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From the Centers for Disease Control and Prevention
August 8, 2001

Vitamin A Deficiency Among Children— Federated States of Micronesia, 2000

JAMA. 2001;286(6):667-668. doi:10.1001/jama.286.6.667-JWR0808-3-1

MMWR. 2001;50:509-512

1 table, 1 figure omitted

Vitamin A, a fat-soluble, heat-stable nutrient (retinol) derived from animal sources and certain fruits and vegetables, forms the basic component of retinal pigments and plays a vital role in optimal health, growth, and development. Vitamin A deficiency (VAD) (serum retinol ≤20 µg/dL [≤0.7 µmol/L] for subclinical VAD) can substantially increase the risk for childhood mortality from infectious and noninfectious causes.1-3 VAD impairs the mobilization and transport of iron and is usually associated with anemia and reduced growth.4,5 VAD is a major public health problem in parts of Africa, Asia, Latin America, and the Western Pacific.1,6 In Chuuk and Pohnpei, two of the four Federated States of Micronesia (FSM) (2000 population: 107,008), nutrition surveys during the early 1990s documented VAD prevalences among the highest in the world (CDC, unpublished data, 1991; U.S. Public Health Service, unpublished data, 1994). In response to these findings, FSM health authorities, with support of the United Nations Children's Fund (UNICEF), began distributing vitamin A supplements in 1993 and 1998 in Chuuk and Pohnpei, respectively. In November 1999, FSM requested assistance from CDC in VAD assessment surveys of children in Kosrae and Yap, the other two FSM states. This report summarizes levels of serum retinol and prevalence of VAD and other indicators of nutritional status among children aged 24-59 months in Kosrae and Yap. The findings indicated low serum retinol levels and high VAD prevalences but no substantial stunting or wasting. A comprehensive, long-term national strategy is needed in FSM to promote sustained improvement in vitamin A status.

FSM is an island nation in the western Pacific Ocean. Kosrae state is a single island divided into 21 enumeration districts. Yap comprises four large islands and 134 small islands, primarily atolls, and is divided into 93 villages. For logistic reasons, only the three large islands connected by bridges (Yap proper) were included in the survey. These islands represent approximately 62% of the Yap population.

During January-February 2000, FSM health authorities, UNICEF, and CDC surveyed children aged 24-59 months and their mothers or reproductive-aged female caregivers in Kosrae and Yap. A separate cluster survey was performed in each state. The sample size for each state was calculated to yield a prevalence estimate with 5% error assuming 50% VAD prevalence. Because of uneven village sizes (range: 157-537 residents per village in Kosrae and one-580 in Yap), clusters were selected using the proportionate-to-population size sampling method. Investigators selected 13 villages in Kosrae and 29 villages in Yap. In each village, all children aged 24-59 months identified from a comprehensive list of vaccination records were eligible for the survey. Children were excluded who had moved into the village during the 6 months preceding the survey or had experienced fever or diarrhea during the preceding 24 hours or cough for ≥4 weeks. If more than one eligible child lived in a household, investigators randomly selected one for the survey.

Caregivers were asked about demographics, feeding history, availability of home garden, number of vitamin A-rich plants grown, and vitamin/mineral supplement intake for each child. Caregiver information included demographics, reproductive history, dietary and nutritional knowledge of vitamin A and iron, and vitamin/mineral supplement intake.

Child height and weight were measured to calculate degree of stunting (height-for-age Z-score, ≤2 standard deviations [SD] below the reference median) and wasting (weight-for-height Z-score, ≤2 SD below the reference median) based on World Health Organization (WHO)/CDC references. Blood was collected by venipuncture to assess serum retinol and hemoglobin. Hemoglobin levels were measured by the cyanmethemoglobin method using a portable HemoCue™* instrument. Children with hemoglobin <11.0 g/dL were considered anemic. Serum samples for retinol were analyzed at CDC using high-performance liquid chromatography under a strict quality-control protocol.

