Hepatic Vitamin A Concentrations and Association with Infectious Causes of Child Death.

OBJECTIVES: To assess postmortem vitamin A (VA) concentrations in children under 5 years of age and evaluate the association between VA deficiency (VAD) and infectious causes of death (CoD). STUDY DESIGN: In this cross-sectional study from the Child Health and Mortality Prevention Surveillance (CHAMPS) Network, liver biopsies collected within 72 hours of death were analyzed from 405 stillbirths and children under 5 years in Kenya and South Africa. Total liver VA (TLVA) concentrations were quantified using ultra-performance liquid chromatography, and cutoffs of ≤0.1 µmol/g, >0.1 to <0.7 µmol/g, ≥0.7 to <1.0 µmol/g, and ≥1.0 µmol/g were used to define VAD, adequate VA status, high VA, and hypervitaminosis A, respectively. CoD were determined by expert panel review. RESULTS: Among 366 liver samples with viable extraction, pooled prevalences of VAD, adequacy, high VA, and hypervitaminosis were 34.2%, 51.1%, 6.0%, and 8.7%, respectively. VAD was more common among neonates compared with stillbirths, infants, or children, and among those with low birthweight (LBW), underweight, or stunting (P < .05). When adjusting for site, age, and sex, there was no significant association of VAD with increased infectious CoD (OR 1.9, 95% confidence interval [CI] 0.9, 3.8, P = .073). In stratified analyses, VA deficient boys, but not girls, had an increased risk of infectious CoD (OR 3.4, 95% CI 1.3, 10.3, P = .013). CONCLUSIONS: Definitive postmortem assessment of VA status identified both VAD and VA excess among children under 5 years of age in Kenya and South Africa. VAD in boys was associated with increased risk of infectious mortality. Our findings may inform a transition from universal VA supplementation (VAS) to targeted strategies in certain countries.

Repeated High-Dose Vitamin A Supplements, Standard of Care for Treating Xerophthalmia, Leads to Hypervitaminosis A in Piglets.

BACKGROUND: Vitamin A (VA) deficiency and excess negatively affect development, growth, and bone health. The World Health Organization's standard of care for xerophthalmia due to VA deficiency, is 3 high-dose VA supplements of 50,000-200,000 IU, based on age, which may cause hypervitaminosis A in some individuals. OBJECTIVES: This study measured VA status following 3 VA doses in 2 piglet studies. METHODS: In Study 1, 5 groups of piglets (n = 10/group) were weaned 10 d postbirth to VA-free feed and orally administered 0; 25,000; 50,000; 100,000; or 200,000 IU VA ester on days 0, 1, and 7. On days 14 and 15, the piglets underwent the modified relative dose-response (MRDR) test for VA deficiency, and were killed. Tissues were collected for high-pressure liquid chromatography analysis. Study 2 used the same design in 3 groups (n = 13/group) weaned at 16 d and administered 0; 25,000; and 200,000 IU doses. RESULTS: In Study 1 (final weight: 3.6 ± 0.7 kg), liver VA concentration was hypervitaminotic in 40%, 90%, and 100% of 50,000; 100,000; and 200,000 IU groups, respectively. The 25,000 IU group was 100% adequate, and the placebo group was 40% deficient. In Study 2 (final weight: 8.7 ± 0.8 kg), where 200,000 IU could be prescribed to infants with a similar body weight, 31% of the piglets were hypervitaminotic, the 25,000 IU group was 100% VA adequate, and the placebo group was 100% deficient. The MRDR test measured deficiency in 50% and 70% of the placebo group in each study but had 3 false positives among hypervitaminotic piglets in Study 1. CONCLUSIONS: Repeated high-dose VA may cause hypervitaminosis, indicating dose sizes may need reduction. The MRDR resulted in false positives in a hypervitaminotic state during malnutrition and should be paired with serum retinyl ester evaluation to enhance VA status assessment in populations with overlapping interventions.

Total Liver Vitamin A Reserves, Determined With 13C2-Retinol Isotope Dilution, are Similar Among Tanzanian Preschool Children in Areas With Low and High Vitamin A Exposure.

