1000
Asia Pacific J Clin Nutr (1997) 6(4): 246-250
Asia Pacific J Clin Nutr (1997) 6(4): 246-250
The
protective effect of red palm oil in comparison with massive vitamin
A dose in combating vitamin A deficiency in Orissa, India
Sarita Mahapatra MSc and R Manorama PhD
Department of Foods & Nutrition,
Centre of Advanced Studies, Post Graduate & Research Centre, Acharya
NG Ranga Agricultural University, Hyderabad, India
Vitamin A deficiency has long been a serious hazard
to the world community, especially to children. The main reason
for a higher incidence among children is lack of vitamin A in the
diet. Carotene rich supplements with sources like Red Palm oil (RPO)
could be used as a measure to combat vitamin A deficiency. This
study evaluates the protective effect of RPO in comparison with
massive vitamin A dose to combat vitamin A deficiency. The study
was carried out for a period of three months in 36 school children.
Twelve children received a massive dose (50,000 IU) of vitamin A,
another twelve children received 4g of RPO containing B-carotene
equivalent to 25,000 IU of vitamin A in "Besan laddu"
and the remaining twelve received 8g of RPO containing B-carotene
equivalent to 50,000 IU of vitamin A in "Besan laddu".
Serum vitamin A levels were estimated initially, after 15 days of
supplementation and 3 months after termination of supplementation.
The levels were maximum 15 days after the supplementation and, though
it fell by the end of 3 months, yet it was significantly higher
than that of the initial levels in all the three groups. Among both
the levels of RPO supplement, 8g RPO was as efficient as was a massive
vitamin A dose in providing protection for three months, after cessation
of supplementation.
Key words: vitamin A deficiency,
Orissa India, children, red palm oil
Introduction
Vitamin A deficiency is the most widespread nutritional
disorder causing blindness to the children in developing countries
particularly in tropical and subtropical countries. The rational approach
for prevention of such wide spread vitamin A deficiency, in our children
would obviously be in the improvement of their diets1.
Carotene rich supplements with sources like red palm oil (RPO) could
be used as a measure to combat vitamin A deficiency. Studies indicated
that Indian school children fed supplementary snacks prepared with
RPO for 60 days had significant increases in serum retinol levels
as well as an increased liver retinol store, suggesting the ready
bioavailability of b -carotene from red palm oil2.
This study proposes to evaluate the protective effect
of RPO in comparison with massive vitamin A dose in combating vitamin
A deficiency. It has been established 1000 that 200,000 IU of massive
vitamin A dose to preschool children and 100,000 IU to school children
have protective effect for 6 months3. Information on the
protective effect of RPO, by giving a gap of three months after supplementation,
was thought to be very valuable in formulating policies for combating
vitamin A deficiency.
Method
Ethical
consideration
Informed consent was obtained from the children's
mothers and the principles required by the Helsinki declaration met.
All children with a clinical diagnosis of vitamin A deficiency were
offered a form of vitamin A supplemen-tation; and long-term nutritional
advice was provided to mothers and children.
Sampling
One hundred children belonging to an interior village
called "Nakhaur" in Puri district, Bhubaneshwar, Orissa,
were screened by a group of trained paediatricians involved in public
health programmes, for clinical signs and symptoms of vitamin A deficiency.
The presence or absence of clinical signs like night blindness, conjunctival
or corneal xerosis and Bitot’s spots, was noted. 36 school children
in the age group of 7-9 years with mild to severe signs of vitamin
A deficiency were selected. The 36 children were randomly assigned
to three groups, each group containing 12 children.
Group I (control) was given a mega dose of vitamin
A (50,000 IU) (half of 100,000 IU which is the dose given to school
age children. Only 50% of the dose was given, as the study period
was only 3 months).
Group II was given 4g RPO every day for 15 days containing
b -carotene equivalent in toto to 25,000 IU of vitamin A in "Besan
laddu" (a sweet snack made from chick pea flour, sugar and fat,
in the shape of balls).
Group III was given 8g RPO every day for 15 days containing
b -carotene equivalent in toto to 50,000 IU of vitamin A in "Besan
laddu".
The carotenoid composition of the RPO was 550ppm.
Clinical
assessment
Children were assessed for general signs and symptoms
of vitamin A deficiency especially for Bitot’s spots and conjunctival
xerosis, at the beginning, after 15 days supplementation and, finally,
3 months after cessation of supplementation.
Anthropometric
assessment
Height, weight and mid-arm circumferences were measured
at the beginning of the study period. The weight and height measurements
of children were converted into weight for age, height for age and
weight for height per cent of standard for each child using NCHS standards4.
