with synthetic carotene also added to soybean oil. Rats receiv-ing diets with carotene-fortified soybean oil increased their liver vitamin A levels (4). Higher levels of plasma carotene were found when healthy adults received rice cooked with carotene-enriched soybean oil (5). We also advise mixing edible soybean and palm oil as a way to supply carotene. Although we did not explore this possibility further, it is certain to be effective. Anyway, our experi-mental and clinical studies sup-port vegetable oil as an effective vehicle to supply vitamin A or carotene to the relevant popula-tion. Unfortunately our studies have not received worldwide recognition. This is a rational and practical intervention and one of the best ways to supply people at community level with vita-min A and carotene. No special

equipment is needed to add the vitamins – it is just adding oil to oil. The work in Bangladesh will certainly prove again that cooking oil has to be accepted and used as one of the most effective and practical low-cost carriers for the control of vitamin A deficiency. I hope other countries will follow it as a voluntary or compulsory way to guarantee the necessary intake of vitamin A everywhere.

Prof. J E Dutra-de-Oliveira, MDMedical School of Ribeirão Preto, University of São Paulo, Brazil, [email protected]

References1. Favaro RMD, Ferreira J, Desai ID,

Dutra-de-Oliveira JE (1991). Studies on the fortification of refined soybean oil with all-trans-retinyl palmitate in Brazil. J Food Comp Anal 4: 237–244.

2. Favaro RMD, Miyassaka C, Desai ID, Dutra-de-Oliveira JE (1992). Evalua-tion of the effect of heat treatment on the biological value of vitamin A forti-fied soybean oil. Nutrition Research, 12: 1357–1363.

3. Dutra-de-Oliveira JE, Desai ID, Favaro RMD, Ferreira JF (1994). Ef-fect of heat treatment during cooking on the biological value of vitamin A fortified soybean oil in humans. Int J Food Sci Nutr 45: 203–207.

4. Dutra-de-Oliveira JE, Favaro RMD, Leonardo IR, Franco MVMJ, Car-valho CG, Jordão Jr AA, Vannucchi H (1994). Effect of heat treatment in the biological value of carotene added to soybean cooking oil in rats. Int J Food Sci Nutr 49: 205–209

5. Dutra-de-Oliveira JE, Favaro RMD, Leonardo IR, Jordão Jr AA, Vannuc-chi H (1998). Absorption, by humans, of carotene from fortified soybean oil added to rice: Effect of heat treat-ment. J Am Coll Nutr 17: 361–365t of heat treatment. J Am Coll Nutr 17: 361–365

Please update your Please update your address and help to address and help to avoid unnecessary avoid unnecessary work and expenseswork and expenses


Continue with support

Dear Sir

In my letter printed in the SIGHT AND LIFE Newsletter 3/2005 I already expressed my thanks to SIGHT AND LIFE. Again I would like to express how helpful all the items I’m receiving are.

Although we are at quite a re-mote place, we normally follow the national campaign to give a vitamin A capsule and a deworm-ing tablet to all children under the age of five years every year, in December. Many health units here have benefited from this sys-tem to improve their vaccination coverage records. The provision of vaccines to all children from 9 months to five years of age has increased from 68% in 2001 to 87.7% in 2005. The coverage of vitamin A supplementation increased from 54% (2001) to 89.4% (2005).

I ask SIGHT AND LIFE to please continue with their support to help me gain more knowledge and better health education, so that I might be able to help the Tanzanians more successfully.

Sincerely,AImandus John Bosco, Mtambo Dispensary, Mpanda, Tanzania

Nkhoma Hospital eye program

Dear Sir

Nkhoma is situated in a rural area of Central Malawi with a popula-tion of predominantly subsistence farmers. We serve some of the poorest people in the world. I was posted to Nkhoma six years ago by the Christoffel Blind Mission International (CBMI) to implement a VISION 2020 Program.

