Status report on vitamin A deficiency and associated factors in the health area of Sanmatenga province (Burkina Faso)

doi:10.21203/rs.3.rs-4693947/v1

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Status report on vitamin A deficiency and associated factors in the health area of Sanmatenga province (Burkina Faso)

https://doi.org/10.21203/rs.3.rs-4693947/v1

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Background

Micronutrient deficiencies are a serious public health problem in sub-Saharan Africa, with particularly devastating consequences for children's health. In Burkina Faso, this burden, which is particularly marked by vitamin A deficiency, is exacerbated in certain areas where security and humanitarian problems are reducing access to health and nutrition services. One of the solutions most promoted at national level to deal with these micronutrient deficiencies is the use of lipid-based nutrient supplements (LNS). In order to understand the extent of this burden of malnutrition and to enable the strategy to be evaluated, it is necessary to carry out an epidemiological assessment of the nutritional status of children before implementing supplementation.

Methods

The nutritional status of the children was assessed using anthropometric measurements and serum retinol concentration. Interviews were conducted with the children's mothers to determine their feeding practices. Binary logistic regression was used to determine the variables associated with vitamin A deficiency with statistical significance at p < 0.05. Candidate variables for this test were obtained by a chi-square test at p < 0.20.

Results

The results showed that 86.6% of the children were vitamin A deficient. In addition, only 11.8% had a minimum dietary diversity. It emerged that 1.4% of the children had eaten roots, tubers and vegetables rich in vitamin A the day before the survey, and only 3.5% had eaten fruit rich in vitamin A. The study also showed that there was a statistically significant association (p < 0.05) between dietary diversity and vitamin A deficiency.

Conclusions

The results show the actual level of vitamin A deficiency in the study area and provide a factual basis for adopting strategies to address the problem of vitamin A deficiency.

Trial registration

the Ethics Committee for Health Research in Burkina Faso has given its authorisation for this study under number 2022_60_/MSHP/MESRSI/CERS of 03/02/2022.

Malnutrition-Micronutrient

deficiency-Vitamin A

deficiency-Serum

retinol concentration

Micronutrient deficiencies are a serious public health problem, with enormous consequences for the health of children under the age of five. Indeed, vitamin A deficiency is a risk factor for blindness and mortality from measles and diarrhoea in children aged between 6 and 59 months(1). In addition, 10% of deaths in children under 5 are due to micronutrient deficiencies, particularly vitamin A and zinc deficiencies(2). Furthermore, these deficiencies have consequences for the physical and psychological development of children and have repercussions for the country's economic development.

In developing countries, vitamin A deficiency is dominated by deficient intake of vitamin A(3). What's more, children's diets in these countries are often monotonous and lack diversity. Monotonous diets and a lack of diversification predispose children to multiple mineral and vitamin deficiencies(4).

Micronutrient deficiencies are a public health problem in Burkina Faso(5). Indeed, according to the results of the demographic and health survey, the relative prevalence of vitamin A deficiency is 129 per 1000 and the adjusted prevalence of clinical deficiency expressed by night blindness is estimated at 7%(6).

Several strategies are being implemented to tackle this problem, such as vitamin A supplementation and the use of LNS. LNS supplementation helps to remedy macronutrient and micronutrient deficiencies and improve the absorption of fat-soluble vitamins(7). As a result, Burkina Faso has adopted a strategy of providing LNS supplements to children aged between 6 and 23 months in areas where the security and humanitarian situation remains worrying due to the climate of insecurity that has prevailed in the country since 2017. In order for the strategy to be implemented effectively and for other strategies to prevent malnutrition to be readjusted to support it, it is necessary to draw up an inventory of vitamin A deficiency and the factors associated with it. Hence the interest of the present study, the general objective of which was to determine the prevalence of vitamin A deficiency and associated factors in children aged 6 to 23 months in the health area of the province of Sanmatenga, which was an area affected by insecurity.

