Vitamin E supplementation in people with cystic fibrosis.

BACKGROUND: People with cystic fibrosis are at an increased risk of fat-soluble vitamin deficiency, including vitamin E. Vitamin E deficiency can cause a host of conditions such as haemolytic anaemia, cerebellar ataxia and cognitive difficulties. Vitamin E supplementation is widely recommended for people with cystic fibrosis and aims to ameliorate this deficiency. This is an updated version of the review. OBJECTIVES: To determine the effects of any level of vitamin E supplementation on the frequency of vitamin E deficiency disorders in people with cystic fibrosis. SEARCH METHODS: We searched the Cochrane Group's Cystic Fibrosis Trials Register and also searched international online trial registries for any ongoing clinical trials that were not identified during our register search. Date of last search of the Register: 11 August 2020. Date of last search of international online trial registries: 20 July 2020. SELECTION CRITERIA: Randomised controlled trials and quasi-randomised controlled trials comparing any preparation of vitamin E supplementation to placebo or no supplement, regardless of dosage or duration. DATA COLLECTION AND ANALYSIS: Two authors extracted outcome data from each study (published information) and assessed the risk of bias of each included study. They assessed the quality of the evidence using GRADE. MAIN RESULTS: Four studies with a total of 141 participants were included in the review, two of these were in children (aged six months to 14.5 years), and two did not specify participants' age. All studies used different formulations and doses of vitamin E for various durations of treatment (10 days to six months). Two studies compared the supplementation of fat-soluble as well as water-soluble formulations to no supplementation in different arms of the same study. A third study compared a water-soluble formulation to a placebo; and in the fourth study a fat-soluble formulation of vitamin E was assessed against placebo. There was limited detail about randomisation and blinding in the included studies which compromises the quality of the evidence base for the review. The heterogeneous mix of the formulations with differing biovailabilities among these studies also limits the generalisability of the data to the wider cystic fibrosis population. None of the studies in either comparison report the review's primary outcomes of vitamin E total lipid ratio or the incidence of vitamin E-specific deficiency disorders, or the secondary outcomes lung function or quality of life. Water-soluble vitamin E Water-soluble vitamin E may improve serum vitamin E levels compared with control at six months, one study (45 participants), mean difference (MD) 19.74 umol/L (95% confidence interval (CI) 13.48 to 26.00) (low-quality evidence). Similar results were also seen at one month, two studies (32 participants), MD 17.66 umol/L (95% CI 10.59 to 24.74) and at three months, one study (45 participants), MD 11.61 umol/L (95% CI 4.77 to 18.45). Only one study (45 participants) reported weight (secondary outcome of growth and nutritional status) at one and six months, but showed no difference between treatment and control at either time point. Fat-soluble vitamin E Two studies (36 participants) reported higher levels of serum vitamin E at one month with fat-soluble vitamin E compared with control, MD 13.59 umol/L (95% CI 9.52 to 17.66); however, at three months one study (36 participants) showed no difference between treatment and control. No studies in this comparison reported on growth or nutritional status. AUTHORS' CONCLUSIONS: Vitamin E supplementation may lead to an improvement in vitamin E levels in people with cystic fibrosis, although evidence we assessed was low quality. No data on other outcomes of interest were available to allow conclusions about any other benefits of this therapy. In future, larger studies are needed, especially in people already being treated with enteric-coated pancreatic enzymes and supplemented with vitamin E, to look at more specific outcome measures such as vitamin E status, lung function and nutritional status. Future studies could also look at the optimal dose of vitamin E required to achieve maximal clinical effectiveness.

Tocopherols, tocotrienols and tocomonoenols: Many similar molecules but only one vitamin E.