Malawi has a population of over 11 million with over 100,000 blind. Vitamin A deficiency, cata-ract and traditional eye medicine account for a high proportion of blindness in children. There are seven ophthalmologists working in Malawi and I am the only one working in a Mission Hospital. During 2005 a total of 9,865 cata-ract operations were carried out in Malawi. Nkhoma accounted for 45% of this total. Also, the number of outpatients increased by more than five times in recent years (2005: 23,077)

The patients are brought to Nkhoma and returned home in the Eye Department vehicle, operated on and provided with meals, all free of charge. We are dedicated to providing a high volume and high quality service. This has been achieved by the excellent team work and dedica-tion of my 27 full time Malawian staff. I thank my staff and others in Malawi and around the world who support us.

We are receiving financial and logistical support through CBMI and we are closely cooperat-ing with the Malawi Ministry of Health and non-governmental organizations to ensure the lim-ited resources are utilized to the maximum. We also thank SIGHT AND LIFE for the very useful vitamin A capsules. Neverthe-less, problems remain such as management, construction and

Vitamin A related support from SIGHT AND LIFE

Dear Sir

We are very thankful for the infor-mation materials and the vitamin A capsules we have received, and naturally for the financial support from SIGHT AND LIFE.

We follow the global agree-ment on the need to combat vitamin A deficiency by applying basic strategies to increase the consumption of foods rich in vitamin A or to provide periodic vitamin A supplements to high risk groups.

Public health and nutrition com-munities should always recognize the need to improve the vitamin A status of young children. Vitamin A supplementation as an approach is among the most cost-effective health interventions available. Therefore, as an organization, we are committed to vitamin A defi-ciency prevention programs.

Mr. Laodicah Nyaribari Nyambati, Director, Chelma Advisory Insti-tute, Kisii 40200, Kenya

staff problems. Also, for example, in the optical department most lenses have been out of stock for six months.

Dr. Nick MetcalfeDirector


Food and Nutrition: a Handbook for Namibian Volunteer Leaders

The Government of the Republic of Namibia (GRN), through the Technical Co-operation Program (TCP) of the Food and Agriculture Organization of the United Na-tions (FAO), launched a new pro-gram called Rural Youth Clubs of Namibia (RYCN), as an outreach for the Rural Youth Development Program.

This program has been designed and tested as a unique methodol-ogy for reaching large numbers of young people, living in even the most isolated rural villages of Na-mibia, with leadership develop-ment and organizational skills as well as non-formal education and training in agriculture and related areas. It has been successfully demonstrated that the new RYCN is an effective delivery mecha-nism enabling rural young people, primarily those who are out of school, to gain basic knowledge, skills and experiences in agricul-ture, nutrition, health, environ-

ment and other essential skills for living. Education and training involves practical, activity-based learning and income-generating activities. By taking this train-ing approach to even the most remote villages, large numbers of our youth should be empow-ered into making economically rewarding and satisfying lives for themselves and their families in rural Namibia.

This manual is designed as a field handbook and guideline docu-ment for rural youth club leaders to enable them to employ coping strategies in nutritional activities taking into account the prevail-ing economic patterns in their respective communities. It was developed through participatory and experiential approaches in-volving the rural young people in selected communities in northern Namibia, a process that involved collaboration with other line ministries such as the Ministry of Agriculture, Water and Rural Development and the Ministry of Health and Social Services.Food and Nutrition: Minister of Higher Education, Training and Employment, Creation, Private Bag 13391, Windhoek, Namibia

Obesity: Dietary and Developmental Influences

Focusing on prevention rather than treatment, Obesity: Dietary and Developmental Influences, reviews and evaluates the de-terminants of obesity. The book uses evidence-based research as a basis to define foods and dietary behaviors that should be supported and encouraged as well as those that should be dis-couraged. This comprehensive

PublicationsSIGHT AND LIFE presents recent publications which may be of particular interest to our readers. However, these publications are not available from SIGHT AND LIFE, nor do we have any privileged access to them.

review represents a critical step forward in the quest to iden-tify feasible strategies to prevent obesity.

