Comparison of Food-Based and Dietary Supplement Approaches to Alleviate Vitamin A

Deficiency and its Health-Related Outcomes in Pregnant Women in Africa

By
Jessica Plasencia

A Senior Project submitted

In partial fulfillment of the requirements for the degree of
Bachelor of Science in Nutrition

Food Science and Nutrition Department

California Polytechnic State University
San Luis Obispo, CA

December 2019
Abstract

Background and Objective: Vitamin A deficiency in pregnant women is most prevalent in

developing countries due to increased food insecurity, low dietary diversity, and an unclear
approach to alleviate rates of deficiency. Vitamin A stores are insufficient in women of
reproductive age and can be further depleted with each consecutive infant born. This leads to
increased rates of infant morbidity and maternal night blindness. Vitamin A deficiency has been
approached in developed countries through food fortification and dietary supplementation. The
purpose of this literature review is to compare the effects of a dietary supplement versus a food-
based approach to alleviate vitamin A deficiency and its health-related outcomes in pregnant
women in Africa.
Methods: PubMed and Cal Poly One Search were used to search journal articles using key
phrases including “maternal vitamin A deficiency”, “pregnant women in Africa”, and “vitamin A
deficiency in reproductive aged women” and relevant studies were identified.
Findings: The studies reviewed revealed similar outcomes. Food-based sources of vitamin A
decreased rates of vitamin A deficiency and vitamin A related health-outcomes more effectively
than dietary supplements alone, although at varying extents. In the included observational and
experimental studies, the food-based vitamin A approach proved beneficial to pregnant women
in Africa, while constituting a safe source of vitamin A for the entire community to consume.
Future Needs: Based on this review, increased food intake of vitamin A rich plant sources paired
with a fat source is beneficial to pregnant women affected by low vitamin A stores. Future
research will need to inquire into types of foods that will be self-sustainable in the African
community and relevant dietary recommendations.

1
 Introduction

Vitamin A is an essential micronutrient that becomes deficient most commonly in

preschool aged children and pregnant women. The focus of this review is vitamin A deficiency

in pregnant women. Adequate vitamin A status is critical during times of rapid growth and

development. During times of rapidly differentiating cells, such as during fetal development, the

need for adequate vitamin A stores is greater than usual. While the prevalence of vitamin A

deficiency has decreased over time, it remains a public health concern in many countries

worldwide, especially in developing African countries. Over half of the countries in Africa are

categorized as severe subclinical or as clinical public health concern with regards to vitamin A

status (World Health Organization [WHO], 2010). Nearly 19 million pregnant women suffer

from vitamin A deficiency worldwide (WHO, 2009). More so, this deficiency disproportionately

impacts pregnant women in their third trimester of pregnancy. The inability to acquire adequate

vitamin A stores prior to pregnancy only leads to further depletion and an increased difficulty

replenishing stores before the next pregnancy, leading to a vicious cycle of vitamin depletion.

The purpose of this literature review is to examine and compare the effectiveness of

supplemental vs food-based approaches towards alleviating vitamin A deficiency in pregnant

women in Africa. Vitamin A status was assessed using serum retinol levels in all but one study,

the latter used dark-threshold adaptation to assess vitamin A status. In the present literature

review, the WHO definition of vitamin A deficiency, i.e. serum retinol level ≤0.70/L μmol, is

used to reflect severity. Additionally, night blindness is used to reflect severity and as a health-

related outcome associated with vitamin A deficiency. PubMed and Cal Poly One Search were

used to search journal articles using key phrases including “maternal vitamin A deficiency”,

“pregnant women in Africa”, and “vitamin A deficiency in reproductive aged women”.

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Observational and experimental studies were utilized in this review. These articles included

prevalence, supplementation approach type, and health-related outcomes.

