Re-Defining the Population-Specific Cut-Off Mark for Vitamin A Deficiency in Pre-School Children of Malawi

Abstract

Retinol Binding Protein (RBP) is responsible for the transport of serum retinol (SR) to target tissue in the body. Since RBP is relatively easy and cheap to measure, it is widely used in national Micronutrient Surveys (MNS) as a proxy for SR to determine vitamin A status. By regressing RBP concentration against SR concentration measured in a subset of the survey population, one can define a population-specific threshold concentration of RBP that indicates vitamin A deficiency (VAD). However, the relationship between RBP and SR concentrations is affected by various factors including inflammation. This study, therefore, aimed to re-define the population-specific cut-off for VAD by examining the influence of inflammation on RBP and SR, among pre-school children (PSC) from the 2015–16 Malawi MNS. The initial association between RBP and SR concentrations was poor, and this remained the case despite applying various methods to correct for inflammation. The World Health Organization (WHO) recommends the threshold of 0.7 µmol/L to define VAD for SR concentrations. Applying this threshold to the RBP concentrations gave a VAD prevalence of 24%, which reduced to 10% after inflammation adjustments following methods developed by the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA). Further research is required to identify why SR and RBP were poorly associated in this population. Future MNS will need to account for the effect of inflammation on RBP to measure the prevalence of VAD in Malawi.

Correlates of Iron, Cobalamin, Folate, and Vitamin A Status among Stunted Children: A Cross-Sectional Study in Uganda

“…The prevalence of vitamin A deficiency in this study was higher (21%) than that previously reported in the general population of children under five years in Africa. Vitamin A deficiency was estimated at 8.9% (RBP < 0.8 µmol/L) in Uganda [27], 9.2% (RBP < 0.7 µmol/L) in Kenya [28], and 10% (RBP < 0.7 µmol/L) in Malawi [29]. Additionally, a cross-sectional study in Uganda found that low S-RBP (<0.8 µmol/L) was associated with higher odds of stunting in children aged 6-59 months [27].…”

Modeling food fortification contributions to micronutrient requirements in Malawi using Household Consumption and Expenditure Surveys

“…38 Recent evidence suggests that the combination of vitamin A fortification and supplementation interventions may be leading to excessive vitamin A intake among PSC in Malawi, 18 although caution is needed in interpreting these data and more research is needed before consideration of any policy changes. 39,40 We found a low risk of excessive vitamin A intakes under the status quo fortification scenario, although the risk of excessive apparent intake increases to 19% among wealthy, urban households under the improved compliance scenario (Table S5, online only). Further research is needed to model how additional micronutrient interventions can meet vitamin A needs unaddressed by oil and sugar fortification.…”

“… 6 , 38 , 45 The national burdens of micronutrient deficiencies are classified using biomarker surveys, but operational and analytical challenges can pose difficulties when interpreting results. 40 Furthermore, some micronutrients that were indicated by this analysis to be of concern for dietary inadequacy are either not commonly assessed using biomarker analyses (e.g., riboflavin) or are challenging to measure using biomarkers, for example, owing to tight homeostatic control of concentrations in blood plasma/serum (e.g., zinc). 46 Using dietary data to assess inadequacies in micronutrient intake can provide information to guide the design of policies centered around food‐based interventions.…”

The prevalence of vitamin A deficiency and its public health significance in children in low- and middle-income countries: A systematic review and modelling analysis

“…Additionally, efforts should be made to ensure transparency and collaboration among researchers, which would facilitate data sharing, harmonisation, and ultimately contribute to more accurate estimates of VAD burden globally. Second, Vitamin A is stored in the liver and transported to the end organs by retinol binding protein (RBP) [24]. Therefore, circulating concentrations of RBP, the carrier protein for serum (plasma) retinol, are also considered a biological indicator of VAD in some large investigations [25].…”