The book describes the potential role of 26 different dietary factors and eight developmental peri-ods in the prevention of obesity among children and adults. The dietary factors examined include macronutrients, micronutrients, specific types of foods and bev-erages, snack and meal patterns, portion size, parenting practices, breastfeeding, and more. The fac-tors from each developmental pe-riod in the life cycle are examined in the context of the likelihood of obesity development. For each dietary factor and developmental period, four lines of evidence are examined: secular trends, plau-sible mechanisms, observational studies, and prevention trials.

Providing easy access to informa-tion, the book features 38 tables that summarize observational studies, 38 graphs depicting trends in dietary intake, and nine tables that summarize preven-


tion trials. It provides a synopsis of the latest research on obesity, investigating all major lines of evidence, and clarifies common misconceptions while identifying which behaviors to target and which dietary factors show the most promise for prevention.

CRC Press, Taylor & Francis, New York,http://taylorandfrancis.com

Setting up and running a school garden

Adequate nutrition and education are key to the development of chil-dren and their future livelihoods. The reality facing millions of chil-dren, however, is that these es-sentials are far from being met.

A country’s future hinges on its youth. Yet children who go to school hungry cannot learn well. They have decreased physical activity, diminished cognitive abil-ities and reduced resistance to infections. Their school perform-ance is often poor and they may drop out of school early. In the long term, chronic malnutrition decreases individual potential and has adverse affects on pro-ductivity, incomes and national development.

its use. All contributors are listed with their contact details. Among many others, the SIGHT AND LIFE CD was useful as a resource and several SIGHT AND LIFE publications, Newsletter articles and slides are included.

The introduction states: “This CD-ROM ... is intended for you if you work with resources-poor com-munities and are training health and other types of development workers and have limited access to nutrition-related materials, particularly if you do not have access to the Internet... Nutrition is a fast-changing world – most of us have very heavy workloads and it is difficult to keep updated with recent developments.”

Ann Burgess, a nutrition consult-ant who worked intensively on this project, commented that the contribution from SIGHT AND LIFE was very useful. At this time 5000 copies are being produced. For distribution, the priority is to get copies to target users such as health practitioners and de-velopment workers in developing countries and their trainers who have limited access to nutrition materials.

To request a copy of the CD please contact TALC at [email protected] or visit the TALC website http://www.talcuk.org, which also gives information on other TALC nutri-tion related education materials.

Schools can make an important contribution to countries’ efforts to overcome hunger and malnu-trition, and school gardens can help to improve the nutrition and education of children and their families in both rural and urban areas.

FAO promotes school gardens primarily as a platform for learn-ing, as well as a vehicle for better nutrition. Schools are encouraged to create learning gardens that are moderate in size so that they can be easily managed by students, teachers and parents, but that also allow for the production of a variety of nutritious vegetables and fruits (and where possible, some small-scale livestock such as chickens or rabbits). Produc-tion methods are kept simple so that they can be easily replicated by students and parents at their homes.

In preparing this manual, intended to assist school teachers, parents and the wider community, FAO has drawn upon experiences and best practices derived from school garden initiatives all over the world. Classroom lessons are linked with practical learning in the garden about nature and the environment, food production and marketing, food processing and preparation, and making healthy food choices.Setting up and running a school garden: FAO, Via Delle Terme di Caracalla, 00100 Rome, Italy

Community Nutrition

A new CD-ROM intended as a teaching material resource has just been produced by Teach-ing-aids At Low Cost (TALC), a UK-based group, with financial support by UNICEF. It contains materials from many sources around the world. Each item (mostly produced between the years 2000 and 2005) is present-ed with a short explanation about


The Micronutrient Forum will hold its first international meeting in Istanbul, Turkey on 16–18 April 2007. The theme of the meeting is “Consequences and Control of Micronutrient Deficiencies: Science, Policy, and Programs – Defining the Issues”.

