Running Head: CORRECTING VITAMIN A DEFICIENCY

Correcting Vitamin A Deficiency:

Reducing the Prevalence of VAD of Preschool-Aged Children in India
Leo Ontiveros
Adam Hernandez
Nicole Keally
Alejandro Valenzuela
California State University, Los Angeles

CORRECTING VITAMIN A DEFICIENCY

Table of Contents
Title Page.1
Table of Contents.2
Abstract....3
Introduction......4-6
Literature Review...7-10
Description of the Population of Interest..10-11
Summary....11
References12-14
Appendices....15

CORRECTING VITAMIN A DEFICIENCY

I.

Abstract
Around the world and especially in developing countries, nutrient deficiencies are a lot

more common than one might suspect. This proposal focuses specifically on vitamin A
deficiency (VAD) as it relates to children in the country of India. VAD in children is associated
with blindness, limited growth, weakened immune systems, increased severity of infections and
increased mortality rates that have been well documented. In India, more than 60% of preschool
aged children are vitamin A deficient, and according to the World Health Organization (WHO),
half of them will go blind every year.
Our proposal lays out a plan whose goal is to reduce the prevalence of VAD in India.
Working together with WHO to take advantage of the infrastructure in place, we propose a
mobile health center similar to a blood drive. The objectives are to reduce blindness caused by
VAD in children, expand nutritional education among the population, and decrease the number of
cases of VAD as a whole by introducing supplements and vitamin A fortified foods. We will also
emphasize breastfeeding in our education in hopes of increasing the number of mothers who
chose to breastfeed. Based on the research, VAD is caused by a variety of issues; biological,
nutritional and socioeconomics. Past peer reviewed research suggests that supplementation alone
is not enough to solve the problem, implying that education and introducing a well-balanced or
fortified diet along with supplementation is ideal.
Keywords: vitamin a, deficiency, VAD, correcting, supplementation, VAS, xerophthalmia,
blindness, nutrition intervention, children, preschool, India

CORRECTING VITAMIN A DEFICIENCY

II.

Introduction

A. Vitamin A deficiency (VAD) is a major public health nutrition related problem that exists among
young children, especially in developing nations. VAD can cause blindness, limit growth,
weaken the immune response, increase the incidence and severity of infections, and increase the
risk of death. Xerophthalmia, the inability to produce tears resulting in dry eyes, is a condition
associated with vitamin A deficiency and further increases the risk of morbidity and mortality.
Approximately 130 million preschool-age children are vitamin A deficient worldwide (West,
2003) and in India alone it is estimated that 62% of all preschool-age children are vitamin A
deficient. According to the World Health Organization (WHO), an estimated 250,000 to 500,000
of the children experiencing vitamin A deficiency go blind every year, half of them dying within
12 months of losing their eyesight.
B.
a. The goal is to reduce the prevalence of vitamin A deficiency in preschool-aged children in India
by providing a short-term solution via supplementation in combination with a long-term strategy
largely based on food fortification and nutrition education.
b. The expected outcome is to decrease VAD related blindness, ensure proper growth, reduce
xerophthalmia and lessen the risk of morbidity and mortality. With VAD correction the immune
response should be enhanced, decreasing the incidence and severity of infections, resulting in an
improved quality of life.
c. The impact on the area of interest is to work in conjunction with the World Health Organization
to take advantage of the infrastructure they have in place to further promote the importance of
breastfeeding, vitamin A supplementation, and food fortification.
d.
i.
ii.

Reduce VAD related blindness by 50% in 1 year.

Expand access to help by creating a mobile movement using vitamin A awareness trucks, similar

iii.
iv.

to a blood drive.
Identify and correct vitamin A deficiency in preschool-aged children via supplementation.
Workshops will provide education and support for women to practice proper breastfeeding.

CORRECTING VITAMIN A DEFICIENCY

v.
vi.

Increase the rate of mothers breastfeeding from 25% to 50% in 1 year.

Introduce fortified Roti bread, new foods such as fortified whole-grain bread and identify foods
rich in vitamin A to grow in the area.
C. Inclusion criteria were as follows:

Children of preschool-age (6 months-5 years)

Vitamin A deficient
Vitamin A supplementation
Both mothers who breastfeed and those who do not
Exhibit symptoms associated with vitamin A (xerophthalmia, blindness, infections, limited

growth)
Programs who have attempted to intervene

Exclusion criteria were as follows:

Children aged under 6 months or over 5 years
Children of more economically developed countries
Data that predates 2009
Search for relevant studies:
The studies in this review were obtained through electronic databases. The
electronic databases PUBMED, SCIENCEDIRECT and Google Scholar were
searched using the following keywords: vitamin a, deficiency, VAD, correcting,
supplementation, VAS, xerophthalmia, blindness, nutrition intervention, children,
preschool, India. The databases were searched for the period of January 2009 to
February 2015. Title and abstracts were examined and, if the abstracts met the
inclusion criteria, the full text of the article was retrieved.

