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Asia Pac J Clin Nutr 2012:21 (1):3-11
Original Article
Effects of vitamin A, vitamin A plus zinc, and
multiplemicronutrients on anemia in preschool children inChongqing,
China
Li Chen MD, PhD '^^ Yong-Fang Liu Ms\ Min Gong MD, PhD*, Wei
Jiang MD, PhD*,Zhen Fan MD, PhD*, Ping Qu BA', Jie Chen PhD',
You-Xue Liu MD, PhD*, Ting-Yu Li
'Nutritional Research Center, Key Laboratory of Developmental
Diseases in Childhood (Chongqing MedicalUniversity), Ministry of
Education, Children's Hospital of Chongqing Medical University,
Chongqing, ChinaDevelopmental and Behavioral Pdiatrie Department
& Child Primary Care Department, Children's
Hospital of Chongqing Medical University, Chongqing, China
This study is to clarify the impact of vitamin A or vitamin A
combined with other micronutrients supplementationon anemia and
growth in preschoolers. In the present study, a total of 290
preschoolers, aged 36-72 months oldwere randomly assigned to 3
treatment groups: vitamin A (A group), vitamin A plus zinc (AZ
group), and vita-min A combined with additional
multiple-mlcronutrient (AMM group). After 6-month supplementation,
theheight and height-for-age z-score gains of the AZ group were
significantly higher than the other groups; theweight gain of the
AMM group was greater than the other groups. Compared with baseline
values, the concentra-tions of hemoglobin, and zinc at the end
significantly increased in all 3 groups. The incremental
concentrations ofhemoglobin in the AMM group were significant
higher than in the other two groups. Furthennore, the incre-mental
concentrations of serum retinol in the AMM group, and the increase
in serum zinc concentrations in theAZ group were significantly
higher, respectively, than in the other groups. These 3 kinds of
supplements in thepresent study are effective in enhancing height
gains and are effective in reducing the prevalence of anemia.
Sup-plementation of zinc plus vitamin A is a better way for
improving children's height and height-for-age z-score.Vitamin A
combined with multiple-micronutdent is more effective in improving
the hemoglobin concentrationsin preschool children.
Key Words: anemia, vitamin A, zinc, muitiple-micronutrient,
supplementation
INTRODUCTIONHidden hunger (contain micronutrient malnutrition)
arecaused by poor dietary intake, and lead to poorer health.
'Vitamin A deficiency and zinc deficiency are regarded byWHO as
global childhood malnutrition risk factors that,among other things,
exacerbate a variety of communica-ble diseases. Vitamin A
deficiency and zinc deficiency,also contribute to anemia, ocular
disorders and growthretardation.^"^
Anemia is a major health concern especially in devel-oping
countries. Children and women of reproductive ageare especially
susceptible. In China, the incidence rate ofanemia is between
9.7-16.3% among preschoolers. Irondeficiency disorder is regarded
as the major cause ofanemia. Nevertheless, it has been recently
reported thatnutritional anemia can be caused, and exacerbated
bydeficiencies in other micronutrients except for iron, suchas
zinc, vitamin A, copper, B-vitamins (such as vitaminBl, vitamin B2,
vitamin B6, vitamin B12, folie acid, nia-cinamide). ' Intervention
trials have confirmed that sup-plementation with vitamin A can
elevate hemoglobin (Hb)concentrations.*"* Our investigation showed
that the prev-alence of anemia was 26.6% in 2002, and 23.5% in
2005among preschoolers in Chongqing, China. Our studies in
2000 showed that 37.9% of preschoolers in Chongqing,China
suffered from vitamin A deficiency disorder(VADD), and this reduced
to 6.3% in 2005. Our previousstudies demonstrated that
supplementation with vitaminA could elevate Hb concentrations in
preschool childrenin the area.' In addition, it was reported that
the incidencerate of zinc deficiency disorder (ZDD) was about
39%among 0 to 6 years old children in China in 2005. Ourprevious
studies also showed that supplementation withzinc eould also reduce
the prevalence of anemia in pre-school children; and that the
impact of zine supplementon preschool children's hemoglobin was
similar to sup-plementation with vitamin A.