Vitamin A Importance

Vitamin A has many functions including regulation of gene expression, vision, cellular

differentiation, and immunity. Carotenoid and retinoid forms of the vitamin have independent

functions playing key roles in proper eye development. Vitamin A also forms rhodopsin, a

pigment protein located in the light-receptors, or rods, of the retina. Vitamin A has several

immune system functions including the ability to maintain T-lymphocyte function and antibody

response. Without proper vitamin A stores, the ability to fight off infection is compromised

(Gropper et al., 2018). Due to the multitude of its functions, vitamin A deficiency may increase

the risk of maternal morbidity while also being a major cause of preventable night blindness in

pregnant women (Harika et al., 2017).

Night blindness is characterized by the inability to see in low-light or darkness and is

typically associated with low levels of vitamin A intake or stores (clevandclinic.org, 2019).

When a flash of light hits the retina, vitamin A in cis-retinal form is converted to trans-retinal

form, cleaving a rhodopsin molecule in the process. When this process is reversed and the eye

encounters darkness, the rhodopsin must be reformed using cis-retinal. If vitamin A stores are

depleted, the rhodopsin is unable to reform and the ability to adjust to low light is compromised

(Gropper et al., 2018). Pregnant mothers, particularly those entering pregnancy with low vitamin

A stores, are disproportionately affected by night blindness during their last trimester of

pregnancy due to further depletion of stores by the increased needs of the growing fetus.

Vitamin A in retinoic acid form plays a role in immune function. Retinoic acid stimulates

phagocytic and natural killer cell activity. Additionally, depletion of vitamin A stores affects T-

3
lymphocyte cell function. T-lymphocytes are non-antibody producing cells that can become

cytotoxic cells or memory cells. The key advantage of memory cells is their near instant humoral

response when encountering a previously experienced antigen, essentially, enhancing immunity.

If vitamin A levels are low and T-lymphocytes are not produced at adequate levels, then the

capacity to combat viral, parasitic, and bacterial infections is compromised (Marieb et al., 2015).

Vitamin A Deficiency Prevalence

Hanson, et al (2018) studied the serum retinol and carotenoid levels of mother-infant

pairs in the U.S. and Nigeria to study the prevalence of maternal vitamin A deficiency,

associated health outcomes, and effects on infant vitamin A levels. The comparison of findings

between a developed and developing country is not only helpful in comparing prevalence, but

also in analyzing possible distinctions responsible for group disparities in vitamin A status. This

comparative study had a total of 278 participants. Excluded were mother-infant pairs with

congenital abnormalities, gastrointestinal problems, liver disease, kidney disease, or inborn

metabolic errors. In Nigeria, 99 mother-infant pairs enrolled to the antenatal clinic at the

University of Abuji Teaching Hospital in Nigeria were recruited to participate in the study. Of

the mother-infant pairs recruited, only 84 mothers and 74 infants had usable blood samples. In

the U.S., 179 mother-infant pairs were strategically recruited from Nebraska Medicine Hospital’s

labor and delivery units to represent the U.S. demographic, however, only 176 mothers and 167

infants had usable blood samples.

Cord and maternal blood samples were collected at the time of delivery to determine

vitamin A status, serum retinol levels, and serum carotenoid levels of mother-infant pairs. Along

with serum samples, infant birth anthropometrics and sex, as well as, maternal age, BMI, and

smoking status were collected. In Nigeria, the hospital followed up with a phone interview 28

4
 days after the hospital discharge date to evaluate mother-infant pair well-being and collect

information regarding any postnatal hospitalizations. In the U.S., mother-infant pair information

regarding health status was collected from hospital records (Hanson et al., 2018).

Table 1. Serum retinol status of mother and infants in the U.S. and Nigeria (Hanson, et al 2018)

The Nigerian mothers demonstrated nearly four times higher rates of vitamin A

deficiency than the U.S. mothers, 35.5% versus 9.3% (Table 1). Nigeria demonstrated almost

double the amount of severely deficient infants, 14.8%, then the U.S., 7.6% (Table 1). Although

both the Nigerian mothers and infants demonstrated elevated rates of vitamin A deficiency, the

two were not found to be correlated (p=0.66). Notably, while Nigerian mothers had higher pro-

vitamin A levels than U.S. mothers, they still demonstrated a higher prevalence of vitamin A

deficiency. This could be attributed to the plant-based diet of the Nigerian population that is

higher in the lower bioavailable pro-vitamin A. One limitation of this study was the small sample

size in relation to the prevalence estimate of the country represented (Hanson at al., 2018).