Critical appraisal, data extraction and analysis:

CORRECTING VITAMIN A DEFICIENCY

The abstract of every article was read and then the full article was obtained. The
inclusion criteria was applied resulting in publications that were related to vitamin
A deficiency in India. The following data was summarized in the literature review
section below: causes of VAD, health concerns, factors contributing to VAD,
hindrances to program effectiveness, program benefits, and nutrition intervention.
Further analysis and comparisons of the findings are reported below.

III.

Literature Review
Malnutrition is the main underlying cause of VAD as a public health nutrition related

problem, insufficient vitamin A in the diet can lead to lower body stores and failure to meet
physiological needs to support tissue growth, resistance to infection, and establish a normal
metabolism. VAD is characterized as low serum levels of retinol (<20 g/dL). Prolonged
inadequate intake of vitamin A causes liver stores to become exhausted, leading to damage in
cellular function along with other associated risks of vitamin A deficiency (Groper & Smith,
2013).
Laxmaiah, A. et al., 2011 researched preschool-aged children (6 months to 5 years) in
India with VAD and found that the major health concerns associated with these children are night
blindness, conjunctival xerosis, bitot spots, corneal ulceration, keratomalacia, and total blindness.
Night blindness occurs when rhodopsin is compromised in the rod cells of the eye. Without
adequate amounts of vitamin A trans-retinal cannot be converted back to cis-retinal when light

CORRECTING VITAMIN A DEFICIENCY

hits the eye. Xerophthalmia, as referenced in the introduction, is a result of inadequate mucus
production from the loss of goblet cells in the conjunctiva along with the enlargement and
keratinization of epithelial cells known as corneal xerosis. As xerosis exacerbates, corneal
scarring, ulcerations and softening of the cornea (keratomalacia) may transpire which can lead to
corneal perforation and ultimately blindness. Vitamin A deficiency can also result in Bitots
spots, characterized as small, white, foamy-looking accumulations of sloughed cells (Groper &
Smith, 2013).
The following are factors contributing to VAD: illiteracy, low socioeconomic status,
occupation and poor sanitation (Laxmaiah, A. et al., 2011). Gebremedhin, 2014 found that
families of higher socioeconomic status were associated with lower rates of VAD. Another factor
of VAD is a cultural belief system of scheduled castes, scheduled tribes, and other backward
classes that contribute to the delay of VAS and exacerbate VAD (Laxmaiah, A. et al., 2011). This
system of castes results in a certain population receiving better health care than others. Education
also contributes to VAD, supplementation is predominantly given to mothers who are educated
compared to those with no education (Semba, Pee, Sun, Bloem, & Raju, 2015).
However, in order to properly combat VAD there are systematic blocks hindering the
implementation and distribution of vitamin A supplementation (VAS). A major gap in the
research pertaining to VAS is poor vitamin A program coverage and improper distribution of
VAS, with roughly only 34% of children receiving a dose/year (Chow, Klein, & Laxminarayan
2010). It is a problem stemming from the governments lack of political stability and regulation
on a federal, state, and local level. This is evidenced by VAS programs in India not extending to
all those in need, but rather covering about half the population and not providing the full dose
proposed (Laxmaiah et al., 2011). Another gap of VAS programs in India is that more than a third