The aim of this article is to correct a very general error in scientific articles, in textbooks and in the Internet that has become an accepted fact. In this literature, the term "vitamin E″ is used for several similar molecules (both tocopherols and tocotrienols) that have never been shown to have vitamin property, i.e. a protective effect against the human deficiency disease. In fact, the name "vitamin E″ should only be used to define molecules that prevent the human deficiency disease "Ataxia with Vitamin E Deficiency" (AVED). Only one such molecule is known, α-tocopherol. This error may confuse consumers as well as medical doctors, who prescribe vitamin E without realizing that the current use of the name includes molecules of unknown, if not unwanted functions.

Vitamin E - The Next 100 Years.

α-Tocopherol is the only tocopherol that has been shown to prevent the human deficiency disease Ataxia with Isolated Vitamin E Deficiency (AVED), and thus it is the only one that, for humans, can be called vitamin E. Vitamin E in addition to preventing AVED has documented immune boosting properties and an activity against nonalcoholic hepatosteatosis and low-grade inflammation. Epidemiological studies indicating that vitamin E could prevent cardiovascular events, neurodegenerative disease, macular degeneration, and cancer were in general not confirmed by clinical intervention studies. Vitamin E and some of its metabolites modulate cell signaling and gene transcription. Future research is needed to achieve a better understanding of the molecular events leading to gene regulation by vitamin E, especially in its phosphorylated form. Isolation and characterization of the vitamin E kinase and vitamin E phosphate phosphatase will help in the understanding of cell regulation processes modulated by vitamin E. A clarification of the pathogenesis of AVED remains an important goal to be achieved. © 2018 IUBMB Life, 71(4):411-415, 2019.

Update on Vitamin E and Its Potential Role in Preventing or Treating Bronchopulmonary Dysplasia.

Vitamin E is obtained only through the diet and has a number of important biological activities, including functioning as an antioxidant. Evidence that free radicals may contribute to pathological processes such as bronchopulmonary dysplasia (BPD), a disease of prematurity associated with increased lung injury, inflammation and oxidative stress, led to trials of the antioxidant vitamin E (α-tocopherol) to prevent BPD with variable results. These trials were all conducted at supraphysiologic doses and 2 of these trials utilized a formulation containing a potentially harmful excipient. Since 1991, when the last of these trials was conducted, both neonatal management strategies for minimizing oxygen and ventilator-related lung injury and our understanding of vitamin E isoforms in respiratory health have advanced substantially. It is now known that there are differences between the effects of vitamin E isoforms α-tocopherol and γ-tocopherol on the development of respiratory morbidity and inflammation. What is not known is whether improvements in physiologic concentrations of individual or combinations of vitamin E isoforms during pregnancy or following preterm birth might prevent or reduce BPD development. The answers to these questions require adequately powered studies targeting pregnant women at risk of preterm birth or their premature infants immediately following birth, especially in certain subgroups that are at increased risk of vitamin E deficiency (e.g., smokers). The objective of this review is to compile, update, and interpret what is known about vitamin E isoforms and BPD since these first studies were conducted, and suggest future research directions.

Effect of RRR-α-tocopherol supplementation on serum of breastfeeding women up to 60 days after delivery: a randomised controlled trial.

BACKGROUND: Maternal supplementation is a viable strategy to combat vitamin E deficiency in newborns, although a protocol for maternal vitamin E supplementation has not been defined. The present study assessed the effect of maternal supplementation in a single dose on the serum of postpartum women up to 60 days after delivery. METHODOLOGY: Fifty healthy breastfeeding women were recruited at two maternity hospitals both located in Natal, RN, Brazil. The participants were randomly allocated to a control group and a treatment group in a 1 : 1 ratio. Serum was collected 1, 20, 30 and 60 days after delivery. Immediately after the first collection, the treatment group received a single dose of 400 IU of RRR-α-tocopherol. α-Tocopherol was quantified by high-performance liquid chromatography. The usual dietary vitamin E intake was determined using four 24-h recalls, and intake adequacy was assessed based on the estimated average requirements for lactating women (16 mg day-1 ). RESULTS: The mean dietary vitamin E intakes of the both groups were similar (P > 0.05) and inadequate. The serum levels of α-tocopherol assessed at 1, 20, 30 and 60 days indicated adequate vitamin E status in both the control group (1194.6, 907.7, 910 and 748.6 µg dL-1 , respectively) and treatment group (1183.7, 956.0, 935.9 and 766.4 µg dL-1 , respectively). The comparison at each day showed no difference between treatments (P > 0.05). CONCLUSIONS: A single vitamin E supplement did not change the mean serum level of α-tocopherol in breastfeeding women; thus, it does not improve their vitamin E status in the first 60 days after delivery.