For each state's analysis, the survey sampling design was taken into account and the data were weighted to represent children aged 24-59 months. For Kosrae and Yap combined, the data were analyzed as a stratified cluster survey and weighted to represent the combined population of children aged 24-59 months. Because of the large proportion of children surveyed in each state (47.3% for Kosrae and 39.8% for Yap), the finite population correction was used to reduce the confidence interval.

A total of 270 children in Kosrae and 228 children in Yap was selected for the survey. Blood could not be collected from 13 children, leaving 267 children from Kosrae and 218 children from Yap included in these analyses. Only 485 children with retinol measurements were included in this report. Approximately half of these children were male, and they were distributed equally among ages 2, 3, and 4 years.

The mean serum retinol of all children surveyed was 20.4 µg/dL (18.0 µg/dL in Kosrae and 22.9 µg/dL in Yap). The prevalence of VAD among all children was 48.8% and was higher in Kosrae (63.3%) than Yap (33.8%). The prevalences of stunting (16.6%), wasting (3.8%), and anemia (11.2%) did not differ between the two states.

VAD risk factors among children for both states combined included residence in Kosrae, male sex, household size (>8 persons), maternal income (no income), education (<8 years), maternal VAD, type of first solid food (local food) given to the child, anemia in children, and vitamin A-rich plants (<2) grown in the garden. However, the specific risk factors for VAD varied between the two states. In Kosrae, male sex, family income (no income), and type of first solid food (local food) were associated with VAD. In Yap, the significant risk factors were outer island ethnicity, maternal education (<8 years), and vitamin A-rich plants (<2) grown in the garden. When stratified by each risk factor, all subgroups of children from Kosrae had VAD prevalence >37%, and on Yap all subgroups had VAD prevalence >17%.

Reported by:

L Englberger, United Nations Children's Fund. J Elymore, National Program for Food and Nutrition; V Ngaden, MD; H Ishmael, MD, Dept of Health, Education, and Social Affairs, Federated States of Micronesia. S Neupane, PhD, Pacific Office, United Nations Children's Fund. F van der Haar, PhD, Dept of International Health; K Sullivan, PhD, Dept of Epidemiology, Emory Univ, Atlanta, Georgia. Div of Laboratory Sciences, National Center for Environmental Health; National Center on Birth Defects and Developmental Disabilities; and an EIS Officer, CDC.

CDC Editorial Note:

The findings in this report indicate that VAD prevalence in virtually all subgroups of children examined in this survey was ≥20%. WHO considers VAD prevalence ≥20% among children aged 6-71 months a severe public health problem.7 Compared with a healthy U.S. population,8 the serum retinol distributions among children from Kosrae and Yap are substantially lower, underscoring the potential risk for increased morbidity and mortality.

Children with VAD often are anemic, stunted, and occasionally wasted. However, in the population surveyed for this report, these indicators were not evident. The findings indicate relatively good nutritional status among these preschool-aged children. According to a proposed WHO classification for stunting and wasting among children aged <5 years, children from Kosrae and Yap have a low prevalence (<20%) of stunting and an acceptable prevalence (<5%) of wasting.9 These children also have lower prevalences of anemia than other Asia Pacific regions.10 This may be, in part, because of the absence of malaria.

The findings in this report are subject to at least one limitation. The survey lacked detailed dietary intake and medical data that would have provided a more complete assessment of the health status of each child.

To address severe VAD in children of Kosrae and Yap, vitamin A capsule distribution is the most practical immediate response. However, because of the magnitude and pervasiveness of VAD among preschool-aged children in all four FSM states and the likelihood that this problem extends to older children and adults, a comprehensive, long-term program is indicated. Although the risk factors for VAD identified in the survey do not fully explain the very low serum retinol distributions, they may be helpful in adjusting intervention programs to suit specific conditions in each state (e.g., promotion of vitamin A-rich plants in household gardens). A national strategy should be aimed at sustained improvement of vitamin A status of the population. Sustained correction of VAD may be achieved only by combining the supplementation effort among children with food fortification, diversification of dietary supply and consumption patterns, or public health education, as appropriate.

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