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Vitamin Deficiencies in Developing World-Assessment and Workable Remedies

by Shirang Netke, Ph.D.
(Matthias Rath Inc., R&D)

We have known for a long time that vitamin deficiencies cause certain symptoms. For example, vitamin C deficiency causes scurvy; vitamin A deficiency gives rise to xeropthalmia; and vitamin D deficiency leads to rickets. Recent research findings have shown that deficiency of folic acid is involved in birth defects and that it must be by women taken throughout the childbearing year's age (Czeizel, 1992).

Regular intake of vitamin C can delay or prevent cataract (Jacques, 1997) and certain forms of cancer (Correa, 1992). It can also reverse early calcification in coronary arteries (Rath, 1996). Folic acid can reduce the risk in coronary heart diseases (Rimm,1998). The list can go on and on (Table1). The intakes of vitamins necessary for these disease prevention activities are much higher than those presently recommended.

Table 1

Vitamin Helps Protect Against Protective Daily Intake Vitamin D Osteoporosis 10-20 ug Folic Acid Birth Defects 400-800 ug Folic Acid Heart Disease and Stroke 400-800 ug Vitamin E Heart Disease 100-400 ug Vitamin A, C Cataracts - Vitamin C Stomach Cancer, Heart Disease 250 mg or more Multivitamins Infectious diseases RDA or greater

All these research findings have emphasized the fact that vitamins are essential and indispensable constituents of food for maintaining health. Further, for providing protections from certain maladies intakes of many vitamins need to be much higher. If foods consumed are deficient, the vitamins must be obtained from some other sources such as vitamin supplements. The information however has yet to impact the life of a common man in developing countries. The intake of vitamins depends on three factors:

(1) Information about the roles that vitamins play in maintaining health

(2) Easy access to the desired types of food and supplements

(3) Ability to afford the foods and supplements.

It is common knowledge that all these factors militate against using the right types of foods and vitamin supplements by a very large segment of population in developing countries. One would therefore expect that the morbidity (ill health) and mortality caused by vitamin deficiency to be commonplace in these countries.

Sadly, this is true. There is ample evidence of this in reports published in recent years.

Reports of vitamin deficiencies

Vitamin A

The eye lesions described in classical deficiency symptoms of vitamin A, about 75 years ago, are still seen today in developing countries.

Recent studies in Nepal, covering about 40,000 children over a period of two years revealed high incidence of xeropthalmia (Pokharel, 1998).

Studies covering 15,000 children in the age group of 6 to 71 months, in Ethiopia, indicated overall prevalence rates of night blindness and Bitot's spots at 53% in males and 26% in females. Stunting and wasting kept company with these vision maladies (Haider, 1999).

In Ghana, higher incidence of diarrhea was seen in 6 to 12 months old children that had low level of vitamin A in blood serum. Supplementation of diet with vitamin A reduced the incidence (Lartey, 2000).

Preschool children in Turkey had low serum levels of vitamin A and beta-carotene. These children had acute respiratory infections and recurrent diarrhea (Kucukbay, 1997).

Investigations on preschool children 6 to 24 months in Vietnam found that 46 % of them were deficient in vitamin A (Thu, 1999).

About 40% of Mexican children in rural areas had deficient values of plasma-vitamin A Ê(Rosado, 1995).

Advanced vitamin deficiency is prevalent in slum children in Dhaka in Bangladesh. Administration of vitamin A to these children had a positive impact (Ahmed, 1992).

Observational studies from India, Thailand, Tanzania, and Guatemala indicate that vitamin-deficient children grow poorly, are more anemic, have more infections and are more likely to die than their peers. Supplementation of diet with vitamin A reduced mortality by 30 to 60% (Sommer, 1989).

The report from the International Science and Technology Institute, Washington states that vitamin A deficiency continues to be a public health problem in Brazil, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras and Nicaragua. It is also common in poor communities in Bolivia, in some parts of Mexico and Peru and, of course, in native tribes in Latin America (Mora, 1994).

According to one estimate, 41% of population under 5 years of age in developing countries suffer from inadequate vitamin A intake. Half million children go blind each year. Thirteen and half million develop night-blindness (Duncan, 2000).