Vitamin E supplementation in people with cystic fibrosis.

BACKGROUND: People with cystic fibrosis are at an increased risk of fat-soluble vitamin deficiency including vitamin E. Vitamin E deficiency can cause a host of conditions such as haemolytic anaemia, cerebellar ataxia and cognitive difficulties. Vitamin E supplementation is widely recommended in cystic fibrosis and aims to ameliorate this deficiency. This is an updated version of the review. OBJECTIVES: To determine the effects of any level of vitamin E supplementation on the frequency of vitamin E deficiency disorders in people with cystic fibrosis. SEARCH METHODS: We searched the Cochrane Group's Cystic Fibrosis Trials Register and also searched international trial registers for any ongoing clinical trials that were not identified during our register search.Date of last search of the Register: 10 October 2016. Date of last search of international trial registers: 15 February 2017. SELECTION CRITERIA: Randomised controlled trials and quasi-randomised controlled trials comparing any preparation of vitamin E supplementation to placebo or no supplement, regardless of dosage or duration. DATA COLLECTION AND ANALYSIS: Two authors extracted outcome data from each study (published information) and assessed the risk of bias of each included study. MAIN RESULTS: Four studies with a total of 141 participants were included in the review, two of these were in children (aged six months to 14.5 years), and the other two did not specify participants' age. All studies used different formulations and doses of vitamin E for various durations of treatment (10 days to six months). Two studies compared the supplementation of fat-soluble as well as water-soluble formulations to no supplementation in different arms of the same study. A third study compared a water-soluble formulation to a placebo; and in the fourth study a fat-soluble formulation of vitamin E was assessed against placebo.At one month, three months and six months, water-soluble vitamin E significantly improved serum vitamin E levels compared with control: at one month, two studies, mean difference 17.66 (95% confidence interval 10.59 to 24.74); at three months, one study, mean difference 11.61 (95% confidence interval 4.77 to 18.45); and at six months, one study, mean difference 19.74 (95% confidence interval 13.48 to 26.00). At one month fat-soluble vitamin E significantly improved serum vitamin E levels compared with control: one month, two studies, mean difference 13.59 (95% CI 9.52 to 17.66). The findings at three months were imprecise; one study; mean difference 6.40 (95% confidence interval -1.45 to 14.25).None of the studies report the review's primary outcomes of vitamin E total lipid ratio or the incidence of vitamin E-specific deficiency disorders, or the secondary outcomes lung function or quality of life. Only one study, comparing water-soluble vitamin E with placebo, reported the secondary outcome of growth and nutritional status (weight), but the results are uncertain due to imprecision around the effect estimate.There was limited detail about randomisation and blinding in the included studies which compromises the quality of the evidence base for the review. The heterogeneous mix of the formulations with differing biovailabilities among these studies also limits the generalisability of the data to the wider cystic fibrosis population. AUTHORS' CONCLUSIONS: Vitamin E supplementation led to an improvement in vitamin E levels in people with cystic fibrosis, although the studies may have been at risk of bias. No data on other outcomes of interest were available to allow conclusions about any other benefits of this therapy.In future, larger studies are needed, especially in people already being treated with enteric-coated pancreatic enzymes and supplemented with vitamin E, to look at more specific outcome measures such as vitamin E status, lung function and nutritional status. Future studies could also look at the optimal dose of vitamin E required to achieve maximal clinical effectiveness.