BACKGROUND: In Tanzania, some districts have single vitamin A (VA) interventions and others have multiple interventions. There is limited information on total liver VA reserves (TLRs) among preschool children (PSC) in Tanzania. OBJECTIVES: We assessed total body VA stores (TBSs) and TLRs among PSC living in 2 districts with low and high exposures to VA interventions using 13C-retinol isotope dilution. METHODS: A cross-sectional, health facility-based study was conducted in 2 districts with access to VA supplementation only (low exposure to VA interventions) or multiple interventions (high exposure to VA interventions) to determine TLRs in 120 PSC aged 36-59 months. A questionnaire was used to collect data. Height and weight were measured, and the prevalence of undernutrition was based on z-scores. Blood samples were collected for measurement of TBSs, TLRs, retinol, biomarkers of infection and inflammation, and hemoglobin. 13C2-retinyl acetate (1.0 µmol) was administered to each child after blood collection, and the second sample was taken 14 days later. Serum was analyzed with HPLC and gas chromatography-combustion-isotope ratio mass spectrometry. Mann-Whitney U test was used to compare medians of nonnormally distributed variables. Pearson χ2 test was used to assess associations between 2 categorical variables. RESULTS: Median TBSs differed between PSC from low-exposure (196 µmol; IQR, 120 µmol) and high-exposure (231 µmol; IQR, 162 µmol) intervention areas (P = 0.015). Median TLRs were 0.23 µmol/g liver (IQR, 0.14 µmol/g liver) and 0.26 µmol/g liver (IQR, 0.16 µmol/g liver) from low- and high-exposure areas, respectively, which did not significantly differ (P = 0.12). Prevalences of VA deficiency (VAD; ≤0.1 µmol/g liver) were 6.3% and 1.7% for PSC from low- and high-exposure areas, respectively. There was no significant difference in VAD (P = 0.25). No child had hypervitaminosis A (≥1.0 µmol/g liver). CONCLUSIONS: TLRs in Tanzanian PSC from 2 districts did not differ between low and high exposures to VA interventions. The majority had adequate VA stores. VAD in the study area presented a mild public health problem.

Breast Milk Retinol Concentrations Reflect Total Liver Vitamin A Reserves and Dietary Exposure in Thai Lactating Women from Urban and Rural Areas.

BACKGROUND: Measuring vitamin A (VA) status during lactation is required to inform dietary recommendations. Limited data exist on VA stores in women. OBJECTIVES: Our objective was to assess VA status in lactating Thai women by measuring total body VA stores (TBSs), serum and breast milk retinol concentrations, and dietary intake. METHODS: Lactating women (n = 94), 6-8 wk postpartum, were enrolled from rural (Ayutthaya) and urban (Bangkok) areas. TBSs were measured by the 13C-retinol isotope dilution (RID) technique using 2.0 µmol 13C-retinyl acetate and a single blood sample 14 d post-dose. Natural 13C-enrichment was determined in nonenrolled women (n = 11). Estimated total liver VA reserves (TLRs) were determined using assumptions for lactation. Serum, foremilk, and hindmilk samples were analyzed for retinol by HPLC. Dietary VA intake was assessed by FFQ and 24-h dietary recalls for 3 d. Multiple regression and Pearson correlation were used to evaluate relations. RESULTS: Median VA intakes were 51.8% of 2003 Thai daily recommendations for lactating women, with the majority from animal-source foods. Many women in Ayutthaya consumed liver weekly. Considering TLRs as 50% TBS, 20% and 11% of mothers in Ayutthaya and Bangkok, respectively, showed deficient reserves (≤0.10 µmol retinol/g). Median (quartile 1, quartile 3) serum [1.58 (1.34, 1.91) and 1.52 (1.30, 1.70) µmol/L] and milk [1.88 (1.29, 2.95) and 1.74 (0.96, 2.26) µmol/L] retinol in Ayutthaya and Bangkok, respectively, were normal. Women with deficient TLRs showed low milk retinol concentrations (≤1.0 µmol/L) and consumed less dietary VA, especially from animal-source foods. Breast milk retinol concentrations, especially hindmilk, demonstrated strong correlation with TBSs and TLRs estimated from the RID test. CONCLUSIONS: Approximately 15% of Thai lactating women had deficient TLRs. Breast milk retinol concentrations in conjunction with dietary intake records show potential to screen mothers at risk of VA deficiency to guide interventions.The Thai Clinical Trials Registry number is TCTR20160824001 for the work in Thailand.

Anthocyanin and Lycopene Contents Do Not Affect ß-Carotene Bioefficacy from Multicolored Carrots (Daucus carota L.) in Male Mongolian Gerbils.