Children were classified into grades of nutritional status using Waterlow’s
classification5. Shakier and Morley cut-off points were
used for the classification of mid arm circumference6.
Thus the children were classified into four grades of nutritional
status: normal, wasted, stunted and both stunted and wasted.
Dietary
assessment
Mothers were interviewed by the 24 hour recall method.
It was conducted four times during the study, initially, at the end
of 15 days of supplementation, one month after supplementation ceased,
and at the end of the study period. The nutrient con 1000 tent of
the child’s diet in terms of vitamin A was calculated using the
food consumption tables for India. No advice was given to change diet
during the study, although it was at the conclusion.
Assessment
of serum vitamin A levels
Serum vitamin A levels of the 36 children were assessed
using high performance liquid chromatography (HPLC) method7.
The HPLC system used was the Shimadzu LC-6A, with a UV detector SPD-6A,
isocratic pump LC-6A, Shimpak Column, CLC-ODS (M) C18, 25 cm x 4.6
nm, rheodyne injection valve, SCL-6A system controller and CR-6A recorder.
100 m l of blood was drawn from each child by the finger prick method to estimate
serum retinol levels. This was done before supplementation, 15 days
after supplementation and, finally three months after supplementation
was completed.
Blood from the finger tip was allowed to run in about
3/4 mm length of a heparinised capillary of 7.5 nm length. The tubes
were then centrifuged in a microhaematocrit for 5 minutes. Serum was
separated and stored at -20o C for estimation of vitamin
A.
Serum, ethanol and an internal standard (retinyl acetate)
were mixed vigorously on a vortex mixer. HPLC grade hexane was added
and the contents again mixed on a vortex mixer, until the bottom layer
was thoroughly extracted. The contents were centrifuged at 2000 rpm
for 5 minutes, the upper hexane layer transferred to a small test
tube and evaporated under nitrogen. The remaining lipid residue was
dissolved in methanol. An aliquot of 20 m l of the solution was injected onto the HPLC column. Plasma retinol
concentrations were calculated from the standard curve after correction
of per cent loss using the internal standard.
Statistical
analysis
One way analysis of variance was conducted to assess
differences between (a) three groups at three time points of the study;
and between(b) three different time points within the same group.
Results
Food
and nutrient intakes
The mean food intake of children for all the three
groups is presented in Table 1, and the percentage of RDA met is presented
in Table 2. Food and nutrient intake of the children was recorded
and calculated without including the daily interventions of massive
Vitamin A dose/ RPO supplements.
Table 1. Mean food intake of children (g)
| Groups |
Cereals
|
Pulses
|
GLV*
|
OV#
|
Milk
|
Fat
|
| Massive dose (n=12) |
254.3± 80.7
|
54.0± 14.8
|
41.0± 14.1
|
44.2± 7.6
|
122.1± 54.2
|
14.7± 5.5
|
| 4g RPO (n=12) |
230.4± 67.1
|
51.8± 18.9
|
45.0± 9.5
|
43.8± 8.3
|
139.9± 47.1
|
15.8± 6.2
|
| 8g RPO (n=12) |
224.9± 68.7
|
47.0± 17.9
|
40.5± 12.5
|
46.9± 11.9
|
122.0± 59.1
|
18.3± 6.1
|
| RDA |
250
|
70
|
75
|
50
|
250< 1000 /font>
|
30
|
Values are mean ± SD; * denotes green leafy vegetables. #
denotes other vegetables.
Table 2. Mean food intake of children as percentage
of RDA met.
| Groups |
Cereal
|
Pulses
|
GLV
|
OV
|
Milk
|
Fat
|
| Massive dose (n=12) |
102
|
77
|
55
|
88
|
49
|
49
|
| 4g RPO (n=12) |
92
|
74
|
60
|
88
|
56
|
53
|
| 8g RPO (n=12) |
90
|
67
|
54
|
94
|
49
|
61
|
GLV = green leafy vegetables; OV = other vegetables.
Almost no children met the recommended dietary allowances
except children with massive dose group who were able to meet their
cereal requirement. For cereals and vegetables the remaining two groups
fell short by only 10%. No significant differences in food intake
were observed between the three groups.
Anthropometric status
Mean nutrient intakes are presented in Table 3. Vitamin
A and iron intakes were found to be less in the 8g RPO group compared
to other groups (P<0.05). None of the groups met the requirement
of any of these nutrients, especially with respect to iron (Table
4). Energy and vitamin A were met at around 63-70%, and protein at
70-80% in the first two groups. The anthropometric data for all children
(Table 5) by grade of nutrition (Table 6) are shown.