Oral Tocofersolan Corrects or Prevents Vitamin E Deficiency in Children With Chronic Cholestasis.

OBJECTIVES: D-Alpha-tocopheryl polyethylene glycol 1000 succinate (Tocofersolan, Vedrop), has been developed in Europe to provide an orally bioavailable source of vitamin E in children with cholestasis. The aim was to analyze the safety/efficacy of Vedrop in a large group of children with chronic cholestasis. METHODS: Two hundred seventy-four children receiving Vedrop for vitamin E deficiency or for its prophylaxis were included from 7 European centers. Median age at treatment onset was 2 months and median follow-up was 11 months. Vedrop was prescribed at a daily dose of 0.34 mL/kg (25 IU/kg) of body weight. Three methods were used to determine a sufficient serum vitamin E status: vitamin E, vitamin E/(total cholesterol), vitamin E/(total cholesterol + triglycerides). RESULTS: Before Vedrop therapy, 51% of children had proven vitamin E deficiency, 30% had normal vitamin E status and 19% had an unknown vitamin E status. During the first months of treatment, vitamin E status was restored in the majority of children with insufficient levels at baseline (89% had a normal status at 6 months). All children with a normal baseline vitamin E status had a normal vitamin E status at 6 months. Among children with an unknown vitamin E status at baseline, 93% had a normal vitamin E status at 6 months. A sufficient vitamin E status was observed in 80% of children with significant cholestasis (serum total bilirubin >34.2 µmol/L). No serious adverse reaction was reported. CONCLUSIONS: Vedrop seems a safe and effective oral formulation of vitamin E that restores and/or maintains sufficient serum vitamin E level in the majority of children with cholestasis, avoiding the need for intramuscular vitamin E injections.

Vitamin E intake, α-tocopherol levels and pulmonary function in children and adolescents with cystic fibrosis.

Pancreatic insufficiency cystic fibrosis (CF) patients receive vitamin E supplementation according to CF-specific recommendations in order to prevent deficiencies. It has been suggested that higher serum α-tocopherol levels could have protective effects on pulmonary function (PF) in patients with CF. Whether current recommendations are indeed optimal for preventing deficiency and whether vitamin E has therapeutic benefits are subjects of debate. Therefore, we studied vitamin E intake as well as the long-term effects of vitamin E intake, the coefficient of fat absorption (CFA) and IgG on α-tocopherol levels. We also examined the long-term effects of serum α-tocopherol and serum IgG on forced expiratory volume in 1 s expressed as percentage of predicted (FEV1% pred.) in paediatric CF patients during a 7-year follow-up period. We found that CF patients failed to meet the CF-specific vitamin E recommendations, but serum α-tocopherol below the 2·5th percentile was found in only twenty-three of the 1022 measurements (2 %). Furthermore, no clear effect of vitamin E intake or the CFA on serum α-tocopherol was found (both P≥ 0·103). FEV1% pred. was longitudinally inversely associated with age (P< 0·001) and serum IgG (P= 0·003), but it was not related to serum α-tocopherol levels. We concluded that in the present large sample of children and adolescents with CF, vitamin E intake was lower than recommended, but serum α-tocopherol deficiency was rare. We found no evidence that higher serum α-tocopherol levels had protective effects on PF. Adjustment of the recommendations to the real-life intake of these patients may be considered.

Maternal supplementation with natural or synthetic vitamin E and its levels in human colostrum.