BACKGROUND: Anthocyanins and carotenoids are phytochemicals that may benefit health through provitamin A carotenoid (PAC), antioxidant, and anti-inflammatory activities. These bioactives may mitigate chronic diseases. Consumption of multiple phytochemicals may impact bioactivity in synergistic or antagonistic manners. OBJECTIVES: Two studies in weanling male Mongolian gerbils assessed the relative bioefficacy of ß-carotene equivalents (BCEs) to vitamin A (VA) with simultaneous consumption of the non-PAC lycopene or anthocyanins from multicolored carrots. METHODS: After 3-wk VA depletion, 5-6 gerbils were killed as baseline groups. The remaining gerbils were divided into 4 carrot treatment groups; the positive control group received retinyl acetate and the negative control group was given vehicle soybean oil (n = 10/group; n = 60/study). In the lycopene study, gerbils consumed feed varying in lycopene sourced from red carrots. In the anthocyanin study, gerbils consumed feed varying in anthocyanin content sourced from purple-red carrots, and positive controls received lycopene. Treatment feeds had equalized BCEs: 5.59 ± 0.96 µg/g (lycopene study) and 7.02 ± 0.39 µg/g (anthocyanin study). Controls consumed feeds without pigments. Serum, liver, and lung samples were analyzed for retinol and carotenoid concentrations using HPLC. Data were analyzed by ANOVA and Tukey's studentized range test. RESULTS: In the lycopene study, liver VA did not differ between groups (0.11 ± 0.07 µmol/g) indicating no effect of varying lycopene content. In the anthocyanin study, liver VA concentrations in the medium-to-high (0.22 ± 0.14 µmol/g) and medium-to-low anthocyanin (0.25 ± 0.07 µmol/g) groups were higher than the negative control (0.11 ± 0.07 µmol/g) (P < 0.05). All treatment groups maintained baseline VA concentrations (0.23 ± 0.06 µmol/g). Combining studies, serum retinol had 12% sensitivity to predict VA deficiency, defined as 0.7 µmol/L. CONCLUSIONS: These gerbil studies suggested that simultaneous consumption of carotenoids and anthocyanins does not impact relative BCE bioefficacy. Breeding carrots for enhanced pigments to improve dietary intake should continue.

Inadequate Niacin Intake Disrupts Growth and Retinol Homeostasis Resulting in Higher Liver and Lower Serum Retinol Concentrations in Male Rats.

BACKGROUND: Niacin-derived nicotinamide adenine dinucleotide is an essential cofactor for many dehydrogenase enzymes involved in vitamin A (VA) metabolism. Several countries with high prevalence of VA deficiency rely on maize, a poor source of available niacin, as a dietary staple. OBJECTIVES: This study evaluated the interaction of dietary niacin on VA homeostasis using male Sprague-Dawley rats, aged 21 d (baseline body weight 88.3 ± 6.6 g). METHODS: After 1 wk of acclimation, baseline samples were collected (n = 4). Remaining rats (n = 54) were split into 9 groups to receive low tryptophan, VA-deficient feed with 3 different amounts of niacin (0, 15, or 30 mg/kg) and 3 different oral VA doses (50, 350, or 3500 nmol/d) in a 3 × 3 design. After 4 wk, the study was terminated. Serum, livers, and small intestine were analyzed for retinoids using high-performance liquid chromatography. Niacin and metabolites were evaluated with nuclear magnetic resonance. Plasma pyridoxal-P (PLP) was measured with high-performance liquid chromatography. RESULTS: Niacin intake correlated with serum retinol concentrations (r = 0.853, P < 0.001). For rats receiving the highest VA dose, liver retinol concentrations were lower in the 30-mg/kg niacin group (5.39 ± 0.27 µmol/g) than those in the 0-mg/kg and 15-mg/kg groups (9.18 ± 0.62 and 8.75 ± 0.07 µmol/g, respectively; P ≤ 0.05 for both). This phenomenon also occurred in the lower VA doses (P ≤ 0.05 for all). Growth and tissue weight at endline were associated with niacin intake (P ≤ 0.001 for all). Plasma PLP correlated with estimated niacin intake (r = 0.814, P < 0.001). CONCLUSIONS: Optimal niacin intake is associated with lower liver VA and higher serum retinol and plasma PLP concentrations. The extent to which vitamin B intake affects VA homeostasis requires further investigation to determine if the effects are maintained in humans.

Comparison of Total Body Vitamin A Stores Using Individual versus Population 13C-Natural Abundance of Serum Retinol in Preschool Children and Women Residing in 6 Diverse African Countries.

BACKGROUND: Stable isotope techniques using 13C to assess vitamin A (VA) dietary sources, absorption, and total body VA stores (TBSs) require determination of baseline 13C abundance. 13C-natural abundance is approximately 1.1% total carbon, but varies with foods consumed, supplements taken, and food fortification with synthetic retinyl palmitate. OBJECTIVES: We determined 13C variation from purified serum retinol and the resulting impact on TBSs using pooled data from preschool children in Burkina Faso, Cameroon, Ethiopia, South Africa, Tanzania, and Zambia and Zambian women. METHODS: Seven studies included children (n = 639; 56 ± 25 mo; 48% female) and one in women (n = 138; 29 ± 8.5 y). Serum retinol 13C-natural abundance was determined using GC-C-IRMS. TBSs were available in 7 studies that employed retinol isotope dilution (RID). Serum CRP and α1-acid-glycoprotein (AGP) were available from 6 studies in children. Multivariate mixed models assessed the impact of covariates on retinol 13C. Spearman correlations and Bland-Altman analysis compared serum and milk retinol 13C and evaluated the impact of using study- or global-retinol 13C estimates on calculated TBSs. RESULTS: 13C-natural abundance (%, median [Q1, Q3]) differed among countries (low: Zambia, 1.0744 [1.0736, 1.0753]; high: South Africa, 1.0773 [1.0769, 1.0779]) and was associated with TBSs, CRP, and AGP in children and with TBSs in women. 13C-enrichment from serum and milk retinol were correlated (r = 0.52; P = 0.0001). RID in children and women using study and global estimates had low mean bias (range, -3.7% to 2.2%), but larger 95% limits of agreement (range, -23% to 37%). CONCLUSIONS: 13C-natural abundance is different among human cohorts in Africa. Collecting this information in subgroups is recommended for surveys using RID. When TBSs are needed on individuals in clinical applications, baseline 13C measures are important and should be measured in all enrolled subjects.