WHO recommends vitamin A supplementation for pregnant women in areas where

vitamin A deficiency is a public health concern. The International Vitamin A Consultative Group

(IVACG) defines severe public health concern as 5% of the population having a vitamin A

deficiency. In Africa, this percentage is nearly doubled at 13.5% (WHO prevalence report,

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2009). While it is clear that action must be taken, the appropriate method for supplementation of

low vitamin A status in at risk groups remains unclear.

Table 2. Prevalence of serum retinol ≤0.70 umol/L and number of pregnant women
affected 195-2005, by WHO region (WHO prevalence report, 2009).

WHO region Prevalence (%) # affected (millions)

Africa 13.5 4.18
(8.9-18.2) (2.73-5.63)
Americas 2.0 0.23
(0.4-3.6) (0.04-0.41)
Dietary Supplement Approach

A trial was conducted in reproductive-aged women in Ghana following a previously used

approach of a weekly low-dose supplement of vitamin A in Nepal. The primary goal of this trial

was to assess the effectiveness of supplementation in reducing pregnancy-related mortality in

women of reproductive age in Ghana (Kirkwood et al., 2010).

The study population consisted of all women aged 15-45 who lived in the seven

prominent districts in the Brong Ahafo Region of Ghana. Women were randomly assigned,

according to their cluster of residence, a vitamin A capsule or a placebo capsule with identical

appearance and taste. The vitamin A capsule contained 25,000 IU retinol equivalents in soybean

oil to enhance absorption. The placebo capsule only contained soybean oil. Women were given 4

capsules in a vial at a time and were instructed to take the supplement weekly. Every four-weeks,

the women were visited at home to receive their next vial, however no direct observation of

capsule consumption took place. Distribution of capsules begun in December 2000. All

distribution stopped in September 2008 and all data collection stopped in October 2008. In order

to encourage consumption of capsules, an Information, Education, Communication (IEC)

program was formed. This educational program was held every Sunday and encouraged women

to consume the capsule that day, to create a sense of community and support while reducing

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forgetfulness. The IEC group addressed any adherence problems through regularly held focus

groups. During home visits to distribute capsules, data was collected regarding any pregnancies,

births, deaths, hospital admissions, morbidity, sociodemographic characteristics, and capsule

consumption. Between March 2003 and May 2003, a sub-study was held. 200 randomly selected

participants were surveyed to assess night blindness within the sample population. Between

September 2008 and October 2008, a second sub-study was held. This time, 440 pregnant

women and 440 women who had not been pregnant in the last year were randomly selected to

give 5 mL of venous blood to assess serum retinol concentrations (Kirkwood et al., 2010).

This trial continued for 8 years, with an average participation duration of 4.5 years, and a

total of 9,440 participants. Adherence to consumption was high. 88.2% of women self-reported

consumption of all four capsules and 84.3% consumed all four based on observed capsules left in

their vial. However, results of this trial suggest that weekly vitamin A supplementation in this

population had no beneficial effect on maternal morbidity, mortality, or vitamin A status. There

was no difference between placebo and supplementation groups rates of pregnancy-related

Table 3. Effect of weekly vitamin A supplement on pregnancy-related mortality and serum retinol
concentrations (Kirkwood, et al 2010)

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hospital admissions (2342 admissions for placebo vs 2332 admissions for supplement). There

was also no significant difference found between mortality rates of the two groups. Vitamin A

supplemented groups had 115 pregnancy-related deaths and the placebo group had 110 deaths,

p=0.80 (Table 3). In the 2008 sub-study, there was no indication of vitamin A supplementation

having any effect on serum retinol levels. Interestingly, the vitamin A supplementation group of

women had higher level of deficiency, 25%, than the placebo group, 15.4% (Table 3). Notably,

the placebo group was given oil capsules to consume weekly, essentially, increasing vitamin A

absorptivity. The study conducted in Nepal concluded that maternal mortality could be reduced

by 44% in the sample population through a weekly, low-dose vitamin A supplement (West et al.,