The Micronutrient Forum builds on the success of the Internation-al Vitamin A Consultative Group (IVACG) and the International Nutritional Anemia Consultative Group (INACG), which were both established by the United States Agency for International Develop-ment (USAID) in 1975.

The Micronutrient Forum will serve as a stimulus for policy-relevant science and as the internationally recognized catalyst for moving the global community towards consensus around evidence-based policies and programs that reduce micronutrient deficiencies around the globe.

Meeting participants are welcome from a wide diversity of relevant disciplines such as maternal and child health, nutrition, biochem-istry, agriculture, horticulture, education, communications, and development. Participants are ex-pected to include representatives from international agencies, na-tional ministries, educational and research institutions, food and chemical industries, and non-governmental organizations.

Program managers and research-ers are encouraged to submit ab-stracts for oral and poster pres-entations describing new data on the topics that follow. Abstracts must pertain to the micronutrient deficiencies of primary interest to the Micronutrient Forum, namely vitamin A, iron, folate, iodine, and/or zinc.• Defining “Deficiency Disorders”• Systems for increasing multiple

micronutrient status• Health consequences of micro-

nutrient deficiencies• The relevance of micronutrient-

micronutrient interactions on mi-cronutrient intervention design

• Cost, coverage, sustainability, and impact of micronutrient in-tervention programs

• The science base needed for national policy formulation and program commitment

• The interactions of micronutrients with infectious diseases

Preference will be given to ab-stracts describing well-designed studies, providing new and poten-tially important findings with data that relate to the above topics.

For more information and to submit your abstract visit: www.a2zproject.org

To submit your abstract di-rectly visit: http://ilsi.confer-ence-services.net/authorlogin.asp?conferenceID=888&lan

Abstracts must be received by 15 August 2006.

To receive more information about the Micronutrient Forum, con-tact the Micronutrient Forum Secretariat at the ILSI Research Foundation, One Thomas Circle, NW, Ninth Floor, Washington, DC 20005-5802, USA. Email: [email protected].

Travel Grants

A limited number of travel grants will be available to help enable participation at the Micronutrient Forum meeting. Each grant will cover some portion of transporta-tion to and from the meeting site, meals, and/or lodging during the event. Preference will be given to individuals whose abstracts are selected for presentation. As one of the sponsors of travel grants for the Micronutrient Fo-rum, SIGHT AND LIFE encour-ages students and post-docs from low-income countries to submit abstracts for the Micronutrient Forum. To apply for a travel grant, please write to the Micronutrient Forum secretariat at [email protected]. In your letter, describe any other financial support you expect to have for your meeting participa-tion. If you are a student or a post-doc, please also attach a let-ter of recommendation from your advisor or supervisor, providing a larger picture of your work. The selection of abstracts for presentation is the responsibility of the organizers of the Micronutri-ent Forum. Some restrictions may accompany the grants.

Call for abstracts

Micronutrient Forum“Consequences and Control of Micronutrient Deficiencies: Science, Policy, and Programs – Defining the Issues”, 16–18 April 2007, Istanbul, Turkey


Anemia is a major health concern in developing countries as well as in the developed world. It im-pairs growth and development, cognition and immune function, as well as school and work per-formance. Anemia affects more than two billion people world-wide, and has a negative impact on economic growth, particularly in low-income countries. Only about half of anemia is thought to be related to iron deficiency; other micronutrient deficiencies such as vitamin A, vitamin C, B-vitamins, zinc and copper as well as infections and undernutrition

Scientific Program, Session 1: Physiology, Metabolism, and InteractionsModerators: James Cook, Kansas City (USA); John Scott, Dublin (IRL)

08:30 – 08:40 Welcome – Klaus Kraemer, Basel (CH); Michael B. Zim-mermann, Zurich (CH)

08:40 – 09:00 Introduction – Venkatesh Mannar, Toronto (CAN); James Cook, Kansas City (USA); Nevin S. Scrimshaw, Boston (USA)