Population studied

The study was carried out on children aged between 6 and 23 months in the province of Sanmatenga in Burkina Faso. This province is located in the Centre-Nord region, which comprises three provinces including Bam, Namentenga and Sanmatenga. The area is characterised by dry-season farming and livestock rearing. Annual rainfall is in the region of 600-700mm. Compared with other regions of the country, rainfall deficits are less significant and less frequent, although they can be severe in certain years. Population density is high and land pressure is considerable. Soils are poor, over-exploited and exposed to erosion(8).

Description of the study

This is a descriptive and analytical study of the nutritional status and factors associated with vitamin A deficiency in children aged 6 to 23 months in the province of Sanmatenga. Data collection took place from 05 to 07 June 2022 and involved mother/child couples aged between 6 and 23 months.

Sample

Children aged between 6 and 23 months whose parents had given informed consent were included in the study. These children had to live in the locality and be available for the duration of the study. In addition, the children enrolled in this study came from households selected at random in each locality where the survey took place.

Given that the primary objective of adopting the LNS strategy at national level is to reduce the prevalence of acute malnutrition, the prevalence of acute malnutrition was used to calculate the sample size. Hence, the ENA (Emergency Nutrition Assessment) software for SMART (Standardized Monitoring and Assessment of Relief and Transition), version dated 11 January 2020, was used, taking into account the prevalence of acute malnutrition in the Centre-Nord region in 2021 (8.2%), the cluster effect and a precision of 5%.

Data collection

Data collection tools

Data was collected from the mothers using a questionnaire administered orally by experienced interviewers. The questionnaire contained three parts. The first part covered anthropometry, morbidity and blood sampling. The second part concerned children's feeding practices. The last part dealt with the socio-economic characteristics of the households of the children enrolled in the study. The questionnaires were administered by trained interviewers with good experience of oral interviews.

Collection methods

Kobocollect software was used for data collection.

In order to assess the nutritional status of the children enrolled in the study, anthropometric measurements and blood samples were taken. Anthropometry is based on the measurement of a certain number of parameters, namely weight, height and brachial perimeter, in accordance with WHO recommendations(9). At the time of enrolment, anthropometric constants (weight, height, arm circumference) were measured, as well as the presence of bilateral oedema. These anthropometric measurements were carried out by investigators trained and experienced in taking such measurements. To determine age, the date of birth was obtained from official documents. The height of all the children was measured using a tape measure. They were all measured lying down. The children's weights were measured using a battery-powered SECA electronic scale with an accuracy of 100g. Arm circumference was measured using the mnemonic method described by Shakir and Morley(10). The anthropometric data was then exported to ENA for SMART software to determine the nutritional status of the children based on anthropometry.

Blood samples collected by experienced biomedical technicians were used to determine serum retinol concentration by reverse-phase high-performance chromatography, using retinol acetate as an internal standard(11).

The 24-hour recall method was used to assess the feeding practices of the children included in the study. To calculate the variables linked to these practices, the method for calculating the ANJE indicators provided by the WHO and UNICEF was used(12).

For each child included in this study, the socio-economic characteristics of the parents were collected (mother's level of education, marital status, etc.).

Variables and indicators

The variables grouping the socio-demographic characteristics of the mothers were marital status, type and level of education of the mother and source of household income.

For anthropometry, the following nutritional indices were used: weight for height, weight for age and height for age.

Interviews with mothers about their children's dietary practices were used to collect the data needed to assess these indicators:

Minimum Dietary Diversity (MDD): percentage of children aged 6–23 months who received at least five of the eight defined food groups (breast milk; cereals, roots and tubers; legumes and nuts; dairy products (milk, yoghurt, cheese); meat products (meat, poultry, offal) and fish; eggs; vitamin A-rich fruit and vegetables; other fruit and vegetables(13).

Minimum Meal Frequency (MMF): percentage of children aged 6 to 23 months who consumed solid, semi-solid or soft foods at least the minimum number of times during the previous day. The minimum number is defined as: (i) two meals for breastfed infants aged 6 to 8 months and (ii) three meals for breastfed children aged 9 to 23 months and (iii) four meals for non-breastfed children aged 6 to 23 months, at least one of which must be a solid, semi-solid or soft food(13).

