Is it time for South Africa to end the routine high-dose vitamin A supplementation programme?

In accordance with World Health Organization guidelines, South Africa (SA) introduced routine periodic high-dose vitamin A supplementation (VAS) in 2002. These guidelines were developed after research in the 1980s and 1990s showed the efficacy of VAS in reducing childhood mortality. However, two recent studies in low- to middle-income countries (2013 and 2014) have shown no effect of high-dose VAS on mortality. Additionally, there is no clear research evidence that 6-monthly doses of vitamin A result in a sustained shift in serum retinol levels or reduce subclinical vitamin A deficiency. These two points should encourage SA to re-examine the validity of these guidelines. A long-term view of what is in the best interests of the majority of the people is needed. The short-term intervention of administering vitamin A capsules not only fails to improve serum retinol levels but may create dependence on a 'technical fix' to address the fundamental problem of poor nutrition, which is ultimately underpinned by poverty. It may also cause harm. Although there are those, some with vested interests, who will argue for continuation of the routine high-dose VAS programmes, SA policymakers and scientists need to evaluate the facts and be prepared to rethink this policy. There is cause for optimism: SA's health policymakers have previously taken bold stands on the basis of evidence. The examples of regulation of tobacco products and taxation of sugar-sweetened beverages, ending the free distribution of formula milk for HIV-positive mothers and legislating against the marketing of breastmilk substitutes provide precedents. Here is a time yet again for decision-makers to make bold choices in the interests of the people of SA. While the cleanest choice would be national discontinuation of the routine VAS programme, there may be other possibilities, such as first stopping the programme in Northern Cape Province (where there is clear evidence of hypervitaminosis A), followed by the other provinces in time.

The targeting of nutritionally at-risk children attending a primary health care facility in the Western Cape Province of South Africa.

AIM: The aim of this study was to determine the practices of primary health care (PHC) nurses in targeting nutritionally at-risk infants and children for intervention at a PHC facility in a peri-urban area of the Western Cape Province of South Africa. METHODOLOGY: Nutritional risk status of infants and children <6 years of age was based on criteria specified in standardised nutrition case management guidelines developed for PHC facilities in the province. Children were identified as being nutritionally at-risk if their weight was below the 3rd centile, their birth weight was less than 2500 g, and their growth curve showed flattening or dropping off for at least two consecutive monthly visits. The study assessed the practices of nurses in identifying children who were nutritionally at-risk and the entry of these children into the food supplementation programme (formerly the Protein-Energy Malnutrition Scheme) of the health facility. Structured interviews were conducted with nurses to determine their knowledge of the case management guidelines; interviews were also conducted with caregivers to determine their sociodemographic status. RESULTS: One hundred and thirty-four children were enrolled in the study. The mean age of their caregivers was 29.5 (standard deviation 7.5) years and only 47 (38%) were married. Of the caregivers, 77% were unemployed, 46% had poor household food security and 40% were financially dependent on non-family members. Significantly more children were nutritionally at-risk if the caregiver was unemployed (54%) compared with employed (32%) (P=0.04) and when there was household food insecurity (63%) compared with household food security (37%) (P<0.004). Significantly more children were found not to be nutritionally at-risk if the caregiver was financially self-supporting or supported by their partners (61%) compared with those who were financially dependent on non-family members (35%) (P=0.003). The weight results of the nurses and the researcher differed significantly (P<0.001), which was largely due to the different scales used and weighing methods. The researcher's weight measurements were consistently higher than the nurses' (P<0.00). The researcher identified 67 (50%) infants and children as being nutritionally at-risk compared with 14 (10%) by the nurses. The nurses' poor detection and targeting of nutritionally at-risk children were largely a result of failure to plot weights on the weight-for-age chart (55%) and poor utilisation of the Road to Health Chart. CONCLUSIONS: Problems identified in the practices of PHC nurses must be addressed in targeting children at nutritional risk so that appropriate intervention and support can be provided. More attention must be given to socio-economic criteria in identifying children who are nutritionally at-risk to ensure their access to adequate social security networks.

Full-term, peri-urban South African infants under 6 months of age are at risk for early-onset anaemia.