Association between Biomarkers of Inflammation and Total Liver Vitamin A Reserves Estimated by 13C-Retinol Isotope Dilution among Preschool Children in 5 African Countries.

BACKGROUND: Vitamin A (VA) assessment is important for targeting public health programs. Retinol isotope dilution (RID) is a sensitive method to estimate total body VA stores (TBSs) and total liver reserves (TLRs), but the impact of subclinical inflammation on RID is unclear. OBJECTIVE: We determined the association between TBSs and TLRs, estimated by RID, and inflammation among preschool children without clinical infection in Burkina Faso, Cameroon, Ethiopia, South Africa, and Tanzania. METHODS: Five studies (n = 532; 47.9 ± 8.3 mo; 49.0% male) included 13C-RID and measurement of inflammation markers, CRP, and α1-acid glycoprotein (AGP). Spearman correlations were used to evaluate TBSs and TLRs with inflammation biomarkers. Wilcoxon and Kruskal-Wallis tests were used to compare TBSs and TLRs by inflammation categories [normal vs. elevated CRP (>5 mg/L) or AGP (>1 g/L)] and inflammation stage [reference, incubation (elevated CRP), early convalescence (elevated CRP and AGP), and late convalescence (elevated AGP)]. RESULTS: Complete data were available for 439 children. Median (Q1, Q3) TLRs ranged from 0.12 (0.07, 0.18) µmol/g in Ethiopia to 1.10 (0.88, 1.38) µmol/g in South Africa. Elevated CRP ranged from 4% in Burkina Faso to 42% in Cameroon, and elevated AGP from 20% in Tanzania to 58% in Cameroon. Pooled analysis (excluding Cameroon) showed a negative correlation between TBSs and AGP (ρ = -0.131, P = 0.01). Children with elevated AGP had higher probability of having lower TBSs (probability = 0.61, P = 0.002). TBSs differed among infection stages (P = 0.020). Correlations between TLRs and CRP or AGP were not significant. CONCLUSIONS: No indication of systematic bias in RID-estimated TLRs was found due to subclinical inflammation among preschool children. The inverse relationship between TBSs and AGP may reflect decreased stores after infection or an effect of inflammation on isotope partitioning. Further research should investigate potential confounding variables to improve TBS-estimate validity.

Urinary 2- to 16α-hydroxyestrone ratio did not change with cruciferous vegetable intake in premenopausal women.

The mass ratio of urinary 2-hydroxyestrone to 16-α-hydroxyestrone (2:16) is hypothesized as a biomarker of breast cancer risk in premenopausal women, with higher ratios being theoretically protective. Cruciferous vegetable intake has been associated with higher urinary 2:16 in some studies. We investigated whether a whole-food supplement made from dried Brussels sprouts and kale would increase urinary 2:16 in comparison with placebo or cruciferous vegetables in women. This randomized, parallel arm, placebo-controlled, partly blinded study included 78 healthy premenopausal women (38-50 y) with screening urinary 2:16 ≤3.0. Subjects received either six capsules containing 550 mg dried Brussels sprouts and kale per capsule, 40 g daily alternating broccoli or Brussels sprouts, or placebo for eight weeks. Urinary 2:16 and creatinine were measured at baseline, four, and eight weeks. Intent-to-treat repeated measures-ANOVA with multiple imputation (n=100) for missing values identified no treatment effect (P=0.9) or treatment-by-time interaction (P=0.6); however, a significant time effect was noted (P=0.02). Per-protocol analyses including complete cases found no treatment effect (P=1) or treatment-by-time interaction (P=0.6); however, the significant time effect remained (P=0.03). Restricting analysis to subjects with >80% compliance maintained the time effect (P=0.02). Using Pearson correlations, android-pattern and android:gynoid fat were predictive of change (P≤0.05). In conclusion, neither cruciferous supplements nor an added vegetable serving altered urinary 2:16 in premenopausal women with eight weeks treatment. This ratio did vary with time, which is important for designing future trials.

Time Since Dose and Dietary Vitamin A Intake Affect Tracer Mixing in the 13C-Retinol Isotope Dilution Test in Male Rats.

