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Vitamin A Deficiency
Nutrition Department
Medical Faculty of Sumatera Utara
November 2009
DKS09
Background
• “Nutrition Related Disease”
• Nutrition problem in Indonesia
• Nutrition Status Survey 1998-2002, 10
million Indonesian children risk of Vit A
deff >> (sub klinis) xeropthalmia
blindness
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What caused deficiency?
• Primary (‘NUTRITION’):
– Protein energy malnutrition (defect on
absorption)
– Minimum daily vit A or β-carotene
intakes (long period)
– No ‘exclusive breast feeding’ for babies
– Imbalanced diet (less fat, protein, Zn, or
other nutrients)
help absorption and
utilization
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Secondary (diseases related to
absorption and metabolism )
–
–
–
–
–
Celiac disease
Sprue
Cystic fibrosis
Pancreatic disease
Congenital partial
obstruction of
duodenum
– Giardiasis
– Cirrhosis
– Chronic hepatitis
– Chronic diarrhea
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Other signs of defficiency
• Frequent infections like measles, diarrhea,
and malaria
• Stunted growth
• Anemia
• Malnutrition
• Thickened toad like skin, goose flesh
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Skin Manifestation
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Clinical signs of vit A deff
X1A
X1B
X2
X3A
X3B
XS
• XN: night blindness is the earliest symptom
of vit A deff. Which is often reported by the
mother as reduced visual acuity of the child
in the evening and the night time
• X1A: conjungtival xerosis or drying of the
conjungtiva
• X1B: bito’s spot on the conjungtiva
• X2: corneal xerosis or dryness of the cornea
with a granular looking swurface
• X3A: keratomalacia involving less than a
third of the cornea
• X3B: Keratomalacia > 1/3
• XF: funduscopy changes in visible in
opthalmoscopy
• XS:Corneal scarring, compromising severly
on visual acuity
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Vitamin A deff and toxicity
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Toxicity
• Excessive dietary intakes of vitamin A produce
symptoms of acute and chronic toxicity including
teratogenecity in developing fetuses
• Normally results from the indiscriminate use of
pharmaceutical supplements, not from the
consumption of usual diets
• Sign:
–
–
–
–
–
–
–
–
–
Serum vit A of 75-2000 RAE/100mL
Bone pain & fragility
Hydrochepalus and vomiting
Dry, fissured skin
Brittle nail
Alopecia
Gingivitis, cheilosis, anorexia, irritability, fatique
Hepatomegaly and abnormal liver function
Ascites and portal hypertention
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How to diagnosed
Clinical sign
Laboratorium:
Serum retinol
Retinol binding protein level
Funduscopic examination
< 10 µg/dL
< 20 µg/dL
Sub clinic
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Vitamin A
Vitamin A
• Vitamin A-active compounds are represented by
retinoids (designated as vitamin A) and their
carotenoid precursors (provitamin A
carotenoids)
• Structure:
– Retinoids: retinol, retinaldehyde, and retinoic acids
– Provitamin A carotenoid (α-carotene, β-carotene, and
β-cryptoxanthin)
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Functions
Retinal is a structural component of the visual
pigments of the rod and cone cells photoreception
RA acts as hormon to affect gene expression
Glycoprotein important for normal cell surface
function such as cell aggregation and cell
recognition
Normal reproduction (retinol), bone
development, immune function
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Absorption and convertion vitamin
A and β-carotene
β-Carotene
bile
2-50%
ENTEROCYTE
β -carotene
Central cleavage
Retinaldehyde
Lymph
mixed micelle
Retinyl ester
Retinol
INTESTINAL LUMEN
Sumber: Erdman dkk, 1993
Retinyl esters
Chylomicron
Retinol
Fatty acids
Retinoic acid
Portal blood
flow (albumin)
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Stability (vitamin A)
• In foods, the indigenous retinyl ester are
dissolved in the lipid matrix, protected from
the oxidizing action of oxygen by vitamin
E and antioxidants
• Destructions of vitamin A compounds
related to accelerated lipid oxidation, such
as exposure to air, heat, traces of certain
metals (Co and Fe), and storage time
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Stability (carotenoids)
• Carotenoids in foods influenced by food
processing and domestic cooking, such as
nonenzymatic or enzymatic oxidation
• Cutting of fruits and vegetables into small
pieces or maceration (non-enzymatic)
increase exposure to carotenoids mix
up carotenoid and lipoxygenase
• Lipoxygenase in plant tissues catalyzes
lipid peroxidation hydroperoxides attack
carotenoids (enzymatic)
