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vitamin A intake and programmes to improve vitamin A status
T. Johns, S. L. Booth, and H. V. Kuhnlein
Programmes to increase the consumption of
natural food sources of vitamin A and provitamin A
Several reviews of programmes designed to eradicate vitamin A
deficiency are available [90-95], including summaries of the
activities being implemented or proposed by major international
agencies and non-governmental organizations.
While the long-term goal of bringing about sustained dietary
change to improve vitamin A intake is proposed for most
programmes, few such programmes have been implemented .
Programmes that have published evaluations have demonstrated
varying levels of success. However, programme strategies and
summaries are difficult to obtain, and the operational details
rarely appear in publicly accessible literature. Therefore, the
programmes described in this section should not be interpreted as
an exhaustive list of all of those designed to increase the
consumption of natural food sources of vitamin A and provitamin
A. Instead, a selection of programmes is used to illustrate the
problems encountered. In particular, the gardening and nutrition
education approaches to improving dietary intake of provitamin A
are stressed, as are alternative approaches that show promise in
achieving the goal of sustained dietary change.
Promoting gardening activity
The promotion of community, school, and household gardens, and
especially the cultivation of foods rich in provitamin A
activity, is currently one of the more common strategies to
promote dietary change. This strategy has been reviewed by
Brownrigg . It has been one component of current or proposed
programmes supported by the ministries of health in Guatemala
, Brazil , and Mali , and elsewhere. In most
countries, programmes are collaborative with other ministries,
international agencies, and local institutions . In Bella
Coola, British Columbia, Canada, a traditional plant food garden
as a source of vitamin A and several other nutrients was
successfully promoted . In Guatemala, promotion of local
foods rich in vitamin A activity has involved collaboration at
the national and international levels, including the ministries
of Health and Education, the United Nations Children's Fund
(UNICEF), the International Eye Foundation, the US Agency for
International Development (USAID), the Institute of Nutrition of
Central America and Panama (INCAP), the National Committee for
the Blind and Deaf, and the University of San Carlos, among
others . Before regional planning and implementation of the
garden projects were undertaken, nutrition and anthropological
surveys were conducted at the household and community levels to
identify local food sources, food habits relating to provitamin
A-rich foods, and marketing behaviours .
The collection of preliminary data on dietary intake and
attitudes towards health, food, and vitamin A deficiency has been
given more importance by certain agencies, and this may help to
reverse an otherwise poor record of success among gardening
projects . The International Vitamin A Consultative Group
(IVACG), for example, has published a simplified approach to the
assessment of dietary intake of provitamin A and preformed
vitamin A to identify high-risk groups or regions, to identify
culturally acceptable foods, and to evaluate programmes designed
to increase the intake of foods rich in vitamin A activity [ 1
A recent evaluation of food beliefs, food habits, and
attitudes towards health in Macina. Mali. confirmed the value of
multidisciplinary collaboration in projects designed to eradicate
vitamin A deficiency . The evaluation demonstrated that
villages in which CARE had gardening and nutrition education
projects had a greater comprehension of and receptivity to the
concept of preventing vitamin A deficiency by using provitamin A
and preformed vitamin A-rich foods. Recommendations were
presented for nutrition education, including specific dietary
behaviour targeted for change and recommendations for mass media
strategies. For example, older women had more time available for
gardening, so it was recommended that programmes promoting this
activity be directed towards this group.
Factors limiting the success of the gardening approach to
increasing the intake of provitamin A include limited access to
water, attack by pests, consumption of plants by domestic
animals, limited availability of seeds and gardening equipment,
and the promotion of inappropriate food items [27, 92, 95].
Shrimpton  argues that, in Brazil, the promotion of
introduced vegetables that are lower in provitamin A activity
than local species has diverted resources, including seeds,
fertilizer, and water, from the indigenous foods. With projected
increases in the percentage of functionally landless people and
those living in poverty, access to land for gardening will also
become increasingly difficult .