1999). Reasons inhibiting paralleled results between the populations studied, could be

differences in initial population status. The population in Nepal demonstrated 10% of

participants affected by night blindness, while this population demonstrated a rare number of

women affected. The study concluded that there is no benefit to an inclusion of a low-dose

vitamin supplement in women of reproductive age in Ghana (Kirkwood et al., 2010).

When nutrient consumption is below recommendations, a supplement is a reliable way to

aid in consuming adequate amounts of said nutrient. However, due to the wide variety of

nutrients within whole foods, a supplement cannot completely replace the nutrient diversity of a

healthy diet (National Institute of Health [NIH], 2011). In several countries in Africa, societal

norms require women to feed their family members before themselves, limiting nutrient status

and increasing risk of micronutrient deficiency. Despite animal sources having the most

bioavailable form of vitamin A, due to low-income status, women often rely on plant sources of

vitamin A (Lietz et al., 2001). The findings of the Kirkwood et al., 2010 study and Africa’s

8
deficiency status suggests that, perhaps, the appropriate approach to improving micronutrient

deficiency is through dietary diversity (Table 2).

Food-Based Approach

Hiwot et al (2014) assessed dark adaptation threshold in pregnant women in Southern

Ethiopia to analyze vitamin A status. This study attempted to find behavioral correlation between

women and adequate vitamin A status. 104 pregnant women were randomly selected for this

study. To perform the dark adaptation threshold, each woman was first adapted in a dark tent for

ten minutes. Each woman was then asked to read black letters on a white background in a dark

room. The room’s light level was tested by researchers prior to the study to assure the subjects

were being asked a reasonable task. The women’s pupillary response was measured using a

Scotopic Sensitivity Tester-1 (SST-1). This tester consists of an illumination device, ranging

from 0 to 30 decibel intensities. The women were tested based on their pupillary response to

illuminations at this range of light intensities. Women were also asked to provide a 24-hour

dietary recall. Dietary diversity scores were given on a scale from 1 to 10 based on the number of

food groups consumed by each female in the 24-hour dietary recall.

The study population was 27.5±6.1 years old at 28±7 weeks of gestation. Of these

women, 80.7% had been pregnant previously. 91.3% of the women sampled had heard of night

blindness before, indicating high prevalence of the issue within the community. Of the women

who had given birth in the past three years, 12.9% had experienced night blindness themselves;

older women, those with no formal education, and those in their third trimester of pregnancy had

a higher proportion affected. The dietary diversity scores revealed that 50% of participants

received a dietary diversity score of less than 3, and only 18.3% received a dietary diversity

score over 6. Women with formal education had higher dietary diversity scores and showed

9
significantly higher consumption of animal-source vitamin A foods (p=0.003) and slightly higher

consumption of plant-source vitamin A foods (p=0.082). For each unit increase in dietary

diversity score, there was a decrease in dark adaptation threshold (p=0.001). Therefore, dietary

diversity appears to be correlated to an improved vitamin A status, supporting a food-based

approach to vitamin A deficiency. Although this study did not indicate any design limitations,

the statistical approach of this study was poorly described. Sufficient narrative explained the

study process; however the results were presented rather vaguely (Hiwot et al., 2014).

The absorption of carotenoids varies but can be up to 60% in pure oil form. Leitz, et al

2001 conducted an experimental study exploring food-based alternatives to increase vitamin A

status in breastfeeding mothers and pregnant women in Tanzania. Red palm oil was the chosen

food-based source of vitamin A due to its dual role in providing provitamin A and oil to enhance

absorption. The population studied consisted of 90 women in their third trimester of pregnancy

from 20 different villages in Tanzania. This study excluded women with severe anemia and

clinical infections. There were no significant differences between socioeconomic status or

dietary intake between the groups. This was determined based on several variables such as

access to water and electricity, and income. All but one of the women were small-scale farmers.