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• Moderate heat, such as blanching and
cooking denature carotenoid binding
proteins releasing the carotenoid
• Optimal retention of carotene is obtained
by steaming vegetables of cooking with
minimal water until the vegetables are
cooked
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Bioavailability
• When meals containing natural amounts
of vitamin A and provitamin A carotenoids
consumed, efficiency vitamin A: 70-90%
compared with 20-50% for the provitamins
• Present of fat in milk protects vitamin A
from degradation
• Pulped better than pieces for carotene
bioaccessibility (carrots), and addition of
cooking oil is more effective
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• Host related factors affecting
bioavailability:
– Malnourished
– Presence of intestinal parasites
– Atrophic gastritis
– Elderly people with little or no acid in stomach
– Drug: Omeprazole pH>4.5 reduced βcarotene serum
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Medical Nutrition Therapy and
Prevention
Therapy
Gejala
Hari 1
XN (buta senja), XIA
(xerosis conjungtiva)
tanpa pernah sakit
campak 3 bulan
terakhir
Beri kapsul vitamin A
dengan dosis sesuai
umur
Ada salah satu gejala
X1B (bercak bitotnanah/radang-kornea
keruh-ulkus korneapernah sakit campak
Beri kapsul vitamin A
dengan dosis sesuai
umur
Hari 2
Hari 15 (mgg II)
-
-
Beri kapsul vitamin A
dengan dosis sesuai
umur
Beri kapsul vitamin A
dengan dosis sesuai
umur
Umur
Dosis
<6 bulan
3 x 50.000 SI (1/2 kapsul biru)
6 bulan – 1 tahun
100.000 SI (1 kapsul biru)
1-5 tahun
200.000 SI (1 kapsulmerah)
(Sumber: Deteksi dan Tatalaksana Kasus Xeroftalmia,Depkes RI, 2003)
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Prevention
• Prevention:
– < 6 months : 50.000 IU oral
– 6-12 months: 100.000 IU oral
– >1-5 year : 200.000 IU oral
February and August
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Requirement
• Not exceed 2 times the RDA (AKG ’04)
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Medical Nutrition Therapy
• Goals:
– Provided an adequate food to reach normal
nutrition status
– Provided high vitamin A food sources
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• Energy:
– Adequate energy to prevent protein breakdown (energy supply and recovery)
– Malnutrition (poor nutrition status):
• Stabilization phase: 80-100 cal/kg BW
• Trantition phase: 150 cal/kg BW
• Rehabilitation phase: 200 cal/kg BW
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• Protein
– High protein
– To form Retinol Binding Protein and
Rhodopsin
– Malnutrition (poor), step by step:
• 1-1.5 g/kg BW/ day
• 2-3 g/kg BW/day
• 3-4 g/kg BW/day
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• Fat
– 20-25%
– For optimal vit A absorption: 3-4 g per meal
– MCT
– PUFA>>SFA
– Palm oil (red), coconut oil
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• High vit A food sources
• How to cooked (fry or light fry)
• Food form: destructive gastrointestinal
epitel condition easy to digest
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Vitamin A Sources
Sumber: Food Standard Agency(2002)
Vitamin A sources (retinol per 100 g edible portion)
Cow’s milk
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Semi-skimmed
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Skimmed
1
Cheese
958
Egg
190
Chicken
11
Liver
19,700
Sardines
6
Butter
958
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Sumber β-karoten
Sumber: Mangels dkk, 1993
β-carotene sources (µg/100g)
Carrot (cooked): 9800
Daun selada: 1200
Sweet potatoes (cooked): 8800
Bawang prei: 1000
Carrot : 7900
Tomato juice: 900
Spinach (cooked): 5500
Celery : 710
Tomato ketchup: 5000
Green beans: 630
Pumpkin : 3100
Tomatoes: 520, sawi : 530
Blewah:3000
Watermelon : 230
Daun singkong:3000
Pickles : 180
Bit: 2560
Papaya: 99
Red pepper: 2200
Corn : 51
Broccoli : 1300
Avocado : 34
Mango: 1300
Apple: 26 and orange: 39
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Contoh makanan lunak kaya
vitamin A
• Pagi:
– Bubur ayam + tomat
cincang
• Selingan:
– Kue sus isi wortel
• Siang:
–
–
–
–
Bubur/tim nasi
Semur daging giling
Oseng tempe
Sayur lodeh (kcg pjg dan
melinjo)
– Pepaya
• Sore:
– Kolak biji salak (ubi
merah/oranye)
• Malam:
–
–
–
–
Lontong
Telur bumbu opor
Tumis buncis
Pisang ambon
• Malam:
– susu
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Contoh makanan biasa kaya
vitamin A
• Pagi:
– Nasi goreng
– Telur ceplok
• Selingan:
– Cake wortel
• Siang:
–
–
–
–
–
Nasi
Goreng ayam mentega
Tumis kacang merah
Cah wortel dan caisim
Jeruk
• Sore:
– Pastel isi sayuran
• Malam:
–
–
–
–
Nasi
Gulai ikan
Tahu telur
Tumis kangkung
• Malam:
– susu
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Thank you
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