The blood samples were used to determine the children's serum retinol concentration and, in turn, to determine vitamin A deficiency based on World Health Organisation thresholds. The indicators linked to vitamin A deficiency were :

Vitamin A deficiency, defined as a serum retinol concentration (SRC) of less than 0.7 µmol/L.

Moderate vitamin A deficiency, defined as a serum retinol concentration of between 0.35 and 0.70 µmol/L.

Severe vitamin A deficiency, defined as a serum retinol concentration of less than 0.35 µmol/L(14).

Statistical analysis of data

The data collected was extracted from the kobocollect server in the form of an Excel spreadsheet and the statistical analyses were carried out using IBM SPSS Statistics 20 software(15).

Bivariate analyses were used to cross-tabulate the different variables to look for possible associations, using Pearson's chi-squared test. Multivariate analyses using binary logistic regression were used to identify factors associated with vitamin A deficiency in the population studied. For all tests, the level of significantly was set at 5%.

The results on the socio-demographic characteristics of the households and mothers of the children showed that 50.7% of the mothers of the children enrolled had no level of education, compared with 20.8% who were literate and 28.5% who had primary or secondary education. Agriculture was the main source of income with 86.1%, followed by trade with 8.3% (Table 1).

Table 1

Socio-demographic characteristics of households and mothers of children
Variable	Modality	Number	Percentage
Source of household income	Agriculture	124	86.1
	Trade	12	8.3
	Others	8	5.6
Marital status	Married	143	99.3
Marital status	Widowed	1	0.7
Mother's type and level of education	Literate	30	20.8
	No education	73	50.7
	Educated	41	28.5

The results of the anthropometry show that the prevalence of global acute malnutrition (GAM) was 8.3%, including 1.4% for the severe form. As for underweight, the prevalence was 18.1%, including 3.5% for the moderate form. The prevalence of stunting was 9.3%, with 2.9% in the severe form (Fig. 1).

In the study, 56.9% of children were female compared with 43.1% male, with a sex ratio of 0.8.

The results on morbidity show that fever was observed in 31.3% of children during the two weeks preceding the survey. Diarrhoea was also observed in 15.3% of children in the two weeks preceding the survey.

Interviews with mothers of enrolled children on feeding practices revealed that 83.3% of children had a minimum meal frequency (MMF). However, only 11.8% had a minimum dietary diversity (MDD). The average number of food groups consumed by the children was 2.25 + 1.106 (Table 2).

Table 2

Characteristics of the children enrolled in the study
Variable	Modality	Number	Percentage (%)
Sex	Female	82	56.9
Sex	Male	62	43.1
Diarrhoea	No	122	84.7
Diarrhoea	Yes	22	15.3
Fever	No	99	68.8
Fever	Yes	45	31.3
MMF	No	24	16.7
MMF	Yes	120	83.3
MDD	No	127	88.2
MDD	Yes	17	11.8

Retinol is the predominant form in which vitamin A circulates in the blood. When tissue needs it, it is released by the liver in the form of a complex(16). Compounds with the biological activity of retinol are also known as vitamin A(17).

Of the 144 children registered, 134 were sampled, giving a coverage of 93.05%. It was not possible to collect blood samples from ten children due to difficulties in taking blood samples from these children. The serum retinol concentration (SRC) was determined from the blood samples. The study showed that the average serum retinol concentration of the children was 0.53 µmol/L. Only 13.4% had a satisfactory SRC. However, almost 86.6% were vitamin A deficient. Of these children, 73.2% had moderate deficiency and 13.4% severe deficiency.

Figure 2 shows the proportions of children consuming the various recommended food groups. The results show that these children's diets consisted mainly of cereals, roots and tubers (91%), and nuts and seeds (56.9%). Of these children, 41.7% ate fruit and vegetables rich in vitamin A. However, food groups such as dairy products (4.2%), meat products (6.3%) and other fruit and vegetables (20.8%) were rarely consumed. None of the children included in the study had eaten eggs in the 24 hours preceding the survey. In addition, only 1.4% of children had eaten roots, tubers and vegetables rich in vitamin A and only 3.5% had eaten fruit rich in vitamin A (Fig. 2).