In many areas deficiencies of other vitamins are also seen, along with deficiency of vitamin A. Vitamin A and E deficiency and anemia is common in non-pregnant adolescent girls in Southern Malawi (Fazio-Tirrozzo, 1998).

The population in Cameroon has been found to be 72% deficient in vitamin A and 66% deficient in vitamin E (Gouado, 1998). School children from metropolitan areas of Chile are exposed to deficiency of calcium, riboflavin and niacin along with vitamin A (Ivanovic, 1992).

In a study conducted in Mexico dietary intakes of vitamin A ranged between 20 to 72% of the requirement. The diets were also low in riboflavin (35-60%) and ascorbic acid (40 to 70%). (Rosado,1995).

Studies in Slovakia provide a strong evidence of the prevalence of low serum levels of vitamins A, C and E in adolescent non-pregnant girls. The deficiencies were accentuated during pregnancy (Babinska, 1995).

Surveys in some countries have indicated that vitamin A plays positive role in reducing incidence of several maladies. Prevalence of gastric cancer was 62 % lower in patients receiving retinol (vitamin A) and zinc in Linxian trials in China (Taylor, 1994).

It seems that vitamin supplementation can help reduce the adverse effects of malarial infection. In Papua- New Guinea vitamin A supplementation significantly reduced febrile episodes by 35%, spleen enlargement by 26% and parasitic density by 68%(Shanker, 2000).

Higher intakes of protein, vitamin A, niacin, thiamin and riboflavin reduced the prevalence of nuclear cataract in China (Li, 1993).

Vitamin D

High incidence of rickets in low birth weight children has been seen in Tanzania (Msomekala, 1999).

Blood calcidol (form of vitamin D) levels in women aged 40-90yrs in Argentina indicated insufficiency of Vitamin D. These levels were considered inadequate to prevent excessive loss bone mass loss (Fradinger, 1999).

Rickets are very common in children under-five in rural and suburban communities in Savel-Savanna in Nigeria (Akpede 1999).

B Vitamins

Thiamin intake in 43% of teacher families in Changsha, China, was below requirement level (Huang, 1998).

Pregnant women in Thailand were deficient in B2 and B6 vitamins. The deficiency ranged between 9 to 57 % for B2 and from 30 to 40 % for B6 (Pongpaew, 1995).

Earlier studies showed that the about 55% of post-partum women had vitamin B2 deficiency (Vudhivai, 1990)

In another study in Thailand, the percentage of children with vitamin B1, B2 and B6 deficiencies ranged from 10 to 20%, 40 to 80% and 14 to 23% in that order. Incidence of riboflavin and folate deficiency seems to be very high in pregnant women Êin Andhra Pradesh in India (Neela, 1994)

The situation in Turkey was not much different. In one study a very high percentage of women was found to be exposed to the risk of B2, B6, B12 and folate vitamin deficiencies. The risk increased with the advance of pregnancy and during post partum period (Ackurt, 1995).

Thiamin deficiency was observed in 37% of the subjects in Seychelles (Bovet, 1998).

One study on elderly persons in Guatemala revealed that in population with low levels of formal education, riboflavin deficiency was detected in 70 % of the subjects. The incidence of B12 deficiency was around 38% (King, 1997).

Chinese women about 80 years of age with a history of vegetarian diet had low intakes of thiamine riboflavin and niacin. Thirty percent of the group had anemic levels of hemoglobin. These were mostly associated with low serum levels of B12 and iron (Woo, 1998).

In studies conducted Beijing, the intakes of riboflavin, zinc and calcium were inadequate in adult and elderly populations. These populations were considered to be enjoying a high standard of nutrition (Zhao, 1992).

In the studies on elderly people in Belgium the incidence of deficiency of B6, B12 and folate was fairly high even in apparently healthy people (Joosten, 1993).

Multiple vitamins

A high proportion of Vietnamese children were found deficient in vitamin A (46%) and pyridoxine (55%) (Setiwan, 2000).

The population of elderly subjects in Croatia had low and deficient values of vitamins C, E, riboflavin and pyridoxine. With vitamin supplementation of their diet over a period of 10 weeks, the age related decline in immune function disappeared (Buzina- Suboticanec, 1998).

