VITAMIN A DEFICIENCY

VITAMINS

• Are a class of organic compounds categorized as essential

nutrients

• Required by the body in very small amounts (Micronutrients).

• Do not yield energy; but enable the body to use other nutrients.

• Broadly divided into two groups: Fat soluble Vitamins (A, D, E

& K)
Water soluble Vitamins (B & C)
 Vitamin A is also called retinol

 Plays essential roles in vision, growth, & development;

maintenance of healthy skin, hair, mucous membranes; immune
functions & reproduction

 Vitamin A includes preformed vitamin → Retinol

and pro vitamin → Beta carotene

 1 mcg of retinol=1 mcg of retinol equivalent (RE)

1 mcg of B-carotene=0.167 mcg of retinol equivalent
(RE)
 History

• Hopkins conducted an experiment in young rats (1906-1912).

• These were fed on casien, starch, sugar, lard and inorganic

salts. These rats failed to grow and died.

• An addition of only 3 ml milk enabled them to thrive! An

‘Accessory food factor’ was thus demonstrated.

• Mc Callum isolated it in 1913 and was named as Vitamin A.

Wald was awarded Nobel Prize for description of ‘dark vision’
and its association with Vitamin A
SOURCES
 SOURCES
• Widely distributed in animal foods as preformed vitamin A and
plant foods as provitamins (carotenes)

• Animal foods: Liver, eggs, butter, cheese, whole milk, fish and
meat.

• Plant foods: Green leafy vegetables, carrot, Yellow

fruits (mango, papaya & pumpkin)
Avocados

Fortified foods: Vanaspati, Margarine, milk

Plant foods rich in vitamin-A
 Absorption and utilization

Absorption and utilization depends upon the

• amount of fat in the diet

• Method of food preparation

• Rate & completeness of digestion

• Absorption is optimal when the body stores are depleted & when
optimal amounts of other nutrients are present

• Presence of Vitamin –E & hormone thyroxin enhances the

absorption of Vitamin -A
 MECHANISM OF ABSORPTION

• Vitamin A esters are hydrolyzed in lumen of intestine by the

enzyme lipase

• The vitamin –taken by intestinal mucosa, where the vitamin is

etherified with palmitic acid

• These esters are absorbed & enter lymphatic & eventually into
circulation

• In blood vitamin esters – attached to ß lipoproteins & are

taken up by the liver
• The vitamin is released as retinol binding protein
 FUNCTIONS

• Essential for normal vision

• Integrity and normal functioning of glandular and epithelial

tissue

• Supports skeletal growth

• Anti infective
 MECHANISM OF ACTION

ROLE IN VISION: Retina contains 2 types of receptor cells:

Rods- Dim light vision
& Cones - Bright light vision

Rhodopsin - Light sensitive pigment in photoreceptor cells of retina

- Made up of retinaldehyde, bound to protein Opsein
- Excitation by a single photon results in transmission of
nerve impulse
-When light falls on rhodopsin it splits into Opsein &
all trans retinal
All trans retinal →converted to 11-Cisretinol
 The challenge

• Vitamin A deficiency (VAD) is the leading cause of

preventable blindness in children and increases the risk of
disease and death from severe infections. In pregnant
women VAD causes night blindness and may increase the
risk of maternal mortality.
• Vitamin A deficiency is a public health problem in more
than half of all countries, especially in Africa and South-
East Asia, hitting hardest young children and pregnant
women in low-income countries.
• Crucial for maternal and child survival, supplying
adequate vitamin A in high-risk areas can significantly
reduce mortality. Conversely, its absence causes a
 Contd …..
• For children, lack of vitamin A causes severe visual
impairment and blindness, and significantly increases the
risk of severe illness, and even death, from such common
childhood infections as diarrhoeal disease and measles.
• For pregnant women in high-risk areas, vitamin A
deficiency occurs especially during the last trimester when
demand by both the unborn child and the mother is
highest.
• The mother’s deficiency is demonstrated by the high
prevalence of night blindness during this period. The
impact of VAD on mother-to-child HIV transmission
needs further investigation.
 Facts

• An estimated 250 million preschool children are vitamin A

deficient and it is likely that in vitamin A deficient areas a
substantial proportion of pregnant women is vitamin A
deficient.