In order to minimize crossover of the different supplement types, the women were allocated into

three groups based on supplement likeness and then separated by distance. The different

supplement groups had a minimum of 3km of distance among them. The study compared a

control group, a group administered sunflower oil (low in vitamin A), and a group administered

red palm oil (rich in provitamin A) to compare outcomes of serum and breastmilk retinol, alpha-

carotene, and beta-carotene levels. Each group was encouraged to consume green leafy

vegetables with their allotted oil; the control group paired their greens with rice. Oil was

10
distributed monthly throughout the last trimester of pregnancy and three months postnatal; a total

of six months. Each woman was given enough oil to feed their entire family, giving all members

the potential to benefit from the study. Each woman was taught how to incorporate the oil into

traditional meals and warned of the dangers of heating oil past the smoke point. Distribution of

oil was done in public spaces in the village. During this time, women completed questionnaires,

gave blood and breast milk samples, and were assessed anthropometrically. Blood samples were

used to analyze plasma alpha-carotene, beta-carotene, and serum retinol levels. Breastmilk

samples were used to analyze alpha-carotene, beta-carotene, retinol levels, and milk fat

percentage which affects newborn absorption of vitamin A. At the start of the study, there were

no significant differences in plasma nutrient composition between groups (Lietz et al., 2001).

Table 4. Plasma retinol, alpha-carotene, and beta-carotene levels at baseline (during third
trimester), one month, and three months postpartum (Lietz, et al 2001).

At one month postpartum, the red palm oil group’s plasma alpha- and beta-carotene

concentrations were 42 times and 3 times higher than the control group (Table 4). At three

months postpartum, this difference remained significant at 51 times greater for alpha-carotene

and 4 times higher for beta-carotene (Table 4). However, no significant difference was found in

plasma retinol levels at one or three months postpartum, p=0.94. Unlike the control group, both

11
the red palm oil and sunflower oil groups demonstrated a maintenance of alpha- and beta-

carotene levels between one and three months postpartum. Breastmilk alpha- and beta-carotene

concentrations were significantly higher per kilogram milk fat in the red palm oil group than the

control group, p=0.041 (Lietz et al., 2001).

This study indicates that red palm oil increases alpha- and beta-carotene concentrations in

plasma and breastmilk (Table 4, Table 5). No group showed a significant difference in change in

retinol levels, however both the red palm oil group and the sunflower oil group showed much

higher postpartum retention rates than the control group. This could be due to oil increasing

absorption and retention of vitamin A. The overall increase in serum retinol of all groups can be

attributed to the increased consumption of dark green leafy greens and fat; typically this

population has a low-fat diet (Lietz et al, 2001).

Table 5. Concentration of breastmilk retinol, alpha-, and beta-carotene levels at one month
and three months postpartum (Lietz, et al 2001).

Red palm oil is widely produced in West Africa, however proper cooking technique is

not as common. Red palm oil is commonly used for deep-fat frying and vegetables consumed are

commonly blanched, decreasing nutrient availability. For this reason, the population was

instructed how to prepare dishes while preserving vitamin A bioavailability. Although further

research is needed, red palm oil consumption is considered of added benefit for increased plasma

12
and breastmilk alpha- and beta-carotene levels and maintenance in the sample population (Lietz

et al., 2001).

In the 2010 Ghana study by Kirkwood et al., the weekly vitamin A supplement

demonstrated no increase in serum retinol levels when compared to the control group. Although

in the study by Lietz et al., 2001 there was no significant difference in serum retinol

concentration increases between the three groups, there were substantial increases across all

groups. The lowest increase observed being the control group, from 0.94 μmol to 1.14 μmol

(Table 4). The commonality between groups was increased consumption of vitamin A rich whole

foods. The red palm oil and sunflower oil groups were instructed to consume 4 tbsp of oil and

avoid cooking past the smoke point. When paired with proper cooking techniques, the increased

consumption of plant-source vitamin A foods proved to increase serum retinol, alpha-, and beta-

carotene levels (Lietz et al., 2001).