BACKGROUND: Retinol isotope dilution (RID) estimates total liver vitamin A reserves (TLRs), the gold-standard vitamin A (VA) biomarker. RID equation assumptions are based on limited data. OBJECTIVES: We measured the impact of tracer choice, mixing period, and VA intake on tracer mixing [ratio of tracer enrichment in serum to that in liver stores (S)] in VA-deficient, -adequate, and hypervitaminotic rats. METHODS: Study 1 was a 3 × 2 × 3 design (18 groups, n = 5/group). Male Sprague-Dawley rats (21 d old) received 50, 100, or 3500 nmol VA/d for 21 d, were administered 52 nmol 13C2- or 13C10-retinyl acetate orally, and killed 5, 10, or 15 d later. Unlabeled VA (50 nmol/d) was given on days 11-14. Study 2 used 100 nmol VA/d for 21 d with 3 groups (n = 6-7): 52 nmol 13C2- or 13C10-retinyl acetate and 100 nmol VA/d throughout 14-d mixing, or 13C2-retinyl acetate without VA. Repeated-measures, 1-factor, and 3-factor ANOVAs were used for analysis. RESULTS: Mean ± SD TLRs (µmol/g liver) reflected intake: 0.11 ± 0.04 (50 nmol VA/d), 0.16 ± 0.04 (100 nmol VA/d), and 5.07 ± 1.58 (3500 nmol VA/d) in Study 1 and 0.24 ± 0.08 (100 nmol VA/d) in Study 2. In Study 1, mean ± SD S was 1.65 ± 0.26 (5 d), 1.16 ± 0.09 (10 d), and 0.92 ± 0.08 (15 d). The interactions tracer*VA intake and time*VA intake were significant between days 10 and 15 (P < 0.05). In Study 2, mean ± SD S was 1.07 ± 0.02 without VA during mixing, and 0.81 ± 0.04 (13C2) and 0.79 ± 0.03 (13C10) with VA intake throughout. Estimated:measured TLRs varied by VA intake and time in Study 1 but not between groups in Study 2. CONCLUSIONS: The 13C-content effect on RID through S is inconsistent. S is highly variable at 5 d, contraindicating early-time point RID. VA intake effects on S vary with timing and quantity. Assuming S = 0.8 at 14 d with consistent VA intake in human studies is likely appropriate.

Geographic and socio-demographic determinants of plasma retinol concentrations in Chinese pregnant and lactating women.

PURPOSE: To examine plasma retinol status and its determinants in Chinese pregnant or lactating women. METHODS: A cross-sectional study involving 1211 healthy women in mid-pregnancy, late pregnancy, or lactation was conducted in northern, central, and southern China. Plasma retinol concentration was determined by high-performance liquid chromatography. Multivariate quantile regression or modified Poisson regression was used to estimate adjusted medians, or to examine the associations of suboptimal retinol concentration (< 1.05 µmol/L) with various factors. RESULTS: The overall median (interquartile range) retinol concentration was 1.25 (1.06-1.46) µmol/L. The adjusted concentration was higher in women at lactation (1.39 [1.20-1.63] µmol/L) and mid-pregnancy (1.26 [1.10-1.44] µmol/L) than late pregnancy (1.07 [0.92-1.28] µmol/L), and higher in women in the central area (1.34 [1.18-1.49] µmol/L) and the north (1.26 [1.10-1.43] µmol/L) than the south (1.19 [1.07-1.31] µmol/L). The retinol concentration was more likely to be low in women with lower pre-pregnancy BMI, younger age, less education, and in lactating women who had a caesarean birth or were breastfeeding exclusively. A total of 290 (24.0%) women had a suboptimal retinol concentration, and the prevalence was higher in women at late pregnancy, residing in the south, with younger age, and having underweight pre-pregnancy. CONCLUSION: About one-fourth of pregnant or lactating women in China had suboptimal retinol concentrations that varied with phases of pregnancy and lactation, region of residence, and socio-demographic characteristics, indicating a need for population-specific public health strategies to optimize vitamin A status.

Breast Milk-Derived Retinol Is a Potential Surrogate for Serum in the 13C-Retinol Isotope Dilution Test in Zambian Lactating Women with Vitamin A Deficient and Adequate Status.

BACKGROUND: Vitamin A (VA) deficiency (VAD) affects ∼19 million pregnant women worldwide. The extent of VAD in Zambian women of reproductive age is unknown owing to lack of survey inclusion or the use of static serum retinol concentrations, a low-sensitivity biomarker. OBJECTIVES: This cross-sectional study employed isotopic techniques to determine VA status with serum and milk among women aged 18-49 y (n = 197) either lactating with infants aged 0-24 mo or nonlactating with or without infants. METHODS: Assistants were trained and piloted data collection. Demographic data, anthropometry, and relevant histories were obtained including malaria and anemia. For retinol isotope dilution (RID), baseline fasting blood and casual breast milk samples were collected before administration of 2.0 µmol 13C2-retinyl acetate and 24-h dietary recalls. On day 14, blood (n = 144) and milk (n = 66) were collected. Prevalence of total liver VA reserves (TLR) ≤0.10 µmol/g was defined as VAD with comparison to the DRI assumption of 0.07 µmol/g as minimally acceptable for North Americans. RESULTS: When a 20% adjustment for dose lost to milk was made in the RID equation for lactation, mean total body VA stores (TBS) for lactating women were 25% lower than for nonlactating women (P < 0.01), which was not the case without adjustment (P = 0.3). Mean ± SD TLR for all women were 0.15 ± 0.11 µmol/g liver. Using retinol purified from breast milk instead of serum for RID analysis yielded similar TBS and TLR, which were highly correlated between methods (P < 0.0001). Serum retinol ≤0.70 µmol/L had 0% sensitivity using either VAD liver cutoff and milk retinol ≤1.0 µmol/L had 42% sensitivity for VAD at 0.10 µmol/g. CONCLUSIONS: Determining accurate VA status among women of reproductive age, especially lactating women, forms a basis for extrapolation to the general population and informing policy development and program implementation.