OBJECTIVES: Newborns are considered a high-risk group for vitamin E deficiency. Breast milk is a source of alpha-tocopherol (α-TOH), a form of vitamin E that prevents deficiency. The present study aimed to assess whether supplementation with a natural or synthetic form of α-TOH, in addition to maternal sources of vitamin E, would increase the concentration of α-TOH in colostrum. METHODS: A total of 109 healthy lactating women were recruited from a Brazilian public maternity clinic and randomized into 3 groups: control without supplementation (n = 36), natural α-TOH supplementation (n = 40), and synthetic α-TOH supplementation (n = 33). Blood and colostrum samples were collected before and after supplementation to check the nutritional status of these women by high-performance liquid chromatography. The Kruskal-Wallis test was applied for independent samples, and Tukey test was used for 2-way analysis of the averages of the groups. The baseline nutritional status of vitamin E of all of the lactating women enrolled in the trial was considered adequate. RESULTS: Women who received supplementation had higher concentrations of α-TOH in colostrum than the control group, with 57% and 39% increases in women supplemented with the natural and synthetic forms of α-TOH, respectively. CONCLUSIONS: Supplementation with both forms of α-TOH increased vitamin E concentrations in colostrum; however, the natural form was more efficient in increasing the levels.

Vitamin E supplementation in people with cystic fibrosis.

BACKGROUND: People with cystic fibrosis are at an increased risk of fat-soluble vitamin deficiency including vitamin E. Vitamin E deficiency can cause a host of conditions such as haemolytic anaemia, cerebellar ataxia and cognitive difficulties. Vitamin E supplementation is widely recommended in cystic fibrosis and aims to ameliorate this deficiency. OBJECTIVES: To determine the effects of any level of vitamin E supplementation on the frequency of vitamin E deficiency disorders in people with cystic fibrosis. SEARCH METHODS: We searched the Cochrane Group's Cystic Fibrosis Trials Register and also searched international trial registers for any ongoing clinical trials that were not identified during our register search.Date of last search of the Register: 10 February 2014. Date of last search of international trial registers: 30 August 2014. SELECTION CRITERIA: Randomised controlled trials and quasi-randomised controlled trials comparing any preparation of vitamin E supplementation to placebo or no supplement, regardless of dosage or duration. DATA COLLECTION AND ANALYSIS: Two authors extracted outcome data from each study (published information) and assessed the risk of bias of each included study. MAIN RESULTS: Four studies with a total of 141 participants were included in the review, two of these were in children (aged six months to 14.5 years), and the other two did not specify participants' age. All studies used different formulations and doses of vitamin E for various durations of treatment (10 days to six months). Two studies compared the supplementation of fat-soluble as well as water-soluble formulations to no supplementation in different arms of the same study. A third study compared a water-soluble formulation to a placebo; and in the fourth study a fat-soluble formulation of vitamin E was assessed against placebo.At one month, three months and six months, water-soluble vitamin E significantly improved serum vitamin E levels compared with control: at one month, two studies, mean difference 17.66 (95% confidence interval 10.59 to 24.74); at three months, one study, mean difference 11.61 (95% confidence interval 4.77 to 18.45); and at six months, one study, mean difference 19.74 (95% confidence interval 13.48 to 26.00). At one month fat-soluble vitamin E significantly improved serum vitamin E levels compared with control: one month, two studies, mean difference 13.59 (95% CI 9.52 to 17.66). The findings at three months were imprecise; one study; mean difference 6.40 (95% CI -1.45 to 14.25).None of the studies report the review's primary outcomes of vitamin E total lipid ratio or the incidence of vitamin E-specific deficiency disorders, or the secondary outcomes lung function or quality of life. Only one study, comparing water-soluble vitamin E with placebo, reported the secondary outcome of growth and nutritional status (weight), but the results are uncertain due to imprecision around the effect estimate.There was limited detail about randomisation and blinding in the included studies which compromises the quality of the evidence base for the review. The heterogeneous mix of the formulations with differing biovailabilities among these studies also limits the generalisability of the data to the wider cystic fibrosis population. AUTHORS' CONCLUSIONS: Vitamin E supplementation led to an improvement in vitamin E levels in people with cystic fibrosis, although the studies may have been at risk of bias. No data on other outcomes of interest were available to allow conclusions about any other benefits of this therapy.In future, larger studies are needed, especially in people already being treated with enteric-coated pancreatic enzymes and supplemented with vitamin E, to look at more specific outcome measures such as vitamin E status, lung function and nutritional status. Future studies could also look at the optimal dose of vitamin E required to achieve maximal clinical effectiveness.