Busse, et al., 2017 conducted a cross-sectional study in five rural districts of Ethiopia.

The populations’ knowledge of vitamin A rich source, vitamin A deficiency, and associated

health behaviors were examined to determine an appropriate food-based approach to reduce

deficiency caused by common population practices. These rural areas have demonstrated

difficulty meeting nutritional recommendations in the past due to low health care access.

The sample population consisted of 150 mothers with at least one child between 6-59

months old. The population was surveyed to assess general knowledge of vitamin A, nutrition

consumption behaviors, family production of potato, white fleshed sweet potato (WFSP), and

orange fleshed sweet potato (OFSP), and health status indicators. The research team considered

that food choice extends beyond simply selecting a food item, and considered social and cultural

dynamics that may influence food consumption.

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 The average maternal age was 36.4 years old. The average woman was married at 16.9

years old and had her first child at 17.8 years old. In a woman with poor vitamin A status, each

child means a further depletion of micronutrient stores. On average, the women in this

population had 6.1 children (Busse et al., 2017).

Table 6. Comparison of maternal consumption of potato crops in the past seven days, separated by
district (Busse et al., 2017).

Production and consumption of potatoes varied across the included distircts. The Boricha

and Duguna districts produced the most potato and WFSP. The Damot Gale produced the most

OFSP. Due to societal norms in many African countries, women often feed their family members

before themselves, indicated by the difference between household production and average

maternal consumption of potatoes. On average, only 15% of the women sampled reported

consuming potato crops in the past seven days. Also, due to traditional low-fat consumption,

none of the districts paired vitamin A sources with a fat source to enhance absorption (Table 6).

The lack of vitamin A and fat pairing could be a strong determinant for relatively high rates of

morbidity (Table 7).

14
 Notably, the district of Damot Woyide was the only district with OFSP consumption

(Table 6). One medium OFSP can provide well over 100% of the daily recommendations for

vitamin A (Ware, 2017). Notably, this district had lower history of eye problems and night

blindness when compared to many other districts, indicating improved vitamin A status (Table

7). Thus, the increased consumption of OFSP is beneficial to eye health (Busse et al., 2017).

Table 7. Comparison of maternal health practices and outcomes, separated by district (Busse
et al., 2017)

This study concluded that the best way to improve vitamin A deficiency related health

implications is through the consumption of vitamin A rich crops, specifically OFSP. Not only

will this improve vitamin A status, but it may additionally help improve other micronutrient

deficiencies due to the high nutrient variety in whole foods. This practice is a more economically

attainable and self-sustainable approach to vitamin A consumption than vitamin supplements in

15
capsule form. While this survey accurately reflected vitamin A practices and knowledge of the

five rural communities sampled at this time, it does not reflect all of Ethiopia or this population

completely due to large seasonal variation in food consumption. This survey was held at the end

of the belg season, or the secondary harvest season, which tends to have lower food production

and stores than the primary harvest season (Busse et al., 2017).

Summary and Future Research Needs

The present literature review assessed supplement- versus food-based approaches and their

effects on vitamin A status. One experimental study was reviewed to evaluate vitamin A

supplementation effectiveness. One observational and two experimental studies were reviewed to

evaluate effectiveness of food-based approaches on vitamin A deficiency. Pregnant women are at

risk for this deficiency due to the increased vitamin A needed to support fetal growth and

development. Women in Africa have a much higher prevalence of vitamin A deficiency when

compared to women in the United States, 13.5% vs 2% (Table 2). With a deficiency prevalence

over 5% indicating public health concern, the current vitamin A status in African pregnant

women constitutes critical interest.