Relation between Timing of High-Dose Vitamin A Supplementation and Modified-Relative-Dose-Response Values in Children 12-23 Months in Uganda.

BACKGROUND: High-dose vitamin A (VA) supplements (VAS) can temporarily affect VA status. Hence, micronutrient surveys might need to be timed around VAS campaigns to accurately estimate VA deficiency (VAD) prevalence. Little is known about optimal timing of micronutrient surveys when the modified-relative-dose-response (MRDR) is used as a VA indicator. OBJECTIVES: We evaluated the association between days since the end of a VAS campaign and MRDR values in children aged 12-23 mo in Uganda. METHODS: We pooled data from 2 cross-sectional, population-based surveys in eastern Uganda conducted in 2015-2016 (n = 118 children). We estimated the prevalence of VAD (MRDR ≥0.060). Days since the end of a VAS campaign ("days since VAS") was calculated as the interview date minus the end date of the VAS campaign. The MRDR value was assessed using HPLC. We excluded children whose MRDR values were below the limit of detection (<0.007). We used linear regression to evaluate the association between days since VAS and log-transformed MRDR. In adjusted analyses, we controlled for potential confounders. Statistical analyses accounted for the surveys' complex design. RESULTS: The prevalence of VAD was 5.2% (95% CI: 1.1%, 9.3%). Mean days since VAS was 54.1 d (range 39-68 d). Days since VAS was not associated with log-transformed MRDR in unadjusted analyses ($\hat{\beta } = \ $0.0055; 95% CI: -0.009, 0.020; P = 0.45) or adjusted analyses ($\hat{\beta } = $ -0.0073; 95% CI: -0.024, 0.010; P = 0.39). CONCLUSIONS: MRDR measurement through a nutrition survey began as early as 1.3 mo after the end of a VAS campaign in eastern Uganda. Days since the end of a VAS campaign was not associated with MRDR in Ugandan children aged 12-23 mo. Future studies should consider longitudinal designs and evaluate time since VAS and MRDR in children of different ages and in regions with higher VAD prevalence.

Consensus recommendations for the use of retinoids in ichthyosis and other disorders of cornification in children and adolescents.

Topical and systemic retinoids have long been used in the treatment of ichthyoses and other disorders of cornification. Due to the need for long-term use of retinoids for these disorders, often beginning in childhood, numerous clinical concerns must be considered. Systemic retinoids have known side effects involving bone and eye. Additionally, potential psychiatric and cardiovascular effects need to be considered. Contraceptive concerns, as well as the additive cardiovascular and bone effects of systemic retinoid use with hormonal contraception must also be deliberated for patients of childbearing potential. The Pediatric Dermatology Research Alliance (PeDRA) Use of Retinoids in Ichthyosis Work Group was formed to address these issues and to establish best practices regarding the use of retinoids in ichthyoses based on available evidence and expert opinion.

Risk factors for anaemia among Ghanaian women and children vary by population group and climate zone.

Anaemia has serious effects on human health and has multifactorial aetiologies. This study aimed to determine putative risk factors for anaemia in children 6-59 months and 15- to 49-year-old non-pregnant women living in Ghana. Data from a nationally representative cross-sectional survey were analysed for associations between anaemia and various anaemia risk factors. National and stratum-specific multivariable regressions were constructed separately for children and women to calculate the adjusted prevalence ratio (aPR) for anaemia of variables found to be statistically significantly associated with anaemia in bivariate analysis. Nationally, the aPR for anaemia was greater in children with iron deficiency (ID; aPR 2.20; 95% confidence interval [CI]: 1.88, 2.59), malaria parasitaemia (aPR 1.96; 95% CI: 1.65, 2.32), inflammation (aPR 1.26; 95% CI: 1.08, 1.46), vitamin A deficiency (VAD; aPR 1.38; 95% CI: 1.19, 1.60) and stunting (aPR 1.26; 95% CI: 1.09, 1.46). In women, ID (aPR 4.33; 95% CI: 3.42, 5.49), VAD (aPR 1.61; 95% CI: 1.24, 2.09) and inflammation (aPR 1.59; 95% CI: 1.20, 2.11) were associated with anaemia, whereas overweight and obese women had lower prevalence of anaemia (aPR 0.74; 95% CI: 0.56, 0.97). ID was associated with child anaemia in the Northern and Middle belts, but not in the Southern Belt; conversely, inflammation was associated with anaemia in both children and women in the Southern and Middle belts, but not in the Northern Belt. Anaemia control programmes should be region specific and aim at the prevention of ID, malaria and other drivers of inflammation as they are the main predictors of anaemia in Ghanaian children and women.