A number of dietary and non-dietary factors can lead to low serum retinol concentrations in children. From the analysis with the Chi2 test, the variables ‘Source of household income’, ‘MDD’, ‘Type and level of mother's education’ were considered as candidate variables for the use of the binary logistic regression model in view of their p-value (p < 0.2) (Table 3).

Table 3

Factors associated with vitamin A deficiency
Variable	Modality	Vitamin A deficiency N (%)	No Vitamin A deficiency N (%)	P value
Source of household income	Agriculture	104 (89.7%)	12 (10.3%)	0.005**
	Trade	6 (60.0%)	4 (40.0%)
	Others	5 (62.5%)	3 (37.5%)
Acute malnutrition	Yes	14 (87.5%)	2 (12.5%)	0.837
Acute malnutrition	No	101 (85.6%)	17 (14.4%)	0.837
Stunting	Yes	16 (84.2%)	3 (15.8%)	0.828
Stunting	No	99 (86.1%)	16 (13.9%)	0.828
Underweight	Yes	25 (92.6%)	2 (7.4%)	0.259
Underweight	No	90 (84.1%)	17 (15.9%)	0.259
MMF	No	21 (91.3%)	2 (8.7%)	0.408
MMF	Yes	94 (84.7%)	17 (15.3%)	0.408
MDD	No	104 (88.1%)	14 (11.9%)	0.037**
MDD	Yes	11 (68.8%)	5 (31.3%)	0.037**
Sex	Female	64 (85.3%)	11(14.7%)	0.855
Sex	Male	51 (86.4%)	8 (13.6%)	0.855
Diarrhoea	No	97 (84.3%)	18 (15.7%)	0.229
Diarrhoea	Yes	18 (94.7%)	1 (5.3%)	0.229
Fever	No	80 (85.1%)	14(14.9%)	0.716
Fever	Yes	35(87.5%)	5(12.5%)	0.716
Martial status	Maried	114 (85.7%)	19 (14.3%)	0.683
Martial status	Widowed	1 (100%)	0 (0%)	0.683
Mother’s type and level of education	Literate	23 (85.2%)	4 (14.8%)	0.187**
	No education	65 (90.3%)	7 (9.7%)
	Educated	27 (77.1%)	8 (22.9%)
Consumption of vitamin A-rich fruit	No	110 (85.3%)	19 (14.7%)	0.354
Consumption of vitamin A-rich fruit	Yes	5 (100.0%)	0(0%)	0.354
Consumption of roots, tubers and vegetables rich in vitamin A	Non	113 (85.6%)	19 (14.4%)	0.562
	Yes	2 (100.0%)	0 (0%)	0.562
Consumption of dark green leafy vegetables	No	72 (87.8%)	10 (12.2%)	0.408
Consumption of dark green leafy vegetables	Yes	43 (82.7%)	9 (17.3%)	0.408

N : Number ** : P < 0.2

Analysis with the binary logistic regression model showed that DAM was significantly (P < 0.05) associated with vitamin A deficiency (Table 4). There was a statistically significant association between minimal dietary diversity and vitamin A deficiency (OR = 0.296; p = 0.046). This means that children with minimal dietary diversity have a lower risk of vitamin A deficiency.

Table 4

Results of the analysis of candidate variables for factors associated with vitamin A deficiency
Variable	Modality	OR	CI (95%)	p-value
MDD	Yes	0.296	0.090–0.979	0.046**
MDD	No	1
Source of household income	Agriculture	0.179	0.033–0.986	0.054
	Trade	0.772	0.087–6.843	0.816
	Others	1
Mother’s type and level of education	Literate	0.634	0.133–3.014	0.567
	No education	0.467	0.139–1.564	0.217
	Educated	1

OR: odd ratio; CI: confidence interval.

This study was conducted to carry out an epidemiological assessment of the nutritional status of children and to identify the factors associated with vitamin A deficiency prior to the implementation of LNS supplementation adopted by the country to combat the problem of malnutrition in children. The study was carried out on 144 children aged between 6 and 23 months. The sex ratio of the study population was 0.8. A similar observation was made in another study carried out in Burkina Faso, where the number of girls (52.36%) was higher than that of boys (47.64%), with a sex ratio of 0.91(18).