Table 3. Mean nutrient intake of children.
| Groups |
Energy (Kcal)
|
Protein (g)
|
Vitamin A (m g/d)
|
Iron (mg)
|
| Massive dose (n=12) |
1365± 399
|
34± 9
|
1743± 345
|
14± 8
|
| 4g RPO (n=12) |
1280± 353
|
34± 9
|
1719± 296
|
12+9
|
| 8g RPO (n=12) |
1283± 339
|
30± 9
|
1521**± 399
|
7**± 3
|
| RDA |
1950
|
41
|
2400
|
26
|
Values are mean ± SD; ** denotes significant differences between
groups (P<0.05).
Table 4. Mean nutrient intake of children as
percentage of RDA met.
| Groups |
Energy
|
Protein
|
Vitamin A
|
Iron
|
| Massive dose (n=12)
|
70
|
84
|
73
|
55
|
| 4g RPO (n=12) |
66
|
82
|
72
|
45
|
| 8g RPO (n=12) |
66
|
73
|
63
|
25**
|
**denotes significant differences (P<0.05) between
rows.
Table 5. Mean anthropometric measurements of
children.
| Groups (n=12) |
Height (cm)
|
Weight (kg)
|
Mid-arm circum (cm)
|
| Massive dose |
116± 7.1
|
19± 2.5
|
14± 1.3
|
| 4g RPO |
118± 6.8
|
20± 1.7
|
13± 1.1
|
| 8g RPO |
116± 8.2
|
19± 2.1
|
14± 1.2
|
Values are mean ± SD.
Table 6. Percentage distribution of children
according to grades of nutrition.
| Grade |
Massive dose (n=12)
|
4g RPO (n=12)
|
8g RPO (n=12)
|
Total
|
| Normal |
17± 2
|
25± 3
|
17± 2
|
19± 7
|
| Wasted |
25± 3
|
33± 4
|
33± 4
|
31± 11
|
| Stunted |
41± 5
|
33± 4
|
50± 6
|
42± 15
|
| Stunted + wasted |
17± 2
|
8± 1
|
0
|
8± 3
|
Values are mean ± SD.
Clinical
assessment
Table 7 shows the occurrence of clinical signs in
the subjects at baseline (I) and at the end (F) of the study period.
No changes in clinical sign frequency were observed following supplementation.
Table 7. Percent distribution of children according
to clinical signs.
| Clinical |
Number of children
|
| symptoms |
Massive dose (n=12)
|
4g RPO (n=12)
|
8g RPO (n=12)
|
| |
I
|
F
|
I
|
F
|
I
|
F
|
| Conjunctival |
75
|
75
|
75
|
75
|
58**
|
58**
|
| Xerosis |
(9)
|
(9)
|
(9)
|
(9)
|
(7)
|
(7)
|
| Bitot’s |
25
|
25
|
25
|
25
|
42**
|
42**
|
| spots |
(3)
|
(3)
|
(3)
|
(3)
|
(5)
|
(5)
|
I = Initial; F = Final; ** denotes significant
differences between groups.
Serum
retinol levels
Mean serum Vitamin A levels are shown in Table 8.
Significant differences were observed between initial and intermediate
Vitamin A levels, and also between initial and final levels in the
massive dose group. Within the 4g RPO group, initial and final levels
differed significantly at the 1% level from intermediate values. In
the 8g RPO group, values at all three periods differed significantly
from each other at the 1% level.
Table 8. Mean serum retinol levels of children
of the three groups.
| Groups |
Serum retinol level (m mol/l)
|
| |
Initial
|
Intermediate
|
Final
|
| Massive dose |
0.56± 0.11**
|
1.07± 0.25
|
0.90± 0.23
|
| 4g RPO |
0.53± 0.12**
|
1.05± 0.27
|
0.67± 0.10**@
|
| 8g RPO |
0.60± 0.13**
|
1.79± 0.70@#
|
0.97± 0.62
|
Values are mean ± S.D. Intermediate - after 15 days of supplementation
; Final - after 3 months of supplementation. **denotes
significant differences between columns; @ denotes significant
differences between rows; # denotes significantly different
from all groups (P<0.01).
Initial levels in all groups were the same. In the
final period, the 4g RPO group had the lowest levels (P<0.01).
The percentage of subjects with serum retinol levels <0.7 m mol/l is indicated in Table 9. Initially, almost all children (80-92%)
had serum retinol levels <0.7 m mol/l. After 15 days of supplementation,
none of the children fell into this category. Finally, 3 months after
cessation of supplementation, only four subjects in the 4g RPO group
(33%) had levels <0.7 m mol/l.