Corresponding Author: Dr Ting-Yu Li, Nutritional ResearchCenter,
Key Laboratory of Developmental Di.seases in Child-hood (Chongqing
Medical University), Ministry of Education,Room 907, 136 Second
Zhongshan Road, Chongqing 400014,China.Tel.; 86 023 636 236 04;
Fax: 86 023 636 269 04Email: [email protected] received 3
November 2010. Initial review com-pleted 5 July 2011. Revision
accepted 15 August 2011.
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L Chen, YF Liu, M Gong, W Jiang, Z Fan, P Qu, J Chen, YX Liu and
TY Li
A few experimental trials showed that zinc supplemen-tation
alone or in combination with vitamin A success-illy improved the
levels of Hb and serum retinol.^'"' Fur-thermore, in the treatment
of anemia, it was suggestedthat the combination of vitamin A and
zinc in addition toiron could increase hemoglobin levels more than
supple-menting iron alone." It was hypothesized that vitamin Aand
zinc should play important roles in increasing hemo-globin levels
and reducing the prevalence of anemia.
Zinc and vitamin A are both antioxidants. There is aconspicuous
relationship between vitamin A and hemato-poiesis, and increasing
serum zinc can induce the releaseof vitamin A from the liver to
serum. It was reported thatsome other micronutrients such as zinc,
and B-vitaminscould enhance the absorption of vitamin A. Zinc is
impor-tant for both intra- and intercellular transport of vitamin
A.It affects synthesis of the transport protein, which trans-ports
retinol from the liver to the blood and other targettissues, and
also participates in the synthesis of cellularretinol binding
protein (cRBP). Researchers thought thatthere was synergy between
zinc and vitamin A, whichcaused the improved circulating retinol
concentrations.
In this study, we conducted a randomized and con-trolled trial
with 3 intervention groups: a vitamin A group,a vitamin A plus zinc
group and a group given vitamin Acombined with other multiple
micronutrients (vitamin Aplus vitamins B-1, B-2, B-6, B-12, vitamin
C, vitamin D,folate, niacinamide, and calcium). One of the aims of
thisstudy is to confirm whether vitamin A plus zinc
supple-mentation is effective in preventing and treating anemia.At
the same time, this study is to compare the effective-ness between
vitamin A alone, vitamin A plus zinc andmultiple micronutrients
fortified food in increasing eryth-ropoietin (EPO), hemoglobin
concentrations, and retinolstatus. At the same time, we observed
the change of sub-jects' health. The effect of supplementation on
growthwas also evaluated.
MATERIALS AND METHODSStudy design, participants and ethical
approvalThe study was designed as a randomized trial with 3
in-tervention groups. It was carried out from November2008 to June
2009 in Banan District, a suburb of Chong-qing. This is an area of
median socioeconomic status in
Table 1. Micronutrients list in the three groups
southwest ChinaThree kindergartens were randomly selected out of
7 in
this region; and 3 classes were chosen from each of them.More
than 300 children from 9 classes, aged between 36-72 months old,
were enrolled from the selected kindergar-tens. The eligibility
criteria for participation were as fol-lows: 1) not having any
chronic infectious diseases; 2)hemoglobin concentration >60 g/L;
3) C-reaction protein(CRP)
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Effects of vitamin A and micronutrients on anemia
VA group
(A group)
VA25000IUI 1 week 2 weeks
3 | 4 5 6 ?( 1 2f 3 4 s 6
6 months
[ \) No suppIementatioB
VA plus zinc group
(AZ group)
2 weeks i lOmg
ZnlOmg
[ \ J No supplementation
VA plus multiple-micronutrients group(AMM group)
I VA S,OOOIV+multiplemicronutrients
2 weeksi V J No supplemen
Figure 1. Methods of supplementations. The vitamin A was
supplemented twice a month; zinc in the form of zinc gluconate
tablets wasgiven 5 days a week, through Monday to Friday; while
multiple micronutrients in the form of chewable tablets were given
every threedays
Code: H10950027; subjects gained vitamin A 2,5000IU per 14days;
and gained 100% DRIs others multi-ple micronutrients per day, by
supplementing chew-able tablets 5 times per 14 days). The
supplementationlasted 6 months.
MeasuresOuestionnaireThere were two parts in the questionnaire.
