Vitamin A Deficiency -...
Transcript of 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
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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
Beri kapsul vitamin A dengan dosis sesuai umur
Beri kapsul vitamin A dengan dosis sesuai umur
Beri kapsul vitamin A dengan dosis sesuai umur
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