The prevalence of global acute malnutrition obtained in this study was 8.3%. This prevalence is below the WHO alert threshold of 10%(9). In 2021, the results of the national nutritional survey showed a prevalence of 8.2 of GAM, including 0.9 for the severe form in the province(19).

The prevalence of underweight is lower than that found by the nutritional survey, which was 32.2% including 10.1% for the severe form(19). These prevalences are much lower than those obtained in a study conducted in Benin, where 31.89% of children were underweight, including 13.95% of severe cases(20).

The prevalence of stunting found, at 9.3%, is lower than that found by the results of the nutritional survey, which was 22.6%, including 4.2% for the severe form(19).

Interviews with mothers about their children's eating habits revealed that 83.3% of children had a minimum frequency of meals. This rate is lower than that of the nutritional survey, which was 89.4%(19). Only 11.8% had minimum dietary diversity. The results of an individual's dietary diversity reflect and give an estimate of the adequacy of that individual's diet in terms of nutrients(21). Low dietary diversity is a problem most often encountered in developing countries among low-income populations, where the daily diet is generally based on cereals and tubers(22). Poor-quality food is a feature of food consumption in West Africa(23).

The average number of food groups consumed by the children in this study was 2.25 + 1.106, with a low consumption of foods rich in vitamin A. These results are similar to those found in studies which have shown that the average dietary diversity score was two food groups(24). However, the average dietary diversity score found was below that found by a study conducted in Burkina which found 3.11(25). This score remains below the five food groups recognised as the minimum dietary diversity score(13). This could be due to food taboos and prohibitions among children of certain ethnic groups. Also, the low availability and accessibility of food could explain the low diversity and non-consumption of certain food groups by children.

Retinol is the predominant form in which vitamin A circulates in the blood. The attribution of serum retinol concentration values in a population and the prevalence of individuals with values below a threshold can provide important information about the vitamin A status of a population and reflect the extent of vitamin A deficiency(14). The children's serum retinol concentration was 0.5329 µmol/L. This average concentration was well below the limit defining vitamin A deficiency(14). Of the children enrolled, only 13.4% had no vitamin A deficiency. More than half of the children, nearly 86.6%, were vitamin A deficient, 73.2% of them in the moderate form and 13.4% in the severe form.

Studies carried out in Burkina Faso in different regions and at different times of the year have revealed a prevalence rate of vitamin A deficiency of 56.8(25), 32.8%(26) and 33.9%(27). A study in Cameroon found that the prevalence of vitamin A deficiency was 35%(28). These prevalences are lower than those found by this study. The high prevalence of vitamin A deficiency found by this study could be due to the fact that vitamin A deficiency is often a corollary of infectious diseases and certain inappropriate dietary practices, such as low consumption of vitamin A-rich fruit and vegetables by children. Furthermore, according to the results of the March 2022 harmonised framework, the study area was classified as phase 3 (crisis). During this period, households were affected by food consumption deficits, and their essential food needs were covered only marginally or by resorting to strategies to adapt to the crisis(29). The drop in production, the rise in food prices and the security situation could also be explanatory factors. Furthermore, pre-school children are more exposed to infectious diseases, gastrointestinal and respiratory infections, which affect vitamin A absorption and increase metabolic needs(30).

Only 1.4% of children had eaten vitamin A-rich roots, tubers and vegetables and 3.5% had eaten vitamin A-rich fruit the day before the survey. A study conducted in Burkina Faso also showed low consumption of vitamin A-rich fruit and vegetables A(24). A diet low in vitamin A causes avitaminosis A(31). The low consumption of foods rich in vitamin A could be due partly to parents' inability to afford them and partly to a lack of knowledge about the benefits of fruit and foods rich in vitamin A for children's health.

Vitamin A deficiency is one of the most common and serious nutritional deficiencies. It can be the result of a number of dietary and non-dietary factors.