First, there wasa brief soeioeconomic survey to be completed at the
be-ginning of the treatment. This part was performed onlyonce at
baseline. Second, there was a 24-h dietary recallquestionnaire for
all the participants to be conducted ex-cept on Saturday, Sunday or
any festival days. The ques-tionnaires were performed for a total
of seven times (atthe beginning, and end of each month). A
Wednesdaywas chosen for interviews for each time. All the
childrenstayed in the kindergartens from 08:00-17:00, and theyhad
their breakfast and lunch there. Therefore, we wereable to collect
information on the food and drink given tothem there. On that
Wednesday, the quantities of foodeaten by the children measured
with utensils currentlyused in the kindergartens (bowl, spoons, cup
etc.) wererecorded in detail. The workers would call the mothersthe
next day for information about the food, especiallysnacks, eaten by
the children in the previous night asmeasured with utensils used in
their household (bowl,spoons, cup etc.). If any child was sick, the
24-hour die-tary recall would be delayed until the next
Wednesday.Intakes were then calculated using energy, protein
andmicronutrient contents of ingredients given in food com-position
tables (set by China Food Composition 2004).
Anthropomtrie measurements
Anthropomtrie measurements of the children were doneat the start
and the end of the supplementation period. Torule out individual
variations in the measuring process, allanthropomtrie measurements
were taken by the sameresearchers who were from the Children's
Hospital. Allmeasurements were performed in duplicate. Weight
wasrecorded to the nearest 0.1 Kg with the children mini-mally
clothed with bare feet and the same weighing scale(100 Med, China)
was used for all children. Height wasmarked to the nearest 0.01 cm
and with the same standingscale (100 Med, China) for all childten.
Anthropomtriedata were assessed as z-scores for HAZ,
weighl-for-age(WAZ) and weight-for-height (WHZ) using the Epi
Infoprogram (version 2002, CDC) and the U.S. National Cen-ter for
Health Statistics data 2000. A cut-off point of < -2SD was used
to define low WAZ (underweight), lowHAZ (stunting) and low WHZ
(wasting).
Sample collectionAt both the start and the end ( 1 week after
supplementa-tion) of the study, about 4 mL of blood was collected
byvenepuncture using aseptic technique, and another aliquot200 |iL
was put in tubes with EDTA for the estimation ofhemoglobin. Then
serum was obtained by centrifugingthe blood at 3000xg for 6 min at
room temperature. It wasthen stored at -80C in the Nutrition
Research Center untilanalysis.
Laboratory analysisHb levels were determined by the
cyanmethemoglobindetermination method. Serum vitamin A
concentrationwas determined by using high-perfonnance liquid
chro-matography (HPLC) in a dark room according to themethod of
Miller and Yang while with some slight modi-
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L Chen, YF Liu, M Gong, W Jiang, Z Fan, P Qu, J Chen, YX Liu and
TY Li
fications. Serum zinc concentrations were measured byflame
atomic absorption spectrophotometry. CRP wasmeasured by
particle-enhanced immunoturbidimetry(Upper, China, Code No:
2400335).'^
DefinitionsAnemia was defined as Hb concentration
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Effects of vitamin A and micronutrients on anemia
Table 3. Daily consumption of major nutrients in the three
groups
Characteristic A group (n=88) AZ group (n=93) AMM group (n=
109)Energy (Kcal)Energy (% Chinese RNI) iProtein (g)Protein
(%Chinese RNI)Vitamin A (ng RE)Vitamin A (%Chinese RNI)Zinc
(mg)Zinc (% Chinese AI )Iron (mg)Iron (%Chinese AI) [Calcium
(mg)Calcium (%Chinese AI)Vitamin C (mg)Vitamin C (%Chinese
RNI)Vitamin B-1 (mg)Vitamin B-1 (%Chinese RNI)Vitamin B-2
(mg)Vitamin B-2 (%Chinese RNI)
1525(1466-1585)^86%-122%48 (46-50) ^
284 (220-346) ^37%-69%
8 (7.6-8.3)^63%-92%