OBJECTIVE: There is a paucity of data on the micronutrient status of low-income, lactating South African women and their infants under 6 months of age. The aim of this study was to elucidate the level of anaemia and vitamin A deficiency (VAD) in peri-urban breast-feeding women and their young infants. DESIGN: Cross-sectional study including anthropometric, biochemical and infant feeding data. SETTING: Peri-urban settlement in Cape Town, South Africa. SUBJECTS: Breast-feeding women (n=113) and their infants (aged 1-6 months) attending a peri-urban clinic. RESULTS: Mean (standard deviation (SD)) haemoglobin (Hb) of the lactating mothers was 12.4 (1.3) g dl(-1), with 32% found to be anaemic (Hb<12 g dl(-1)). Maternal serum retinol was 49.8 (SD 13.3) microg dl(-1), with 4.5% VAD. Using breast milk, mean (SD) retinol concentration was found to be 70.6 (24.6) microg dl(-1) and 15.7 (8.3) microg/g milk fat, with 13% below the cut-off level of <8 microg/g fat. There was no correlation found between breast milk retinol and infant serum retinol. Z-scores (SD) of height-for-age, weight-for-age and weight-for-height were -0.69 (0.81), 0.89 (1.01) and 1.78 (0.83), respectively. Mean (SD) infant Hb was 10.9 (1.1) g dl(-1), with the prevalence of anaemia being 50%, 33% and 12% using Hb cut-offs below 11 g dl(-1), 10.5 g dl(-1) and 9.5 g dl(-1), respectively. Mean (SD) infant serum retinol was 26.9 (7.2) microg dl(-1), with 10% being VAD. None of the infants was exclusively breast-fed, 22% were predominantly breast-fed and 78% received complementary (mixed) breast-feeding. Thirty-two per cent of infants received weaning foods at an exceptionally young age (< or =1 month old). CONCLUSION: A high rate of anaemia is present in lactating women residing in resource-poor settings. Moreover, their seemingly healthy infants under 6 months of age are at an elevated risk of developing early-onset anaemia and at lower risk of VAD.

Lowered plasma vitamin C, but not vitamin E, concentrations in dementia patients.

BACKGROUND: Alzheimer s disease (AD), according to the free radical hypothesis, affects brain regions where free radical damage occurs. Antioxidant nutrients may help to protect these brain regions. OBJECTIVE: To investigate whether plasma vitamin C and E status is lowered in subjects with AD and dementia. DESIGN: A case control study was conducted in 93 institutionalized subjects aged 65 + yrs. The dementia group (N = 43) included 15 subjects with Alzheimer s Disease (AD) and 28 subjects with senile dementia, while the control group included 50 subjects with no cognitive impairment. Subjects with uncontrolled hypertension and/or diabetes were excluded from the study. Plasma vitamin C and E was determined using the 2,6- dichlorophenolindophenol and the HPLC methods, respectively. Dietary intake, including dietary supplements, was assessed using a 2-day plate-waste method. Cognitive function was measured using the MMSE and nutritional status assessed using the Mini Nutritional Assessment (MNA) tool. RESULTS: The control group had significantly higher scores for the MNA, MMSE and Activities of Daily Living, compared with the dementia group. Controls had a significantly higher plasma vitamin C concentration than dementia patients (median = 0.84 (IQR = 0.54) mg/dl and 0.56 (0.80) mg/dl, respectively; P<0.05). The dementia group were more likely to have sub-optimal plasma vitamin C levels (< 0.6 mg/dl) than control subjects (OR = 2.99; 95 % CI = 0.95 9.79; P<0.05), despite having similar dietary vitamin C intakes. Plasma vitamin C was positively associated with MMSE score (r = 0.21; P<0.05). No difference was found between the groups for either plasma or dietary vitamin E. CONCLUSION: Plasma vitamin C levels were lower in subjects with dementia compared to controls, which was not explained by their dietary vitamin C intakes. This data supports the free radical theory of oxidative neuronal damage. Further investigations of whether supplementation with this vitamin may prevent or delay the progression of cognitive decline in patients with AD and senile dementia appear warranted.

The effect of a micronutrient-fortified complementary food on micronutrient status, growth and development of 6- to 12-month-old disadvantaged urban South African infants.