To address children's lack of dietary diversity, the World Health Organisation recommends that the complementary diet should be varied and include meat, eggs, fruit and vegetables rich in vitamin A, on a daily basis(32).

Analysis with the regression model showed that there was a statistically significant association between dietary diversity and vitamin A deficiency (OR = 0.296; p = 0.046). In fact, children who have a minimum of dietary diversity are less exposed to vitamin A deficiency. Similar results were obtained by a study which showed that dietary diversity was associated with the slight increase in serum retinol observed during an intervention(33). Studies have shown that eating a diet made up of a wide range of foods increases micronutrient intake(34,35). In addition, a statistically significant correlation has been demonstrated between the dietary diversity score and the nutritional adequacy ratio for various nutrients(23). Diet therefore plays a vital role in maintaining and improving health. It must be balanced and contain all the nutrients the body needs.

This study recognises certain strengths and weaknesses. The use of experienced investigators and biomedical technicians for data collection and blood sampling was a strength. Despite these strengths, the study had limitations, such as the use of the 24-hour recall method to determine children's dietary practices. It did not provide any information about children's eating habits. Individual dietary intakes are not stable over time. They vary qualitatively and quantitatively from one day to the next, from one week to the next and even from one year to the next. In general, food intakes can only be collected over short periods and cannot reflect the usual intakes of individuals(36).

The results of this study show that vitamin A deficiency is a public health problem in Sanmatenga province. Indeed, 86.6% of children had a low serum retinol concentration.

A statistically significant association was found between serum retinol concentration and dietary diversity. Diversifying children's diets could be one way of tackling vitamin A deficiency.

In view of the high prevalence of vitamin A deficiency in the study area, in addition to the vitamin A supplementation and deworming campaigns which are carried out every six months, communication strategies for social change in favour of an adequate complementary diet with dietary diversification and the consumption of vitamin A-rich foods need to be intensified. LNS supplementation is also necessary, as it can remedy both micronutrient and macronutrient deficiencies.

Ethics approval and consent to participate

This study was conducted in accordance with the principles of the Declaration of Helsinki.

The protocol was reviewed by the Burkina Faso Health Research Ethics Committee, which granted authorisation under number 2022_60_/MSHP/MESRSI/CERS dated 03/02/2022.

The objectives, the methodological approach as well as the impact of the study were clearly explained to the children's mothers. Written informed consent was obtained from mothers of children included in the study before the start of data and biological sample collection.

Consent for publication

Not applicable

Consentement à la publication

Not applicable

Availability of data and materials

Data from this study is available from the corresponding author on reasonable request.

Conflicts of interest

All authors have no conflicts of interest.

Funding

This study was partly funded by Nutriset France. The costs of analysing samples to determine serum retinol concentration and purchasing certain equipment to measure haemoglobin levels were covered by this organisation.

Authors' contributions

N.K., E.W.R.C., O.O., S.T. designed and carried out the study. E.W.R.C. and E.A.B. contributed to the search for funding. N.K., O.O., S.T., J.S.R.K. and B.S. were involved in collecting samples and analysing and interpreting the data. N.K., E.W.R.C., O.O., I.K., E.A.B., S.T. and J.S.R.K. drafted the preliminary version of the manuscript. The final manuscript was approved by M.H.D. All authors read and approved the final manuscript.

Acknowledgements

The authors would like to thank Nutriset France and Inno Faso for their financial contribution and support in carrying out this study. They would also like to express their gratitude to the General Secretariat of the Ministry of Health and the Directorate of Nutrition, which made this work possible. They would also like to thank the Centre-Nord Regional Department of Health and Public Hygiene and the health districts for their collaboration and support in collecting the data. Thanks to all those who were directly or indirectly involved in carrying out this study.

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No competing interests reported.

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Status report on vitamin A deficiency and associated factors in the health area of Sanmatenga province (Burkina Faso)

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Abstract

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Background

Material and methods

Population studied

Description of the study

Sample

Data collection

Data collection tools

Collection methods

Variables and indicators

Statistical analysis of data

Results

N : Number ** : P < 0.2

Discussion

Conclusion

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References

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Version 1