15.0(12.0-17.0)100%-142%
455 (243-597)30%-75%
33.0 (30-37.0)43%-53%
0.55 (0.47-0.63)67%-90%
0.74(0.58-1.06)83%-151%
1466(1420-1512)^'84%-116%45 (43-47) *78%-104%
260(195-326)^33%-65%
7(7.1-7.7)*59%-86%
14.0(12.0-15.0)100%-125%
439 (283-554)35%-69%
34.0 (28.0-40.0)40%-57%
0.54 (0.46-0.58)66%-83%
0.69 (0.48-0.92)69%-131%
1428(1395-1462)*82%-112%45 (44-47) *80%-104%
284 (200-368) *33%-74%
7 (7.4-7.9) *62%-88%
14.0(12.0-15.0)100%-125%
475 (296-579)37%-72%
35.0 (30-38)43%-54%
0.61 (0.54-0.59)0.77%-84%
0.7 (0.48-0.94)69%-134%
RNI, Recommended Nutrient Intake.AI, Adequate Intakes.Values are
median ((range in 25"' and 75"'-parentheses), * ' median values
within a row with unlike superscript symbols are sig-nificantly
different among the corresponding treatment groups, withp
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L Chen, YF Liu, M Gong, W Jiang, Z Fan, P Qu, J Chen, YX Liu and
TY Li
the AZ group was significantly greater than in the othertwo
groups (p
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Effeets of vitamin A and micronutrients on anemia
ment of hemoglobin was in a decreasing order of AMMgroup, AZ
group, and A group. And hemoglobin concen-trations gain in the AMM
group was significant higherthan in the A group. Nevertheless,
there were no signifl-cant differences in hemoglobin concentrations
gain be-tween A group and AZ group.
Serum zinc concentrations increased signiflcantly dur-ing the 6
months in all groups (p
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10 L Chen, YF Liu, M Gong, W Jiang, Z Fan, P Qu, J Chen, YX Liu
and TY Li
This study demonstrates that supplementation of micro-nutrients,
such as supplementation of vitamin A alone,vitamin A combined with
zinc, and vitamin A plus multi-ple micronutrients, are effective in
enhancing height gains,and effective in reducing the prevalence of
anemia. Sup-plementation of zinc combined with vitamin A is a
betterway to improve children's height and HAZ, while vitaminA
combined with multiple micronutrients is more effec-tive to improve
the levels of hemoglobin as well asweight in preschool
children.
ACKNOWLEDGMENTSSources of funding: The work was supported by the
SIGHTAND LIFE Grants, SIGHT AND LIFE, Switzerland, and Grantsfor
excellent Ph.D. of the Chongqing Medical University, theChongqing
Medical University, China. Authorship responsibili-ties: The
present paper has been facilitated by TY.L, L.C andYX.L designed
the study; L.C, Y.Fang.L, M.G, W.J, and Z.Fperformed research; P.Q
and J.C detennined the biochemicalindicator. TY.L had primary
responsibility for final content. Allauthors read and approved the
final manuscript. We appreciateProf. Alford Sommer for revising the
paper, and appreciate allof the editors and reviewers for their
perfect work.
AUTHOR DESCLUOSURESAll authors declared there is no conflict of
interest.
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Original Article
Effects of vitamin A, vitamin A plus zinc, and
multiplemicronutrients on anemia in preschool children inChongqing,
China
Li Chen MD, Ph''^ Yong-Fang Liu Ms\ Min Gong MD, PhD', Wei Jiang
MD, PhD\ Zhen* ' ^ ' '^Fan MD, PhD*, Ping Qu BA', Jie Chen PhD ,^
You-Xue Liu MD, PhD', Ting-Yu Li
Nutritional Research Center, Key Laboratory of Developmental
Diseases in Childhood (Chongqing MedicalUniversity), Ministry of
Education, Children's Hospital of Chongqing Medical University,
Chongqing, ChinaDevelopmental and Behavioral Pdiatrie Department
& Child Primary Care Department, Children's
Hospital of Chongqing Medical University, Chongqing, China
^ 3
^ A ( V A ) ^ V A ^ ^ ^ t # ^ t tZ 36-12 ^n^f^Jli '
: VA E (A a) - VAi?o#M (AZ a.) aA VA ^(AMM 3.) o ^ S^b#)L 6 ^ ^
^ 5 ' AZ
n^^ (HAZ) i f^^^f^f -^^^a ; AMM 3.ii^\^)HhLx:^ (Hb)
Ajk>f#>;!c.ti^li#^^a;f^if;,o - J. AMMt Hb >^.^it-fel:^^-f
^ ^ M o i^i. , AMM Mjk>f VA ^ AZ
^ ^ HAZ
A
-
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