• An estimated 250 000 to 500 000 vitamin A-deficient

children become blind every year, half of them dying
within 12 months of losing their sight.
 Problem of VAD in India

• In india level of Bitot’s Spot which was 2% in 1979 has

declined to 0.7% in 2001,indicates that it is public health
problem
Volnerability :-
 Young children <the age of 3 years
 Pregnant and lactating women
Sex:-
Male childen > female children
 DEFICIENCY
• Signs of vitamin A deficiency are → 2 types

• Ocular and Extra ocular

• Ocular manifestations: are the most common ones.

Night blindness,
Conjunctival xerosis,
Bitots spots,
Corneal xerosis,
keratomalasia.
• First clinical sign of vitamin A deficiency- Conjunctivital
xerosis

• First clinical symptom of vitamin A deficiency-Night

Blindness
 Signs and symptoms of Vitamin A
Deficiency
• Dryness, itching, redness of conjunctiva
• Night blindness (inability to see in dim light)
• Other signs of xerophthalmia : Bitot spots; Corneal
xerosis;
• Keratomalacia
• Dry, rough, itchy skin; rash
• Dry, brittle hair and nails
• Loss of acuity of senses: smell and taste
• Loss of appetite
• Anaemia, fatigue
• Poor growth
• Low immunity: Increased vulnerability to infections
• Increased risk of certain cancers
 NIGHT BLINDNESS

• Initial ocular manifestation of vitamin-A

• Inability to see in dim light

• Condition may worsen unless the child is supplemented with

vitamin –A

• Condition may worsen in children suffering from diarrhoea

and other infections
Bitot spots Keratomalacia

Conjunctival Xerosis Keratomalacia

 XEROPHTHALMIA

It is a consequence of vitamin A deficiency in which there is

drying and thickening of the conjunctiva and ultimately ulceration
and destruction of the conjunctiva.
 Pathophysiology:
• Vitamin A is necessary for the growth and differentiation
of epithelial cells, conjunctival and corneal epithelial cells
are involved in this process.
• Night blindness is the earliest sign of vitamin A
deficiency. Next phase is the loss of normal mucous cells
from the cornea
• Dryness causes keratinazation of the epithelial cells lining
the cornea
• Dull, hazy and luster (shine) less appearance i.e.
xeropthalamia
• Final consequence keratomalacia, Bitot’s spot may be
seen, which are glistering white plaques of desquamated
thickened conjunctival epithelium, usually triangular in
shape.
 Causes of blindness:

• Vitamin A deficiency.
• Trauma, retinoblastoma.
• Cataract, other congenital eye anomaly.
• Diabetic retinopathy and hypertensive retinopathy.
Source of vitamin A deficiency:

 Vegetables: carrot, papaya, pumpkin etc.

 Green vegetables, tomatoes.
 Ocular manifestation of vitamin A
deficiency

• XN: Night blindness.

• XIA: Conjunctival xerosis.
• XIB: Conjunctival xerosis with Bitot’s spot.
• X2: Corneal scar.
• X3A: Corenal ulceration with xerosis involving less than
1/3 rd of the cornea.
• X3B: Corenal ulceration with xerosis involving more than
1/3 rd of the cornea.
• XF: xeropthalmic fundus.
• XS: corneal scar.
 Preventive measures

• Ensure breast feeding and the mother should be given

adequate vitamin A completed food.
• In pregnant mother doses of vitamin capsule in three
maternal visits or 1 capsule at least at last trimester.
• Sufficient dose of green leafy vegetables should be given
to the child.
 Curative measures

1. Corneal lesion or severe illness or malnutrition:

– 1, 00,000 IU vitamin A intramuscularly.
– 1, 00,000 IU vitamin A in the following day.
– 1, 00,000 IU vitamin A on two successive days.
2. Non-corneal xerophthalmia, healthy and well nourished.
– Less than 14 years-1, 00,000 IU vitamin A orally.
– More than 14 years old-2, 00,000 IU vitamin A orally.
Operative measures:
• For restoration of the vision keratoplasty can be done if
there is corneal opacity.
 CONJUNCTIVAL XEROSIS

 First clinical sign of vitamin deficiency.