In many studies multiple vitamin supplementation has produced beneficial results. The studies in China show incidence of esophageal cancer was reduced by regular consumption of beta-carotene, vitamin E and selenium (Taylor, 1994).

These studies also showed that supplementation of the diet with multiple vitamins reduced the mortality in the patients suffering from the stomach cancer (Yang, 2000).

Cancer Institute of China conducted collaborative studies in Linxian. In this area the incidence of gastric/esophageal cancer is the highest in the world. In ÒGeneral Population trialÓ significant reduction in total mortality (9%), cancer mortality (13%), gastric cancer mortality (20%) and mortality from other cancers (19%) was noticed among those receiving beta-carotene, and vitamin E/selenium supplement (Li, 1993).

The incidences reviewed above could only be a fraction of those that are prevalent in developing countries. Those with the knowledge of the eating habits and socio-economic level of the people in the developing world know that any deficiency seen in the developed world would certainly be present in the developing world. Many vitamin deficiencies in this part of the world are waiting to be discovered. It would therefore be not illogical to assume that all the maladies resulting from vitamin deficiencies seen and reported from developed nations are present in the developing nations, perhaps in much aggravated form. Most of the time the deficiencies will be multiple ones. If they are not reported, it is because the countries did not have enough resources to conduct needed studies. Absence of direct evidence in such a situation is not the evidence of absence.

Such a consideration will make it imperative for us to evolve strategies to ensure a vast supply of multiple vitamin supplements for the developing world. It is gratifying to realize that world bodies are moving in this direction. Just a few months back "Manila Forum"composed of delegates from PeopleÕs Republic of China, Kyrgyz Republic, Fiji, India, Thailand, Indonesia and Vietnam proposed the "Food Fortification Policy"Ñ"for protecting the populations from mineral and vitamin deficiencies in Asia and Pacific regions." One principle enshrined in their "Vision for 2010" states: "All people of the region should have access to affordable safe and efficacious fortified food as a long term and permanent commitment to the elimination of micronutrient malnutrition." The success of this approach presumes that fortified foods fulfill the following criteria:

(a) They contain adequate amounts of desired micronutrients

(b) They are easily available to the consumers.

(c) The targeted population accepts the foods and consumes them in a quantity that ensures adequate intake of micronutrients.

(d) The technology used in production of the foods does not interfere with the availability of micronutrients.

(e) The micronutrients in foods can withstand long shelf life.

Production and supply of fortified foods is a good approach. But this is a workable solution for the people, who have an access to fortified rice, fortified cereals, fortified flour, fortified oil and of course a fortified wallet. Such fortified foods will certainly be more costly because, the cost of technology, cost of production, profits of the manufacturer, distribution cost and profits of middleman will be added to the cost of micronutrients in the foods.

At this point a quick look of the lifestyle of the population in the developing countries will be worthwhile. Most people in these areas get their supplies of rice, wheat, millets, lentils and vegetables directly from the producers- local farmers. Receipt of wages in the form of millets is not uncommon. The grains are ground in household stone grinder or taken to a local flourmill. Only industrial products the people use are salt and very small amounts of oil and "joggery". These people, who constitute a vast majority in the developing world, find it difficult to meet even the cost of plain unfortified foods. The proposed production of fortified foods will offer them scarcely any relief for the simple reasons that they will not be able to afford them, even if they have access to them. We also have to bear in mind the fact that entry of fortified food in the dietary of the targeted population demands a radical change in their existing life style and dietary habits. Such a change is very difficult.

In such a situation it is very unlikely that production and availability of fortified food will make us realize the goal. There is no denying the possibility that some segment of urban "haves" may benefit from this approach. But in the words of Dr Brundtland, Director General of World Health Organization "Our values cannot support market oriented approaches that ration health services to those with the ability to pay"(1999).