The study was conducted to look at the effectiveness of a multimicronutrient-fortified complementary food on the micronutrient status, linear growth and psychomotor development of 6- to 12-month-old infants from a black urban disadvantaged community in the Western Cape, South Africa. The study was designed as an intervention study. In both the experimental and control groups, serum retinol concentration showed a decline over the intervention period of 6 months. The decline was less pronounced in the experimental group. This resulted in a significantly (P<005) higher serum retinol concentration at 12 months in the experimental group (26.8+/-5.8 microg/dl) compared with the control group (21.4+/-5 microg/dl). Serum iron concentration also declined over the intervention period. The decline was less pronounced in the experimental group. No difference was observed in haemoglobin levels between the groups at 12 months. Serum zinc concentration did not differ significantly between the two groups at follow up. Weight gain over the 6 months period did not differ significantly between the experimental (2.1+/-0.9 kg) and control groups (2.1+/-1.2 kg). There was no difference in linear growth between the experimental (10.0+/-1.5 cm) and control group (10.1+/-2.1 cm) at the end of the follow-up period. Weight and length at 6 months significantly predicted weight and length at 12 months. No difference was observed in psychomotor developmental scores between the two groups after 6 months of intervention. Introducing a multimicronutrient-fortified complementary food into the diet of 6- to 12-month-old infants seemed to have an arresting effect on declining serum retinol and iron concentration in the experimental group. No benefit was observed in serum zinc concentration, linear growth and psychomotor development.

Disadvantaged black and coloured infants in two urban communities in the Western Cape, South Africa differ in micronutrient status.

OBJECTIVES: To determine the nutritional and health status of urban infants in two disadvantaged communities in the Western Cape, South Africa with special reference to micronutrient status. The results of this study will serve to plan an intervention study in these communities in the same age group. DESIGN: Cross-sectional study. SETTING: Two disadvantaged urban black and 'coloured' communities in the Western Cape, South Africa. SUBJECTS: Sixty infants aged 6-12 months from each community. OUTCOME MEASURES: Dietary intake, anthropometric measurements, micronutrient status and psychomotor development. RESULTS: Stunting and underweight were more prevalent in coloured infants (18% and 7%, respectively) than in black infants (8% and 2%, respectively). Anaemia (haemoglobin (Hb) < 11 g dl(-1) was prevalent in 64% of coloured and 83% of black infants. Iron-deficiency anaemia (Hb < 11 g dl(-1) and ferritin < 10 ng ml(-1) was found in 32% of coloured infants and in 46% of black infants. Zinc deficiency was prevalent in 35% and 33% of the coloured and black infants, respectively. Marginal vitamin A deficiency (serum retinol < 20 microg dl(-1) was observed in 23% of black infants compared with 2% of coloured infants. Of black infants, 43% and of coloured infants 6% were deficient in two or more micronutrients. Six per cent of coloured infants had C-reactive protein concentrations above 5 mg l(-1) compared with 38% of the black infants. The dietary intake of micronutrients was in general lower in black infants than in coloured infants. The overall psychomotor development, assessed by the Denver Developmental Screening Test, was different between the two groups. The coloured infants scored higher in three out of the four categories as well as in their overall score. CONCLUSIONS: This study shows that information on stunting and wasting only in urban disadvantaged infants is not sufficient to make recommendations about specific community intervention programmes. Information on the micronutrient status, independent of wasting and stunting, is necessary to design nutrition programmes for different communities. The study also showed a substantially higher prevalence of micronutrient deficiencies among black infants.

The effect of a biscuit with red palm oil as a source of beta-carotene on the vitamin A status of primary school children: a comparison with beta-carotene from a synthetic source in a randomised controlled trial.

OBJECTIVE: To determine the effect of a biscuit with red palm oil as a source of beta-carotene on the vitamin A status of primary school children and to compare this with the effect of a biscuit with beta-carotene from a synthetic source. DESIGN: Randomised controlled trial. SETTING: A rural community in KwaZulu-Natal, South Africa. SUBJECTS: A total of 437 primary school children, aged 5--11 y; 400 completed the study. INTERVENTION: Subjects were randomly assigned to one of three groups, receiving, respectively: (i) a placebo biscuit; (ii) a biscuit with synthetic beta-carotene as a vitamin A fortificant (SB); (iii) a biscuit with red palm oil as a source of beta-carotene (PB); SB and PB supplied 30% of the RDA for vitamin A per serving of three biscuits. Biscuits were distributed daily during the school week; vitamin A status was assessed at baseline and after 3 months. RESULTS: There was a significant improvement in serum retinol compared to the control group in both the SB and PB groups (P<0.005); the treatment effect for the two groups was equivalent (difference in treatment effect 0.62 microg/dl, with a 90% CI -0.33--1.57). CONCLUSIONS: A biscuit with red palm oil as a source of beta-carotene is as effective as a biscuit with synthetic beta-carotene in improving the vitamin A status of primary school children. The additional qualities of red palm oil (ie no trans fatty acids; rich source of antioxidants) make it an excellent alternative fortificant for addressing vitamin A deficiency.