Nutrition education is often incorporated into gardening
projects and is provided at health centres in conjunction with
the distribution of vitamin A supplements. In some regions, when
a woman becomes pregnant, her previous child who has been being
breast-fed is abruptly weaned to a diet devoid of vitamin A
. Indonesian mothers may not give their children green leafy
vegetables for numerous reasons, including a lack of knowledge of
cooking methods. Cases such as these suggest that nutrition
education is necessary for the promotion of foods rich in
Using data on maternal attitudes on infant feeding, a rapid
education workshop was used in rural Egypt to demonstrate methods
of meal selection and preparation (W. Mousa, personal
communication). This was a general education project that
included some vitamin A-rich foods. While the CARE programme in
Mali, previously mentioned. has been favourably evaluated, it was
found that a number of constraints, including money, time, and
market availability of promoted foods, limited the capacity of
women to incorporate their knowledge into meal preparation to
increase the use of vitamin A-rich foods . At a nutrition
rehabilitation centre in south India, mothers could recite the
recommended diet to increase vitamin A intake at the centre
during nutrition education sessions; however, few actually
incorporated the dietary guidelines into family meal preparation
In contrast, reports from a five-year programme to improve
vitamin A status implemented by the Tanzania Food and Nutrition
Centre stated that nutrition education through the media was
successful . However, funding was limited and active
promotion at the community and household levels was not attempted
. Local nutrient analyses of indigenous leafy green
vegetables, palm oil, and commercial baby formula were
incorporated into the programme. Analyses of freshwater fish
revealed no traces of contamination with pesticides and heavy
metals, and the fish were found to have high levels of preformed
vitamin A . Future goals of the programme include expansion
of the data base on nutrient values for locally analysed food
items, and the introduction of improved techniques for the
extraction of red palm oil. These were incorporated into
programmes to increase the production and consumption of red palm
oil and green leafy vegetables .
The promotion of a wide variety of indigenous foods resulted
in increased intake of these foods, many of which are rich in
preformed vitamin A and provitamin A, and improved serum retinol
levels among Canadian Nuxalk women, men, and teenaged girls and
boys [100, 107].
Current trends in nutrition communication include the use of
social marketing. Social marketing techniques are used to
influence the acceptability of social action and to create
programmes that elicit desired behaviours . Behavioural
changes perceived by the community as beneficial are the target
for this approach . Social marketing requires the active
involvement of community members and a mixture of communication
Programmes using social marketing techniques to promote
vitamin A intake are being conducted by Helen Keller
International in Bangladesh, Indonesia, and the Philippines. The
programme in Bangladesh was preceded by an evaluation of factors
creating hypovitaminosis A in the region, and the results
challenged many of the assumptions found in earlier literature
[7, 110]. In an informative review of causality, Rizvi  argues
that Bangladesh does not have abundant sources of provitamin A,
because fruits such as papayas and mangoes are too prohibitive in
price and availability for most families. The situation is
further hampered by the belief that infants cannot digest greens.
It is argued that successful promotion of provitamin A sources
should focus on alternative food items that are affordable for
poorer sectors of the population, are widely available, and are
not prohibited by dietary proscription. Underwood  suggested
that social marketing techniques that attempt to improve the
prestige of local provitamin A sources may be more effective in
creating dietary change than promoting horticultural activities.
In the Indonesian project, the use of social marketing
techniques through inter-personal and mass-media interaction has
had mixed success to date . Although success in reaching the
target population through posters, radio, and health personnel
was demonstrated, there was poor recall of the messages promoting
the consumption of provitamin A-rich foods. However, a
preliminary report indicates that consumption of greens has
increased among pregnant women and children. This has also been
documented in a project in the Philippines, which included a
component to increase the use of oil when preparing greens .
Social marketing using a decentralized approach has also
demonstrated success in promoting the production and intake of
the vitamin A-rich ivy gourd grown in household gardens .
Most problems encountered within the three-year programme were
resolved through cooperation at all levels. When individuals
involved in the local programme requested auxiliary information
on pest control, fertilizers, and construction of trellises, an
expanded education component evolved from the coordination
between the agricultural and health sectors of the programme.
When agricultural advisers failed to control pests, a local
treatment using extracts of leaves was added to the commercial
solution and eradicated the infestation. All these auxiliary
efforts substantially enhanced the programme's success.
- The few programmes promoting dietary change that have
been implemented and evaluated to date indicate that the
potential for applying community-based research to the
vitamin A deficiency problem is substantial.
- Preliminary collection of locally relevant data on
dietary intake and attitudes towards health, food, and
vitamin A deficiency appears to improve the success of
gardening and nutrition education programmes.
- Social marketing is a recently introduced concept in
nutrition communication that has the potential to create
programmes for increasing the intake of natural foods
rich in vitamin A activity that are appropriate to the
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