Bioavailability of vitamin E in humans: an update.

Vitamin E is essential for human health and may play a role in the prevention of some degenerative diseases. Its bioavailability, however, is wide ranging and is affected by numerous factors. Recent findings showing that the intestinal absorption of vitamin E involves proteins have raised new relevant questions about factors that can affect bioavailability. It is, therefore, opportune to present a current overview of this topic. This review begins by exploring what is known, as well as what is unknown, about the metabolization of vitamin E in the human upper gastrointestinal tract and then presents a methodical evaluation of factors assumed to affect vitamin E bioavailability. Three main conclusions can be drawn. First, the proteins ABCA1, NPC1L1, and SR-BI are implicated in the absorption of vitamin E. Second, the efficiency of vitamin E absorption is widely variable, though not accurately known (i.e., between 10% and 79%), and is affected by several dietary factors (e.g., food matrix, fat, and fat-soluble micronutrients). Finally, numerous unanswered questions remain about the metabolization of vitamin E in the intestinal lumen and about the factors affecting the efficiency of vitamin E absorption.

Vitamin E deficiency in developing countries.

In addition to its role as a potent antioxidant, vitamin E is involved in a wide range of physiological processes, ranging from immune function and control of inflammation to regulation of gene expression and cognitive performance. Results from multiple studies suggest that poor nutritional status and higher prevalence of other oxidative stressors such as malaria and HIV infection predispose populations in developing countries for vitamin E deficiency. Although direct comparison between study outcomes is complicated by varied definitions of vitamin E deficiency, data trends indicate that children and the elderly are more vulnerable age groups and that men may be at higher risk for deficiency than women. Public health initiatives aimed at improving the vitamin E status of high-risk populations in developing countries would be prudent to counteract oxidative stress, improve immune function, and protect against neurologic and cognitive deficits. Additional research is needed to establish dose-response relationships of various interventions and to develop cost-effective, culturally-appropriate, and targeted programs.

Status of vitamins A and E in schoolchildren in the centre west of Tunisia: a population-based study.

OBJECTIVE: The present study was undertaken to assess the status of vitamins A and E (VA and VE, respectively) and their main determinants in Tunisian children. DESIGN: Cross-sectional population-based study. SETTING: Kasserine Governorate in the centre west of Tunisia. SUBJECTS: A total of 7407 children attending the first grade of elementary school were included. VA and VE were assessed by HPLC. RESULTS: The prevalence of moderate VA deficiency (VAD; <0·70 µmol/l) was 2·3 % and VE deficiency (VED; <6·97 µmol/l) was 5·4 %. Low status in VA (0·70-1·05 µmol/l) and VE (6·97-11·61 µmol/l) was observed in 17 % and 20·2 % of children, respectively. No child exhibited severe VA or VE deficiency (<0·35 and <2·32 µmol/l, respectively). The main predictors of VAD were advanced age (OR = 1·65; 95 % CI 1·13, 2·41; P = 0·05) and sickness within the past 2 weeks (OR = 1·51; 95 % CI 1·09, 2·09; P = 0·01). Predictors of VED were living in the peri-urban region (OR = 1·60; 95 % CI 1·28, 2·01; P < 0·001) and sickness within the past 2 weeks (OR = 0·75; 95 % CI 0·60, 0·94; P = 0·01). CONCLUSIONS: Moderate VAD and VED were uncommon in Tunisian children. However, low status in VA and/or VE remains frequent. A reinforcement of the national strategies for children's nutrition and health is needed, particularly in disadvantaged regions. Supplementation of VA and VE is not necessary in Tunisia, but food fortification may be beneficial.

