Overlapping vitamin A interventions in the United States, Guatemala, Zambia, and South Africa: case studies

Abstract

Vitamin A (VA) deficiency is a serious public health problem, especially in preschool children who are at risk of increased mortality. In order to address this problem, the World Health Organization recommends periodic high‐dose supplementation to children 6–59 months of age in areas of highest risk. Originally, supplementation was meant as a short‐term solution until more sustainable interventions could be adopted. Currently, many countries are fortifying commercialized common staple and snack foods with retinyl palmitate. However, in some countries, overlapping programs may lead to excessive intakes. Our review uses case studies in the United States, Guatemala, Zambia, and South Africa to illustrate the potential for excessive intakes in some groups. For example, direct liver analysis from 27 U.S. adult cadavers revealed 33% prevalence of hypervitaminosis A (defined as ≥1 μmol/g liver). In 133 Zambian children, 59% were diagnosed with hypervitaminosis A using a retinol isotope dilution, and 16% had ≥5% total serum VA as retinyl esters, a measure of intoxication. In 40 South African children who frequently consumed liver, 72.5% had ≥5% total serum VA as retinyl esters. All four countries have mandatory fortified foods and a high percentage of supplement users or targeted supplementation to preschool children.

Perspective: Integration to Implementation (I-to-I) and the Micronutrient Forum—Addressing the Safety and Effectiveness of Vitamin A Supplementation

“…In Zambia, VAD has been addressed as a problem of public health significance, leading to different approaches that include vitamin A capsule supplementation targeting since 1990 children aged 6–59 mo, mandatory fortification of sugar with vitamin A targeting the general population since 1998, and biofortification of maize and orange-fleshed sweet potato with provitamin A carotenoids for the general population in selected areas of the country since 2007 ( 14 , 63 ). To support these interventions, the country has laid emphasis on nutrition education programs encouraging the population to demand vitamin A–related services and adopting behavior change after public communication around diet diversification with a focus on promotion of foods rich in vitamin A ( 71 ).…”

Global Concerns with B Vitamin Statuses: Biofortification, Fortification, Hidden Hunger, Interactions, and Toxicity

“…Fortification programs are long-term interventions to prevent deficiency in areas where a major percentage of the target population consumes the selected food vehicle regularly. These interventions are costly, require oversight, infrastructure, and regulations; do not adequately target the rural poor; and overlapping interventions can cause concern for excessive intakes for some micronutrients (Tanumihardjo, Kaliwile, Boy, Dhansay, & van Stuijvenberg, 2019). Food diversification and behavior-based strategies to alleviate micronutrient deficiencies are considered ideal for long-term success in low-income countries (Nair, Augustine, & Konapur, 2016;Reinbott et al, 2016).…”

The upper level: examining the risk of excess micronutrient intake in pregnancy from antenatal supplements

“…Several recent publications have begun to assess and address the potential for excessive intake when multiple programs and interventions overlap in a community, but these are not pregnancy specific. 22,23 A study in Australia assessed the prevalence of exceeding the UL during pregnancy and found that around 20% of women exceeded the UL for iron and folate (owing to supplements). 14 However, most studies in LMIC do not report the full range of intake including the highest intake of micronutrients.…”