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of mothers of children in need of supplementation reported not being aware of any existing VAS
program, with half stating that the location and time of VAS were inconvenient (Laxmaiah et al.,
2011).
However, there are examples of VAS programs that have had benefits such as that of Faber et al.,
2015, which found that rural children benefited more from the national food fortification
program in terms of vitamin A intake. This suggests that program initiatives do work as long as
they are properly governed.
Beyond programs of VAS to help alleviate VAD, practices that include the engineering of
food to increase their vitamin A content are being devised. One such method is to genetically
modify foods such as mustard oil (Chow, Klein, & Laxminarayan 2010) and ultra-rice (Li, Lam,
Diosady, & Jankowski 2009) which is a local food staple for the poor. Golden rice provides
enough beta-carotene to supply vitamin A in humans (Tang, Qin, Dolnikowski, Russell, &
Grusak 2009). Fortification is a method of intervention conducted by Uchendu & Atinmo, 2012
who used vitamin A fortified bread that significantly reduced VAD.
A study conducted by Awasthi et al., 2013 contradicted later works that found VAS
reduced child mortality by 20-30%. Instead, Awasthi et al., 2013 found only an 11% reduction.
Another article inconsistent with WHO and other data was that of Yakymenko et al., which found
that the effects of lowering VAS levels was more beneficial in young children (12 months and
younger) (2011).
In conjunction with WHO, we to take advantage of their current infrastructure to prevent
VAD and disperse VAS. The novelty of our intervention is a proposed mobile health center
delivery system, which would educate the locals on proper breastfeeding and use preventative
methods to stop VAD through education while giving VAS to those in need.

CORRECTING VITAMIN A DEFICIENCY

In summary, the serious health consequences to VAD include cellular damage, a

compromised immunity, night blindness, conjunctival xerosis, bitot spots, corneal ulceration,
keratomalacia, total blindness and Xerophthalmia. What the research shows is that certain
program interventions have been addressed in the efforts to prevent and halt VAD in rural and
poor communities. However, there are systematic problems in Indias cultural beliefs such as
scheduled castes, scheduled tribes, and other backward classes allowing only certain groups to
receive better health care than others. Another issue exacerbating VAD is Indias federal, state,
and local policies that are hindering those that need VAS by not regulating the distribution of
these supplements. While some of the data was contradictory or inconsistent, the major
consensus of these articles argued in favor of VAS and food fortification and GMOs to help
alleviate VAD in South Asia, India.

IV.

Description of the Population of Interest

The population of interest we decided to focus our research on are preschool-aged

children living in India, the seventh largest country in the world with the second highest
population (Population Reference Bureau, 2014).
Laxmaiah et al. (2011) found illiteracy, low socioeconomic status, occupation and poor
sanitation to be contributors to VAD. Indias literacy rate for those 7 years and older is 72.99%
according to the 2011 India Census. The Economic Times: India reports that 55% of Indias
population is poor as measured by a composite indicator made up of ten markers of education,
health and standard of living achievement levels and only 39.1% of the total population make up
the Indian workforce (2011 India Census). Most of Indias underprivileged sections of society as
recognized by the Indian Constitution belong to a scheduled caste, scheduled tribe or other

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backward classes (Laxmaiah et al., 2011). The 2011 India Census reports that 53.1% of Indian
household have no latrine and 48.9% have no drainage. In 2013, The World Bank reported that
68% of Indias population lives in rural areas.
The rationale for focusing on preschool-age children in this area is because almost half of
the worlds micronutrient-deficient population is in India (USAID, 2005). A large proportion of
the worlds malnourished children live in India (Pasricha et al., 2010). It is reported that Bitots
spots, a symptom of vitamin A deficiency, is 13 times more prevalent in children raised in the
scheduled caste and 20 times more prevalent in the children of laborers (Aplappa et al.).
According to the World Health Organization (WHO) (2104), 62% of Indian preschoolaged children are vitamin A deficient, having serum retinol concentrations lower than 20 g/dL,
making vitamin A deficiency a severe public health problem in India. An estimated 600,000
children in India go blind each year due to VAD (USAID, 2005).

V.

Summary
As mentioned earlier in the population section of this proposal, India is the second most

populated country in the world and this particular region holds close to half of the worlds
vitamin A deficient population. For this reason our proposed intervention could be significant in
reducing VAD in India by expanding the access of VAS to rural regions. Vitamin A is vital to the
development of young children, especially their eyes and immune function. VAD is the leading
cause of childhood blindness and is easily prevented with adequate vitamin A intake. The
proposal would help improve the health status of the population of interest by applying mobile
health centers to supply vitamin A and provide education. We estimate a decline in childhood

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blindness, reduce xerophthalmia, improve immune function, increase growth, and lessen the risk
of morbidity and mortality

VI.