Alpha-tocopherol concentration in the colostrum of nursing women supplemented with retinyl palmitate and alpha-tocopherol.

BACKGROUND: Vitamins A and E are recognisably important in the initial stages of life, and the newborn depends on nutritional adequacy of breast milk to meet their needs. These vitamins share routes of transport to the tissues and antagonistic effects have been observed in animals after supplementation with vitamin A. The present study aimed to determine the effect of maternal supplementation with a megadose of retinyl palmitate in the immediate post-partum on α-tocopherol concentration in the colostrum. METHODS: Healthy parturient women at a Brazilian public maternity were recruited for the study and divided into two groups: control (n = 37) and supplemented (n = 36). Blood and colostrum samples were collected up to 16 h post-partum. The supplemented group was administered with a retinyl palmitate capsule and, 24 h after the first collection, the second colostrum sample was obtained in the two groups for analysis of α-tocopherol. The cut-off points for deficiency are <1.05 µmol L(-1) for retinol and <11.6 µmol L(-1) for α-tocopherol. RESULTS: The mean (SD) serum concentration of 1.77 (0.50) µmol L(-1) for retinol and 30.81 (6.46) µmol L(-1) for α-tocopherol indicates an adequate biochemical status. The supplemented group showed an increase of α-tocopherol in the colostrum 24 h after supplementation (P = 0.04), and this finding was not observed in the control group. CONCLUSIONS: Supplementation with a 200,000 IU megadose of vitamin A did not negatively affect α-tocopherol levels in colostrum.

Dietary counseling in the management of moderate malnourishment in children.

BACKGROUND: Dietary counseling is an integral part of treating malnutrition. A first step toward improving the management of moderate malnutrition is to evaluate dietary messages in current programs and assess their adequacy and effectiveness. OBJECTIVES: To ascertain current recommendations regarding family foods for the treatment of moderate malnutrition and assess whether these are likely to meet nutritional requirements for rehabilitation; to review the effectiveness of dietary counseling in the management of moderate malnutrition. METHODS: Information was requested from 10 United Nations agencies or donors, 20 international nongovernmental organizations, 3 pediatric associations, and 6 national programs about the dietary advice they give to caregivers of moderately malnourished children. Adequacy was assessed by comparing dietary recommendations with nutritional requirements. Linear programming was used to identify problem nutrients. A literature search was conducted of studies using family foods for rehabilitating malnourished children. RESULTS: There was a greater emphasis on providing food supplements for rehabilitation than on utilizing family foods. Dietary recommendations were mostly vague and unlikely to be effective. Those developed by the World Health Organization and the Food and Agriculture Organization for well-nourished children may meet nutritional requirements in moderate malnutrition if the recommendations are made more prescriptive. Zinc and vitamin E emerged as possible problem nutrients. Intervention studies in wasted children suggest that counseling caregivers about family foods can achieve good rates of weight gain. CONCLUSIONS: Dietary counseling can be effective in managing malnutrition, but it is often weak or absent and should be strengthened. More attention will need to be given to formulating the messages and improving counseling skills.

Vitamin E.

Vitamin E refers to a family of tocopherol and tocotrienol isomers discovered in 1922 as anti-infertility factor. Vitamin E deficiency causes infertility and delayed-onset ataxia in experimental animals, and it leads to neuronal dysfunctions in humans. However, based largely on its radical-scavenging antioxidant activity in vitro, vitamin E supplements are commonly thought to provide health benefits against diseases associated with oxidative damage, most notably cardiovascular diseases. Contrary to this belief, the outcome of recent large, prospective, randomized and placebo-controlled clinical studies does not encourage the use of vitamin E supplements. These overall disappointing results can be explained and substantiated by scientific data critically testing the strengths of evidence for many of the underlying assumptions and examining the possibility that in vivo vitamin E may have function(s) other than, or in addition to, acting as an antioxidant.