Is there any simple workable solution? What is wrong with orthodox method- making available multiple vitamin supplements to the people? After all there are several reports where providing vitamin supplements to the needy have produced beneficial results. Some health professionals and policy makers have reservations about making the vitamins available directly to the consumers. They fear that some consumers will use excessive amounts of these supplements leading to toxic effects. Another fear is that people will disregard the importance of well balanced diet and will simply rely on correcting everything by supplement. Both of these fears seem to be irrelevant to developing countries. The low socio-economic status of the people will simply limit the amount of vitamins they can purchase and consume. Even if vitamin supplements are supplied free of cost by some agency the probabilities that parents will consume the capsules meant for their children or will consume in one week the amount meant for a month are very remote.

The fears of over-consumption mostly originate form developing countries. They mostly relate to vitamins A, C and E. Let us review the results of dietary surveys conducted in the USA. The Second National Health and Nutrition Examination Survey (NHANES II) data show that even in USA where, in general, nutrition literacy and socio-economic level is much higher and access to vitamins is easy, percent of people consuming less than 100% of recommended allowances is 64,46 and 70% of vitamin A, C and E respectively.Ê Then again the intakes of vitamins that would lead to toxicity have not been firmly established. On the other hand the higher intakes of vitamin that can be taken without any problems (Tolerable Upper Levels) are very high (Table 2). Given these facts, the fears of excessive use of vitamins by the people even in developing countries are unfounded. Given these facts it is intriguing that "Codex Alimentarius Commission" (Codex Alimentarius Commission has been entrusted by Food and Agriculture Organization with the task of proposing draft guidelines for use vitamin and mineral supplements) is considering a proposal to prevent excess intakes of vitamins. This proposal will ban the sale of preparations of vitamins containing higher than RDA levels. Supplements with higher levels will be available only on medical prescription. Remember that RDA levels are being revised upwards to "Recommended Dietary Intakes".

Table 2: Recommended and Tolerable Upper Levels
for some Critical Vitamins

Nutrient Recommended Dietary Intake Tolerable Upper Level Vitamin D (ug/d) 5-15 25-50 Niacin (mg/d) 16 35 Pyridoxine (ug/d) 1.3-1.7 100 Folate (mg/d) 400 1000 Vitamin C (mg/d) 90 2000 Vitamin E (mg/d) 15 1000 Carotenoids (mg/d) - 25mg for B carotene* Vitamin A 5,000iu** 10,000iu*

*NOEAL - No Observed Adverse Effect Levels
** Recommended Dietary Allowances

Such a move presumes that an average man in developing countries will abstain from his work, walk miles along with his family to a physician. He pays the physician to examine his entire family. The physician prescribes supplements with higher levels of vitamins and warns them not to finish their weekly supply in a day. The man then goes to a pharmacy and obtains the supply of vitamin supplements for one week. By the time he comes back home with his vitamin supplements he finds that after loosing day's wages, and after paying doctor's fees and cost of vitamins he has not enough money to purchase rice for the family. Essentially in his efforts to save the family from osteoporosis, anemia, rickets or communicable diseases the farmer has exposed it to pangs of hunger.Ê Imagine the average man doing this every week or every month if the physician takes pity on the family. Then after all these regulated processes what is the guarantee that the farmer does not use his weekly supply in one day? Evidently the physician or policymakers will have to depend on good sense of the farmer or make it incumbent on the physician or his nurse to personally administer the vitamin supplement to every individual in the family.Ê Imagine the cost in terms of lost wages, the fees of the physician and the inconvenience to the farmer. How many can afford this routine?

Dr. Brundtland, Director General of WHO, has outlined a corporate strategy for addressing the concept of positive health (1999).

He states:
(1) We need to be more focused in improving health outcomes.
(2) We need to be more impact oriented in our work.
(3) We need to be more effective in supporting health system development.

Does making vitamin supplements available through medical prescription improve health outcome? Is this move positive impact oriented? Is this measure more effective in supporting health system development? The answer on all counts is NO.

Like maize which is mostly a source of energy, like lentils which supply proteins, like milk which is a source of valuable proteins calcium and other nutrients, vitamin supplements are a part of the food that supply some very essential nutrients which ensure proper utilization of other nutrients, and which ensure maintenance of sound health over long periods.

Everyone therefore must have the same free access to vitamins, that he has to other food items, at least cost, as a long term and permanent commitment to eliminate ill health and morbidity, commitment to prolonged healthy life for everyone and not to few privileged ones.

Let us channel our resources towards these commitments.

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