09:00 – 09:15 Iron Metabolism – Sean Lynch, Norfolk (USA)09:15 – 09:30 Bioavailability of Iron Forms and Enhancers – Richard

Hurrell, Ines Egli, Zurich (CH)09:30 – 09:45 Copper and Zinc Interactions in Anemia: a Public

Health Perspective – Ricardo Uauy, London (UK)09:45 – 10:00 Folate, Vitamin B12 and other B-Vitamins – John Scott,

Dublin (IRL) 10:00 – 10:15 Vitamin A – Keith P. West, Alfred Sommer, Baltimore

(USA)10:15 – 10:30 Vitamin E and other Antioxidants – Maret G. Traber,

Corvallis (USA)10:30 – 11:00 Coffee and Tea11:00 – 11:15 Interactions of Micronutrients – Michael B. Zimmer-

mann, Zurich (CH)11:15 – 11:30 Protein Energy Malnutrition – Alan Jackson, South-

ampton (UK)11:30 – 11:45 Effect of Infections on Nutritional Anemia – David

Thurnham, Coleraine (UK)11:45 – 12:00 Diagnosis of Anemia – Hans-Konrad Biesalski, Hohen-

heim (DE); Jürgen Erhardt, Jakarta (IND) 12:00 – 13:00 Discussion13:00 – 14:30 Lunch

also play a crucial role. Guidelines for supplementation and food fortification to address anemia usually focus on iron and folic acid, however. On this account, we feel that it is timely to highlight all contributing factors in a work-shop on Nutritional Anemia.

Top international experts from dif-ferent fields related to Nutritional Anemia have agreed to make presentations to the workshop. The satellite workshop is being organized by Klaus Kraemer (SIGHT AND LIFE, Basel) and Michael B. Zimmermann (Swiss

Federal Institute of Technology, Zurich). It will be held at the Bar-celona Hilton Hotel on 27 Sep-tember 2006, the day before the opening of the I World Congress of Public Health Nutrition, Bar-celona, 28–30 September 2006 (http://www.nutrition2006.com). The Nutritional Anemia workshop is planned to correspond closely with the Congress of Public Health Nutrition, and thus to pro-vide a forum for networking and alliance building. The workshop on Nutritional Anemia is an open event for those interested in gain-ing insight into the latest develop-ments in this topic area.

The proceedings of the workshop will be published early next year. We expect this publication to be highly authoritative and provide expert guidance on the preven-tion and treatment of Nutritional Anemia.

The workshop and publication will be sponsored by SIGHT AND LIFE, Basel (www.sightandlife.org). In focusing on Nutritional Anemia SIGHT AND LIFE is pursuing its new mission of ad-dressing multiple micronutrient deficiencies (hidden hunger) re-lated to important health issues in developing countries.

For registration please contact SIGHT AND LIFE, PO Box 2116, 4002 Basel, Switzerland. Email: [email protected]

SIGHT AND LIFE Workshop Nu-tritional Anemia

Venue: Hilton Barcelona, 27 Sep-tember 2006

Organizers: Klaus Kraemer, SIGHT AND LIFE, Basel, and Michael B. Zimmermann, Swiss Federal Institute of Technology, Zürich

SIGHT AND LIFE Workshop Nutritional Anemia


Scientific Program, Session 2: Prevalence, Interventions, and EconomyModerators: Nevin S. Scrimshaw, Boston (USA); Venkatesh Mannar, Toronto (CAN)

14:30 – 14:45 Worldwide Prevalence of Anemia – Erin McLean, Ge-neva (CH); Ines Egli, Zurich (CH); Bruno de Benoist, Geneva (CH)

14:45 – 15:00 Strategies to Fight Nutritional Anemia – Martin Bloem, Rome (I); Regina Moench-Pfanner, Geneva (CH); Rich-ard Semba, Baltimore (USA)