References

Awasthi, S., Peto, R., Read, S., Clark, S., Pande, V., & Bundy, D. (2013). Vitamin A
supplementation every 6 months with retinol in 1 million pre-school children in north
India: DETVA, a cluster-randomized trial. Lancet Elsevier, 381(9876) 1469-1477. doi:
10.1016/S0140-6736(12)62125-4
Census of India. (2011). Census 2011. [Data file]. Retrieved from http://censusindia.gov.in/2011prov-results/data_files/maharastra/6-%20Chapter%20-%203.pdf
Census of India (2011). Economic Activity. Retrieved from
http://censusindia.gov.in/Census_And_You/economic_activity.aspx
Census of India (2011). India Having latrine facility within the premises: Total Households.
Retrieved from
http://www.devinfolive.info/censusinfodashboard/website/index.php/pages/sanitation/tota
l/totallatrine/IND

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Census of India (2011). India Literacy rate, 7+ yrs. Retrieved from

http://censusindia.gov.in/2011census/censusinfodashboard/index.html
Census of India (2011). India Type of waste water outlet connected to: No drainage
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l/nodrainage/IND
Chow, J., Klien, Y. E., & Laxminarayan, R. (2010, August 10). Cost-Effectiveness of Golden
Mustard for Treating Vitamin A Deficiency in India. PLoS ONE 5(8): e12046. doi:
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uri=info:doi/10.1371/journal.pone.0012046&representation=PDF
Faber, M., van Jaarsveld, P. J., Kunneke, E., Kruger, H. S., Schoeman, S. E., & van Stuijvenberg,
M. E. Vitamin A and anthropometric status of South African preschool children from four
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Gebremedhin, S. (2014). Effect of a single high dose vitamin A supplementation on the
hemoglobin status of children aged 6-59 months: propensity score matched retrospective
cohort study based on the data of Ethiopian Demographic and Health Survey 2011. BMC
Pediatrics 14(79), 1-8. doi: 10.1186/1471-2431-14-79
Laxmaiah, A., Nair, M. K., Arlappa, N., Raghu, P., Balakrishna, N., Rao, K. M., Galreddy, C.,
Kumar, S., Ravindranath, M., Rao, V. V., & Brahmam, G. N. V. (2011). Prevalence of

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ocular signs and subclinical vitamin A deficiency. Public Health Nutrition, 15(4), 568577. doi: 10.1017/S136898001100214X
Li, Y. O., Lam, J., Diosady L. L., & Jankowski, S. (2009). Antioxidant system for the
preservation of vitamin A in Ultra Rice. Food and Nutrition Bulletin 30(1), 82-89.
http://www.ingentaconnect.com/content/nsinf/fnb/2009/00000030/00000001/art00009
Osei, A. K., Rosenberg, I. H., Houser, R. F., Bulusu, S., Mathews, M., & Hamer, D. H. (2010).
Community-Level Micronutrient Fortification of School Lunch Meals Improved Vitamin
A, Folate, and Iron Status of Schoolchildren in Himalayan Villages of India. The Journal
of Nutrition, 140 (6), 1146-1154. doi: 10.3945/jn.109.114751
Semba, R. D., Saskia, D. P., Sun, K., Bloem, M. W., & Raju, V. K. (2010). The Role of Expanded
Coverage of the National Vitamin A Program in Preventing Morbidity and Mortality
among Preschool Children in India. The Journal of Nutrition, 8, 208S-212S. doi:
10.3945/jn.109.110700. http://jn.nutrition.org/content/140/1/208S.full.pdf
Shrinivassan, R. (2010, July 15). 55% of Indias population poor: Report. The Economic Times:
India. Retrieved from http://articles.economictimes.indiatimes.com/2010-0715/news/27599998_1_child-mortality-nutrition-oxford-poverty
Tang, G., Qin, J., Dolinkowski, G. G., Russell, R. M., & Grusak, M. A. (2009). Golden Rice is an
effective source of vitamin A. The American Journal of Clinical Nutrition 89(6), 17761783. http://ajcn.nutrition.org/content/89/6/1776.full.pdf+html
Uchendu, F., & Atinmo T. (2012). Nigerian Bread Contribute One Half of Recommended
Vitamin a Intake in Poor-Urban Lagosian Preschoolers. International Journal of Social,
Education, Economics and Management Engineering, 6(10), 405-410.

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http://waset.org/publications/7032/nigerian-bread-contribute-one-half-of-recommendedvitamin-a-intake-in-poor-urban-lagosian-preschoolers
U.S. Agency for International Development. (1996). OMNI Micronutrient Facts: India [Data
file]. Retrieved from http://pdf.usaid.gov/pdf_docs/pnacg701.pdf
World Health Organization. (2007). WHO Global Database on Vitamin A Deficiency: India
[Data file]. Retrieved from
http://who.int/vmnis/vitamina/data/database/countries/ind_vita.pdf

VII.

Appendices:

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