vitamin a deficiency -...

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

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million Indonesian children � risk of Vit A deff >> (sub klinis) � xeropthalmia�blindness

What caused deficiency?

• Primary (‘NUTRITION’):– Protein energy malnutrition (defect on

absorption)

– Minimum daily vit A or β-carotene

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– 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

Secondary (diseases related to

absorption and metabolism )

– Celiac disease

– Sprue

– Cystic fibrosis

– Pancreatic disease

– Giardiasis

– Cirrhosis

– Chronic hepatitis

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– Pancreatic disease

– Congenital partial

obstruction of

duodenum

– Chronic hepatitis

– Chronic diarrhea

Other signs of defficiency

• Frequent infections like measles, diarrhea, and malaria

• Stunted growth

• Anemia

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• Anemia

• Malnutrition

• Thickened toad like skin, goose flesh

Skin Manifestation

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X2

X1B

X1A • 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

Clinical signs of vit A deff

7XS

X3B

X3A

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

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:

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• 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

How to diagnosed

Laboratorium: < 10 µµµµg/dL

Clinical sign

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Funduscopic examination

Laboratorium:Serum retinol Retinol binding protein level

< 10 µµµµg/dL

< 20 µµµµg/dL

Sub clinic

Vitamin A

Vitamin A

• Vitamin A-active compounds are represented by

retinoids (designated as vitamin A) and their

carotenoid precursors (provitamin A

carotenoids)

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• Structure:

– Retinoids: retinol, retinaldehyde, and retinoic acids

– Provitamin A carotenoid (α-carotene, β-carotene, and

β-cryptoxanthin)

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

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� Glycoprotein � important for normal cell surface function such as cell aggregation and cell recognition

� Normal reproduction (retinol), bone development, immune function

Absorption and convertion vitamin

A and β-carotene

β-Carotene

bile

2-50%

ENTEROCYTE

β -caroteneCentral cleavage

Retinaldehyde

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mixed micelle

Retinyl ester

Retinol

INTESTINAL LUMEN

Retinaldehyde

Retinol

Retinoic acid Portal bloodflow (albumin)

Fatty acids

Retinyl esters Chylomicron

Lymph

Sumber: Erdman dkk, 1993

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

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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

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

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• 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)

• Moderate heat, such as blanching and cooking denature carotenoid binding proteins� releasing the carotenoid

• Optimal retention of carotene is obtained

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• Optimal retention of carotene is obtained by steaming vegetables of cooking with minimal water until the vegetables are cooked

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

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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

• Host related factors affecting bioavailability:

– Malnourished

– Presence of intestinal parasites

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– Presence of intestinal parasites

– Atrophic gastritis

– Elderly people with little or no acid in stomach

– Drug: Omeprazole � pH>4.5� reduced β-

carotene serum

Medical Nutrition Therapy and

PreventionPrevention

Therapy

Gejala Hari 1 Hari 2 Hari 15 (mgg II)

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 Beri kapsul vitamin A Beri kapsul vitamin A Beri kapsul vitamin A

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Ada salah satu gejala X1B (bercak bitot-nanah/radang-kornea keruh-ulkus kornea-pernah sakit campak




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)

Prevention

• Prevention:– < 6 months : 50.000 IU oral

– 6-12 months: 100.000 IU oral

– >1-5 year : 200.000 IU oral

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– >1-5 year : 200.000 IU oral

February and August

Requirement

23• Not exceed 2 times the RDA (AKG ’04)

Medical Nutrition Therapy

• Goals:

– Provided an adequate food to reach normal

nutrition status

– Provided high vitamin A food sources

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– Provided high vitamin A food sources

• Energy:

– Adequate energy to prevent protein break-

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down (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

• Protein

– High protein

– To form Retinol Binding Protein and

Rhodopsin

– Malnutrition (poor), step by step:

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• 1-1.5 g/kg BW/ day

• 2-3 g/kg BW/day

• 3-4 g/kg BW/day

• Fat

– 20-25%

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– 20-25%

– For optimal vit A absorption: 3-4 g per meal

– MCT

– PUFA>>SFA

– Palm oil (red), coconut oil

• 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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epitel condition � easy to digest

Vitamin A Sources

Vitamin A sources (retinol per 100 g edible portion)

Cow’s milk 30

Semi-skimmed 19

Sumber: Food Standard Agency(2002)

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Semi-skimmed 19

Skimmed 1

Cheese 958

Egg 190

Chicken 11

Liver 19,700

Sardines 6

Butter 958

Sumber β-karoten

β-carotene sources (µg/100g)

Carrot (cooked): 9800 Daun selada: 1200

Sweet potatoes (cooked): 8800 Bawang prei: 1000

Carrot : 7900 Tomato juice: 900

Sumber: Mangels dkk, 1993

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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

Contoh makanan lunak kaya

vitamin A• Pagi:

– Bubur ayam + tomat cincang

• Selingan:

– Kue sus isi wortel

• Sore:

– Kolak biji salak (ubi merah/oranye)

• Malam:

– Lontong

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– Kue sus isi wortel

• Siang:

– Bubur/tim nasi

– Semur daging giling

– Oseng tempe

– Sayur lodeh (kcg pjg dan melinjo)

– Pepaya

– Lontong

– Telur bumbu opor

– Tumis buncis

– Pisang ambon

• Malam:

– susu

Contoh makanan biasa kaya

vitamin A

• Pagi:

– Nasi goreng

– Telur ceplok

• Selingan:

– Cake wortel

• Sore:

– Pastel isi sayuran

• Malam:

– Nasi

– Gulai ikan

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– Cake wortel

• Siang:

– Nasi

– Goreng ayam mentega

– Tumis kacang merah

– Cah wortel dan caisim

– Jeruk

– Gulai ikan

– Tahu telur

– Tumis kangkung

• Malam:

– susu

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Thank you

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