Although a dietary supplement in capsule form can be beneficial to some populations, it

has not proven beneficial in African countries (Kirkwood et al., 2010). The weekly supplement

administered in the Ghana study contained 25,000 IU retinol equivalents paired with soybean oil,

but the capsule alone did not significantly affect vitamin A status (Kirkwood et al., 2010).

Animal sources of vitamin A have an increased absorbance rate in the body, however, due to

lower socioeconomic status and food availability, plant-based diets are more common in Africa.

Notably, while having a lower bioavailability, the plant sources of vitamin A proved beneficial to

vitamin A status and related health outcomes when cooked correctly and supplemented with a fat

16
source (Hiwot et al., 2014; Lietz et al, 2001). The red palm oil was particularly beneficial in

increasing serum and breastmilk beta-carotene levels (Lietz et al, 2001). In the observational

study conducted by Hiwot et al., 2014 dietary diversity was correlated to decreased dark

threshold adaptation, p=0.001. Although the red palm oil study conducted by Lietz et al., 2001

did not assess eye health, carotenoids play key roles in eye development and maintenance.

Further research is needed to correlate increased red palm oil intake and eye health status.

The food-based vitamin A approach indicates higher effectiveness in improving vitamin

A status in pregnant women in Africa, while constituting a safe source of vitamin A for the entire

community to consume. Additionally, this approach is more sustainable and economically sound,

and may increase jobs, income, crop production, and sales, while potentially, addressing issues

of social inequality and food insecurity. Future research is needed to identify the most beneficial

types of foods that will be self-sustainable year-round in African communities, and intake

recommendations needed for improving vitamin A status.

17
 Table 8. Summary of Research Studies Evaluated

Study & Participants Treatment Outcome Measured Findings

Design
Kirkwood et Women aged -Vitamin A -Serum retinol levels -No significant differences
al., 2010; 15-45 years capsule -Maternal mortality between group morbidity rates
Cluster- living in the (25000 IU - Maternal morbidity (compared using group
randomized, seven retinol hospital admission rates)
double-blind, prominent equivalents in -No significant difference
placebo- districts in the soybean oil) between mortality rates
controlled Brong Ahafo -Placebo -Vitamin A capsule group had
trial Region of capsule nearly 10% higher rates of
(total Ghana (soybean oil) serum retinol levels <0.7
duration= 8 (n=9,440) umol/L
years; -Weekly, low-dose vitamin A
average supplementation has no
participation= beneficial result on population
4.5 years)
Hiwot et al., 104 pregnant Observational -Dark adaptation - For each unit increase in
2014; women study threshold dietary diversity score, there
Cross- randomly -Dietary Diversity was a decrease in dark
sectional, selected using (scored 1-10 based adaptation threshold
observational two stage on number of food - Dietary diversity appears to
study cluster groups consumed in be correlated to an improved
sampling 24-hour dietary vitamin A status
recall)
Lietz et al., -90 pregnant -Red palm oil -Serum: alpha- -At one-month post-partum,
2001; women in their + dark, leafy carotene, beta- the red palm oil group’s alpha-
Cluster- third trimester greens caortene, and retinol and beta- carotene levels were
randomized, of pregnancy -Sunflower levels 42 times and 3 times higher
placebo- -no significant oil + dark, -Breastmilk: alpha- than the control
controlled differences in leafy greens carotene, beta- -All groups demonstrated
trial; socioeconomic -Control: rice carotene, retinol, and increased serum retinol levels;
6 months status + dark, leafy milkfat levels however, no significant
greens difference was found between
the groups
-Red palm oil is of benefit to
increased alpha- and beta-
carotene concentrations and
maintenance
Busse et al., 150 mothers Observational -General knowledge -Mothers reported low vitamin
2017; with ≥1 child study of vitamin A A knowledge and consumption
Cross- 6-59 months -Vitamin A -The only district with OFSWP
sectional, old consumption consumption had decreased
observational -Family production eye health issues; suggesting
study of food-sources of vitamin A are
-Health status of benefit to eye health and
indicators maternal morbidity

18
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