Table 9. Percentage distribution of children
with serum retinol levels < 0.7 m mol/l in different groups
| Groups |
Serum retinol level (m mol/l)
|
| (n=12) |
Initial
|
Intermediate
|
Final
|
| Massive dose |
92
|
0
|
0
|
| 4g RPO |
92
|
0
|
57(33)
|
| 8g RPO |
83
|
0
|
0
|
Discussion
Food
and nutrient intakes
When the mean food intake was compared with RDA, none
of the children met the standards, except the children of the massive
dose group who were able to meet their cereal requirement (Table 1).
Green leafy vegetables were consumed in a very small quantity because
of parental ignorance of their nutritional value. Fruits like papaya
and vegetables like yellow pumpkin and carrot were not consumed at
all. About 50% of children consumed egg and meat only once in a month.
So none of the children were found to meet the vitamin A requirement.
In a similar study carried out in preschool children
of urban slums of Hyderabad, it was reported that the daily intake
of vitamin A was far below the requirement, ranging from 60 to 100m g whereas the recommended level is 300m g8. Proteins and fats
are essential for the absorption and utilisation of vitamin A, but
the intakes of protein and fat were also low and none of the children
met the requirements. These will be reasons for vitamin A malnutrition
in these Orissa children.
Anthropometric
status
Nearly 80% of the children had grades of nutrition
which reflect an inadequate and poor quality of food intake over a
long period of time. This poor dietary intake will in turn predispose
to vitamin A deficiency. Again, inadequate and poor quality food intake
leads to malnutrition and infections which further contribute to vitamin
A deficiency. Corneal xerophthalmia often precedes an episode of infection9,
constituting a vicious cycle.
Clinical
assessment
1000 In the final round of clinical assessment, the
same number of cases as that of the initial round was found to have
conjunctival xerosis or Bitot’s spots. Though in most of the
cases the severity of conjunctival xerosis and Bitot’s spots
was reduced with 15 days RPO supplementation, they were not completely
reversed. The reason may be the short period of supplementation. Sivakumar10
states that clinical diagnosis, though commonly used, has its own
limitations with subjective error and non-specificity. Clinical methods
used in conjunction with biochemical analysis or any other improved
functional methods like Relative dose response test and conjunctival
impression cytology are more accurate. For practical reasons these
methods were not used. However, it was encouraging that there was
no case where vitamin A deficiency increased after 15 days of supplemen-tation
clinically or biochemically.
Biochemical
assessment
Though serum retinol levels of these children were
initially much lower than normal (£ 0.7 m mol/l), after 15 days of supplementation
with massive vitamin A dose and RPO at two different levels (4g and
8g), their serum retinol levels increased significantly. After 3 months
of termination of supplementation, their retinol levels were still
significantly higher than the initial level, but considerably below
the concentration seen after 15 days supplementation.
Among both groups of RPO supplementation, the final
serum retinol levels of 8g RPO group were higher compared to 4g RPO
group. The 8g RPO group was supplemented with 50,000 IU of vitamin
A from RPO (120g) for the entire 15 days of supplementation. Obviously,
this group was able to maintain the serum retinol level beyond three
months even after cessation of supplementation and was able to give
protective effect as that of massive dose group. In the massive dose
and 8g RPO groups, liver stores seemed to have built up adequately
to meet requirements for the entire non-supplemented period, in spite
of ongoing diets low in b
-carotene or vitamin A. But in the 0-4 group which provided only 25,000
IU of vitamin A for the entire 15 days of supplementation, protection
afforded was not equal to that achieved for the massive dose group.
However, even in this group, a marginal increase in serum retinol
was seen at the end of the three month period of non-supplementation,
compared to baseline.
Relationship
between anthropometry and retinol levels
When serum retinol levels were compared in relation
to grades of malnutrition (Table 10), almost the same trend was observed
among anthropometrically acceptable as for malnourished children,
with supplementation. Initially (VAI), in the massive dose group,
anthropometrically "normal" children had significantly higher
(P<0.01) serum Vitamin A levels in comparison with all other grades
of malnutrition. But in the other two treatment groups, all children
had similar levels, irrespective of anthropometry.