15:00 – 15:15 Successful Approaches with Sprinkles - Stanley Zlot-kin, Toronto (CAN)

15:15 – 15:30 Technical Aspects of Programs – Omar Dary, Wash-ington (US)

15:30 – 15:45 Safety of Interventions – Noel Solomons, Guatemala City (GUA); Klaus Schümann, Munich (DE)

15:45 – 16:00 Economic Impact of Anemia and Cost Effectiveness of Interventions – Harold Alderman, Meera Shekar, Washington (USA); Sue Horton, Waterloo (CAN)

16:00 – 16:15 Global Perspectives – Ian Darnton-Hill, New York (USA); Tommaso Cavalli-Sforza, Manila (PHI)

16:15 - 16:45 Coffee and Tea16:45 – 18:00 Discussion18:00 – 18:15 Summary – Klaus Kraemer, Basel (CH); Michael B.

Zimmermann, Zurich (CH)

www.sightandlife.org

A new issue of the SIGHT AND LIFE CD

The updated CD with almost the complete content of the our website is in preparation. It will be dated of August 2006. As the capacity of the disc is limited, some adjustments were needed, and the new CD does not replace the older ones, which may con-tain objects such as the movies or some pictures in higher resolu-tion. The new CD will be available soon from SIGHT AND LIFE.

The SIGHT AND LIFE art gallery

We still have some of the posters presented in the Newsletter 2/2004 on pp. 50–51. Printable PDFs are on our website at (http://sightandlife.org/poSALartGal/aasalpo.html)

Publisher: SIGHT AND LIFEEditor: Klaus KraemerAssistance: Anne-Catherine Frey, Martin Frigg Translation and language: transparent - translation & text services, Berlin, Yvonne Bearne

SIGHT AND LIFE is a humanitar-ian initiative of DSM Nutritional Products (for more information see the SIGHT AND LIFE website: www.sightandlife.org). We are committed to the improvement of nutrition and health with emphasis on children and mothers in devel-oping countries. It is the aim of SIGHT AND LIFE to combat ‘hid-den hunger’, and to raise aware-ness of micronutrient deficiencies as public health issues.

Low micronutrient intakes and other forms of malnutrition are impairing the health of many people in numerous developing countries. The most vulnerable groups are children and mothers. Increased health risk with suscep-

SIGHT AND LIFE PO Box 2116, 4002 Basel Switzerland. Tel.: +41 61 688 74 94 Fax: +41 61 688 19 10E-mail: [email protected]://sightandlife.org ISBN 3-906412-31-8

tibility to infections and increased child and maternal mortality are the consequences. Moreover, this impairs growth and development, cognition, vision and immune function, as well as school and work performance.

For its humanitarian work, SIGHT AND LIFE can draw on the expertise in nutrition, technol-ogy and analytics of DSM Nu-tritional Products. SIGHT AND LIFE supports many locally and internationally active organiza-tions. It has sponsored research, application projects, training of health professionals, and health and nutrition education in many countries in Africa, Asia and Latin America.

Support is given in the form of vitamin A capsules, premixes containing micronutrients, grants, information and educational ma-terials such as manuals, books, posters, reprints, etc. Further-more, SIGHT AND LIFE gives technical assistance where re-quired and promotes training and education in order to increase local knowledge and expertise, and works towards sustainable improvement of nutrition.

SIGHT AND LIFE publishes edu-cational materials as well as the SIGHT AND LIFE Newsletter to increase knowledge on micronu-trient nutrition and health, and to disseminate relevant information on programs and scientific news.

Printer: Druckerei Dietrich, BaselOpinions, compilations and figures con tained in the signed articles do not necessarily represent the point of view of SIGHT AND LIFE and are solely the responsibility of the authors.


Women in Burkina Faso during “good nutrition training”, see article on page 35.

sight and lifesight and life 2 newsletter 2/2006 sight and life is a humanitarian initiative of dsm...

Documents