Long-term evaluation of a micronutrient-fortified biscuit used for addressing micronutrient deficiencies in primary school children.

OBJECTIVE: To evaluate the long-term effect on micronutrient status of a beta-carotene-, iron- and iodine-fortified biscuit given to primary school children as school feeding. DESIGN: Children receiving the fortified biscuit were followed in a longitudinal study for 2.5 years (n = 108); in addition, cross-sectional data from three subsequent surveys conducted in the same school are reported. SETTING: A rural community in KwaZulu-Natal, South Africa. SUBJECTS: Children aged 6-11 years attending the primary school where the biscuit was distributed. RESULTS: There was a significant improvement in serum retinol, serum ferritin, haemoglobin, transferrin saturation and urinary iodine during the first 12 months of the biscuit intervention. However, when the school reopened after the summer holidays, all variables, except urinary iodine, returned to pre-intervention levels. Serum retinol increased again during the next 9 months, but was significantly lower in a subsequent cross-sectional survey carried out directly after the summer holidays; this pattern was repeated in two further cross-sectional surveys. Haemoglobin gradually deteriorated at each subsequent assessment, as did serum ferritin (apart from a slight increase at the 42-month assessment at the end of the school year). CONCLUSIONS: This study has shown that fortification of a biscuit with beta-carotene at a level of 50% of the Recommended Dietary Allowance (RDA) was enough to maintain serum retinol concentrations from day to day, but not enough to sustain levels during the long school holiday break. Other long-term solutions, such as local food production programmes combined with nutrition education, should also be examined. The choice of the iron compound used as fortificant in the biscuit needs further investigation.

Red palm oil as a source of beta-carotene in a school biscuit used to address vitamin A deficiency in primary school children.

The effect of a biscuit with red palm oil as a source of beta-carotene was compared with the effect of a biscuit with beta-carotene from a synthetic source on the vitamin A status of primary school children in a randomised controlled trial. Children aged 5-11 years (n = 265) were randomly assigned to one of three groups: (1) placebo biscuit; (2) biscuit with synthetic beta-carotene as a vitamin A fortificant; and (3) biscuit with red palm oil as a source of beta-carotene. The two non-placebo biscuits were designed to provide 34% of the RDA for vitamin A per serving (4 x 15 g biscuits). The biscuits were distributed daily during the school week and compliance was closely monitored and recorded. Children were assessed at baseline and after 6 months of intervention. Mean serum retinol in all three groups increased significantly compared to baseline (P < 0.0001). The prevalence of low serum retinol levels (< 20 micrograms/dL) dropped from 50 to 24.4% in the control group, from 48.2 to 16.9% in the synthetic beta-carotene group, and from 50.6 to 22.8% in the red palm oil group. There was no significant treatment effect compared to the control group in either the synthetic beta-carotene or red palm oil group. The increase in the control group was probably due to a school feeding scheme (providing 33% of the RDA for vitamin A) introduced during the latter part of the study. Our results were thus confounded and the 'true' effect of the red palm oil biscuit on vitamin A status could not be established. The study has, however, shown that red palm oil can be incorporated in a biscuit and that the end product with regard to taste and appearance was well accepted by the school children. A follow-up study in a school where there is no school feeding is indicated.

Effect of catfish supplementation on the fatty acid status and growth of undernourished rural preschool children under 6 years of age: An intervention trial in Lebowa, South Africa.

A group of 102 preschool children aged 13-69 months from a rural area of Lebowa were selected from a cross-sectional study of 659 children for an intervention trial (12 months) to study the effect of catfish (Clarias gariepinus) supplementation on their plasma phospholipid fatty acid status and growth. They were classified into undernourished and control groups according to their weight-for-age. The undernourished children (n = 52) received 43 g fish and 7.5 g sunflower cooking oil per day, whereas a matched (age and sex) well-nourished control group (n = 50) was not supplemented. At baseline, after 6 months and after 12 months of the study, anthropometry, haematology, blood biochemistry and plasma phospholipid fatty acid analyses were done. In the undernourished group, high baseline oleic acid (18:1 9) levels in plasma phosphatidylcholine (PC) were replaced by docosahexaenoic acid (22:6 3) with supplementation. In plasma PC, this reduction in 18:1 9 and increase in 22:6 3 was associated with significant increases in weight-for-age Z-scores, P = 0.0378 and P = 0.0415, respectively. The fish supplement and cooking oil that supplied additional 7% energy (7% E) and nutrients promoted growth of undernourished children, although this was inadequate for sustained growth during the second 6 months of intervention.