Table 10. Mean serum vitamin A (m mol/l) levels amongst clinically
vitamin A deficient children in relation to nutritional status, indexed
by anthropometry.
| Nutritional status |
Massive dose
1000 |
4g RPO
|
8g RPO
|
| by anthropometry |
VAI
|
VAIM
|
VAF
|
VAI
|
VAIM
|
VAF
|
VAI
|
VAIM
|
VAF
|
| Normal |
0.71*
|
1.49
|
1.31
|
0.59
|
1.46*
|
0.75
|
0.57*
|
1.92
|
1.42
|
| % Increase |
|
(109)
|
(85)
|
|
(147)
|
(27)
|
|
(237)
|
(149)
|
| Wasted |
0.44*
|
0.99
|
0.74
|
0.53
|
0.86*
|
0.57
|
0.56*
|
1.61
|
0.86*
|
| % Increase |
|
(125)
|
(68)
|
|
(62)
|
(8)
|
|
(187)
|
(54)
|
| Stunted |
0.59*
|
1.02
|
0.83
|
0.50
|
1.02*
|
0.69
|
0.64*
|
1.62
|
0.88*
|
| % Increase |
|
(73)
|
(41)
|
|
(104)
|
(38)
|
|
(153)
|
(38)
|
| Wasted + stunted |
0.50*
|
0.89
|
0.79
|
0.45*
|
0.78
|
0.68
1000 |
-
|
-
|
-
|
| % Increase |
|
(78)
|
(58)
|
|
(73)
|
(51)
|
|
|
|
* denotes significantly different treatment responses
(P<0.01), within the same group. VAI = vitamin A initial; VAIM
= vitamin A after 15 days of supplementation; VAF = vitamin A finally,
3 months after supplementation
The percentage increase after supplementation (VAIM)
was >100% in normal and wasted children (Table 10), and around
75% in stunted, and wasted + stunted children, in the massive dose
group. Final levels (VAF) were also higher in the "normal"
children of this group.
In the 4g RPO group, normal and stunted children had
a higher percent increase from initial (VAI), after 15 days supplementation
(VAIM) and wasted children had only an 8% increase at the end of the
study period (VAF).
In the 8g RPO group, a 237% increase was found in
"normal" children whereas in wasted and stunted children
it was 187% and 153% respectively, at the intermediate point (VAIM).
Final (VAF) levels were significantly higher in "normal"
children.
In spite of these differences, in all grades of nutritional
status, supplementation improved Vitamin A status.
A study conducted by Pee et al11,
indicates that b -carotene from dark green leafy vegetables was poorly absorbed in comparison
with enriched wafers in lactating women with low haemoglobin status.
No improvement in Vitamin A status was observed in women fed vegetables
or in control wafer groups in comparison with enriched wafer fed groups.
Hume and Krebs12 reckon that bioavailability of b -carotene from vegetables and carrots is
only a third of that of b -carotene in oil. Since RPO contains b -carotene naturally in the oil itself, it also may be more bioavailable,
as suggested in the present study.
Continuous consumption of carotene rich sources like
RPO may not be necessary all through the year, as intermittent bouts
of RPO may be sufficient to maintain serum levels. Longitudinal studies
using larger sample sizes would be worthwhile. Given the limitations
in long term use of massive vitamin A doses, twice a year13,
periodic intakes of RPO twice or thrice a year may prove to be equally
effective in maintaining adequate nutritional status in vulnerable
children, especially if it can be a food-based approach.
Summary
RPO was found to be equally effective in maintaining
serum retinol levels a 1000 s megadose vitamin A in those prone to
vitamin A deficiency. In planning supplementary feeding programmes,
rather than regular daily feeding, periodic feeding of RPO at regular
three monthly intervals may be successful in maintaining normal childhood
vitamin A nutriture.
Acknowledgements. The author wishes to thank Mr Prakash Kumar, Mohanty, Pathologist,
Governor House Hospital, Bhubaneswar, Orissa, for his kind cooperation,
and to Mr PTK Mahapatra for his valuable suggestions and keen encouragement
throughout the study. The author also wishes to extend her thanks
to Dr Satyanarayana, Director, and Dr Amarendra Mahapatra, Research
Officer of Regional Medical Research Centre, Indian Council of Medical
Research, Bhubaneswar, Orissa, for their guidance during the course
of the study & to the Indian Council of Agricultural Research
(ICAR) for providing financial assistance in the form of ICAR Junior
fellowship.
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The protective effect of red palm
oil in comparison with massive vitamin A dose in combating vitamin
A deficiency
Sarita Mahapatra and R Manorama
Asia Pacific Journal of Clinical Nutrition (1997) Volume 6, Number
4: 246-250
Copyright © 1997 [Asia Pacific Journal of Clinical
Nutrition]. All rights reserved.
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