High-Dose Neonatal Vitamin A Supplementation to Bangladeshi Infants Increases the Percentage of CCR9-Positive Treg Cells in Infants with Lower Birthweight in Early Infancy, and Decreases Plasma sCD14 Concentration and the Prevalence of Vitamin A Deficiency at Two Years of Age.

BACKGROUND: Vitamin A (VA) stores are low in early infancy and may impair development of the immune system. OBJECTIVE: This study determined if neonatal VA supplementation (VAS) affects the following: 1) development of regulatory T (Treg) cells; 2) chemokine receptor 9 (CCR9) expression, which directs mucosal targeting of immune cells; and 3) systemic endotoxin exposure as indicated by changed plasma concentrations of soluble CD14 (sCD14). Secondarily, VA status, growth, and systemic inflammation were investigated. METHODS: In total, 306 Bangladeshi infants were randomly assigned to receive 50,000 IU VA or placebo (PL) within 48 h of birth, and immune function was assessed at 6 wk, 15 wk, and 2 y. Primary outcomes included the following: 1) peripheral blood Treg cells; 2) percentage of Treg, T, and B cells expressing CCR9; and 3) plasma sCD14. Secondary outcomes included the following: 4) VA status measured using the modified relative dose-response (MRDR) test and plasma retinol; 5) infant growth; and 6) plasma C-reactive protein (CRP). Statistical analysis identified group differences and interactions with sex and birthweight. RESULTS: VAS increased (P = 0.004) the percentage of CCR9+ Treg cells (13.2 ± 1.37%) relative to PL (9.17 ± 1.15%) in children below the median birthweight but had the opposite effect (P = 0.04) in those with higher birthweight (VA, 9.13 ± 0.89; PL, 12.1 ± 1.31%) at 6 and 15 wk (values are combined mean ± SE). VAS decreased (P = 0.003) plasma sCD14 (1.56 ± 0.025 mg/L) relative to PL (1.67 ± 0.032 mg/L) and decreased (P = 0.034) the prevalence of VA deficiency (2.3%) relative to PL (9.2%) at 2 y. CONCLUSIONS: Neonatal VAS enhanced mucosal targeting of Treg cells in low-birthweight infants. The decreased systemic exposure to endotoxin and improved VA status at 2 y may have been due to VA-mediated improvements in gut development resulting in improved barrier function and nutrient absorption. This trial was registered at clinicaltrials.gov as NCT01583972 and NCT02027610.

The "Super-Child" Approach Is Applied To Estimate Retinol Kinetics and Vitamin A Total Body Stores in Mexican Preschoolers.

BACKGROUND: Retinol isotope dilution (RID) and model-based compartmental analysis are recognized techniques for assessing vitamin A (VA) status. Recent studies have shown that RID predictions of VA total body stores (TBS) can be improved by using modeling and that VA kinetics and TBS in children can be effectively studied by applying population modeling ("super-child" approach) to a composite data set. OBJECTIVES: The objectives were to model whole-body retinol kinetics and predict VA TBS in a group of Mexican preschoolers using the super-child approach and to use model predictions of RID coefficients to estimate TBS by RID in individuals. METHODS: Twenty-four healthy Mexican children (aged 3-6 y) received an oral dose (2.96 µmol) of [13C10]retinyl acetate in corn oil. Blood samples were collected from 8 h to 21 d after dosing, with each child sampled at 4 d and at 1 other time. Composite data for plasma labeled retinol compared with time were analyzed using a 6-component model to obtain group retinol kinetic parameters and pool sizes. Model-predicted TBS was compared with mean RID predictions at 4 d; RID estimates at 4 d were compared with those calculated at 7-21 d. RESULTS: Model-predicted TBS was 1097 µmol, equivalent to ∼2.4 y-worth of VA; using model-derived coefficients, group mean RID-predicted TBS was 1096 µmol (IQR: 836-1492 µmol). TBS at 4 d compared with a later time was similar (P = 0.33). The model predicted that retinol spent 1.5 h in plasma during each transit and recycled to plasma 13 times before utilization. CONCLUSIONS: The super-child modeling approach provides information on whole-body VA kinetics and can be used with RID to estimate TBS at any time between 4 and 21 d postdose. The high TBS predicted for these children suggests positive VA balance, likely due to large-dose VA supplements, and warrants further investigation.