 Conjunctiva becomes dry & non-wet table
 Looks muddy & wrinkled instead of smooth & shiny
 Most common in children aged 1-3 yrs
 Associated with PEM
 Most widespread & serious nutritional disorder leading
to blindness

 Andhra, TN, Karnataka, Bihar, and WB → badly

affected states
 BITOTS SPOTS

• Triangular, pearly white or yellowish, foamy spots on

bulbar conjunctiva on either side of cornea

• In young children→ Vitamin A deficiency

• In older children → Sequel of earlier disease

 KERATOMALACIA

• Keratomalacia or liquefaction of cornea is a grave medical

emergency

• The cornea may be soft & may burst open

• The process is a rapid one & the vision is lost permanently

• Mostly associated with PEM

 EXTRA – OCULAR MANIFESTATIONS

Non specific and difficult to quantify

Comprise follicular hyperkeratosis, anorexia, and growth retardation

Cessation of bone growth→ overcrowding of brain &

CNS →Paralysis from
cranial pressure
Damage to mucous membrane (loss of integrity of epithelial cells)

Mild vitamin deficiency →↑Morbidity & mortality

due to respiratory &
Intestinal infection
 HYPERVITAMINOSIS

 Acute symptoms are developed on ingestion of very large

amounts of vit-A:
Headache, drowsiness, sluggishness & peeling of
skin & palms

In Infants→ Sudden rise of intracranial pressure

 Continued intake of excessive amount → Roughening of skin
Irritability
Coarsening & falling of hair
Head ache
Leukopenia
 All these symptoms vanish on withdrawal of vit -A
 RECOMMENDED ALLOWANCES (ICMR)

GROUP RETINOL (mcg) or B-CAROTENE (mcg)

Man 600 2400
woman 600 2400

Pregnancy 600 2400

lactation 950 3800

INFANTS(0-12) 350 1200
months
CHILDREN
1-6 Yrs 400 1600
7-12 yrs 600 2400
ADOLSCENTS
13-19 Yrs 600 2400
 Prevention and Control

• Improve the diet to include more intake of foods rich in vitamin A

• Reducing frequency & severity of contributory factors like PEM ,
respiratory infections, diarrhoea and measles
• Every half yearly a massive dose 200,000 IU of Vitamin A in oil (retinol
palmitate) is administered orally to preschool children(1yr -6yr)
• A massive dose 100,000 IU of Vitamin A to children between 6 months
-1 year of age

• ASSESMENT OF VITAMIN –A DEFICIENCY→ Population

surveys (clinical&
bio chemical
criteria)
• Was part of Child Survival Safe Motherhood before;
Now part of RCH Program
 REVISED STRATEGY OF WHO FOR VISION
2020

• It has
been estimated that blindness cost the world 25 billion
annually in productivity

• A global initiative has been taken initiated to reduce the

preventable & curable blindness by 2020

• Strengthening of vitamin –A supplementation; School eye

screening programme

• Treatment of minor ailments at primary level; ICDS, & IEC for

awareness
 References

1. Park .k text book of preventive and social medicine, 23rd

edition, bhanarsidas bhanot publishers. 2015: 615-616
2. B rajvir, textbook of public health and community
medicine, published by department of community
medicine pune,and WHO. 1st edition 2009: 731-732
3. Gupta M., Mahajan., Text book of Preventive and
Social Medicene, 3(Edn):533
4. http://www.who.int/nutrition/topics/vad/en/
5. Lal. Sundar, text book of preventive and social
medicine, 4th edition, CBS publishers.2014:222-223
6. Yadav Dr. Sudeep, a book on pathophysiology,1st
edition, 2011 A.D: 211-212
THANK YOU