Overlapping Vitamin A Interventions with Provitamin A Carotenoids and Preformed Vitamin A Cause Excessive Liver Retinol Stores in Male Mongolian Gerbils.

BACKGROUND: Vitamin A (VA) deficiency is a public health problem in some countries. Fortification, supplementation, and increased provitamin A consumption through biofortification are efficacious, but monitoring is needed due to risk of excessive VA intake when interventions overlap. OBJECTIVES: Two studies in 28-36-d-old male Mongolian gerbils simulated exposure to multiple VA interventions to determine the effects of provitamin A carotenoid consumption from biofortified maize and carrots and preformed VA fortificant on status. METHODS: Study 1 was a 2 × 2 × 2 factorial design (n = 85) with high-ß-carotene maize, orange carrots, and VA fortification at 50% estimated gerbil needs, compared with white maize and white carrot controls. Study 2 was a 2 × 3 factorial design (n = 66) evaluating orange carrot and VA consumption through fortification at 100% and 200% estimated needs. Both studies utilized 2-wk VA depletion, baseline evaluation, 9-wk treatments, and liver VA stores by HPLC. Intestinal scavenger receptor class B member 1 (Scarb1), ß-carotene 15,15'-dioxygenase (Bco1), ß-carotene 9',10'-oxygenase (Bco2), intestine-specific homeobox (Isx), and cytochrome P450 26A1 isoform α1 (Cyp26a1) expression was analyzed by qRT-PCR in study 2. RESULTS: In study 1, liver VA concentrations were significantly higher in orange carrot (0.69 ± 0.12 µmol/g) and orange maize groups (0.52 ± 0.21 µmol/g) compared with baseline (0.23 ± 0.069 µmol/g) and controls. Liver VA concentrations from VA fortificant alone (0.11 ± 0.053 µmol/g) did not differ from negative control. In study 2, orange carrot significantly enhanced liver VA concentrations (0.85 ± 0.24 µmol/g) relative to baseline (0.43 ± 0.14 µmol/g), but VA fortificant alone (0.42 ± 0.21 µmol/g) did not. Intestinal Scarb1 and Bco1 were negatively correlated with increasing liver VA concentrations (P < 0.01, r2 = 0.25-0.27). Serum retinol concentrations did not differ. CONCLUSIONS: Biofortified carrots and maize without fortification prevented VA deficiency in gerbils. During adequate provitamin A dietary intake, preformed VA intake resulted in excessive liver stores in gerbils, despite downregulation of carotenoid absorption and cleavage gene expression.

Community mobilization during biofortified orange maize feeding trials in Zambia.

In some societies, studies involving blood draws, oral vaccinations, or supplementation are surrounded by myths and disbeliefs. If not clarified, they may affect study implementation and negatively impact the outcome of well-intended studies from inadequate participation. Through participatory action research, this paper suggests how future trials could be enhanced with reference to community mobilization, drawing from the experience of two interventions in Zambian children with nutritionally enhanced, biofortified orange maize conducted by the National Food and Nutrition Commission and Tropical Diseases Research Center (Zambia), and University of Wisconsin-Madison (USA). The preparatory phase included site visits, signing of a Memorandum of Understanding, equipment inventory, hiring staff, and community meetings. Prior results were shared before the second intervention. After Institutional Review Boards' approval of procedures, written informed consent was obtained from caregivers. There was overwhelming community participation attributed to the demystification that the project was run by satanists prior to and during the study. Participation led to excellent compliance with 92.8 and 96.4% of subjects completing the final blood draw in 2010 and 2012, respectively. The results of the trials were successfully shared with the district officials and communities from where the study participants were drawn. The positive response by partners and communities, including information sharing, suggests that community mobilization, with the use of varied methods, is effective for full participation of the target groups in feeding trials and would be the case in similar trials if effectively carried out. Community participation in research studies may result in long-term adoption of biofortified foods.

Mining maize diversity and improving its nutritional aspects within agro-food systems.

Agro-food systems are undergoing rapid innovation in the world and the system's continuum is promoted at different scales with one of the main outcomes to improve nutrition of consumers. Consumer knowledge through educational outreach is important to food and nutrition security and consumer demands guide breeding efforts. Maize is an important part of food systems. It is a staple food and together with rice and wheat, they provide 60% of the world's caloric intake. In addition to being a major contributor to global food and nutrition security, maize forms an important part of the culinary culture in many areas of Africa, the Americas, and Asia. Maize genetics are being exploited to improve human nutrition with the ultimate outcome of improving overall health. By impacting the health of maize consumers, market opportunities will be opened for maize producers with unique genotypes. Although maize is a great source of macronutrients, it is also a source of many micronutrients and phytochemicals purported to confer health benefits. The process of biofortification through traditional plant breeding has increased the protein, provitamin A carotenoid, and zinc contents of maize. The objective of this paper is to review the innovations developed and promoted to improve the nutritional profiles of maize and outcomes of the maize agro-food system.