STATUS OF VITAMIN A, D, E IN CHILDREN OF JIAMUSI AREA; A CROSS SECTIONAL STUDY

Santosh Adhikari 1 , Wang Li Min 1 , Chang Shan Wang 2 , Zhang Shuqin 3 , Hai Sheng Xu 4 and Li Li 1 . 1. Department of Pediatrics, First affiliated Hospital of Jiamusi University, Jiamusi, China. 2. College of basic Medicine, Jiamusi University, Jiamusi, China. 3. Changzhou Children Hospital, Changzhou, China. 4. Children’s hospital of Nanjing medical university, Nanjing, China. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 2 August 2018 Final Accepted: 4 September 2018 Published: October 2018

less number of data in research so this will be helping to add one more research and find real scenario of the vitamin levels. 2. There are researches done about vitamins A, D, E in children with different diseases and their relation. This study is aimed to study in normal healthy children and find the status. This will help to adjust the vitamin supplement to the children. 3. Very less number of researches have been done to find the seasonal aspect of vitamins in children. This study will find out the relation of vitamins in different seasons and try to help to find the adjustment of vitamin supplement to the children.

Background
Vitamins are essential chemically unrelated to the organic compounds which cannot be synthesized in adequate amount in human body. These are essential for normal growth and development. Vitamin A, D, E are fat soluble vitamin as they are released, absorbed and transported with help of dietary fat.
Vitamin A deficiency (VAD) is a major nutritional problem found in developing, economically poor and illiterate society. The less supply, poor feeding habit, periodic illness and infections are main cause leading to deficiencies of vitamins for the children. This deficiency will fail to meet the physiologic need of our body. This deficiency will impair normal growth and development, normal metabolism, development of immune system and causes many disorders related to vitamin A deficiency like xerophthalmia, anemia, and chances of getting chronic illness [1].
The deficiency of vitamin D (VDD) is more common throughout the pediatric age group which present as signs of rickets including tremor, carpel pedal spasm, failure to thrive, frontal bossing, rachitic rosary, large anterior fontanel, cranoiotabies, Harrison's groove, widened wrists and ankle, bowing of leg. It is also supposed to be associated in autoimmune disease, cancer, endocrinal diseases, high blood pressure and infectious disease [2]. They may also have the chances of having hyper-reflex, developmental delay, delayed dentition and increased chances of having decayed teeth. Also children may present with multiple fractures and bone frangibility. Severe deficiency of vitamin D can present with seizures and tetany from profound hypocalcaemia. Older children may present with short stature and loss of appetite in VDD [3].
Vitamin E is the other essential fat soluble vitamin which was not much known vitamin needed to our body in past. This vitamin is having a great role in providing immune function, preventing inflammation, regulation of gene expression and cognitive performance [4]. It is a potent antioxidant. Vitamin E deficiency (VED) is common in population who don't consume the food rich in vitamin E like almonds, germinating seeds, mustard green, spinach, plants oil, avocado, papaya, and broccoli. VED is associated with motor and sensory neuropathy, intestinal fat malabsorption which includes bowel disease, pancreatic disease, chronic cholestasis, celiac disease, cystic fibrosis, short bowel syndrome, intestinal lymphangiectasis where as excess of vitamin E may be associated with heart failure, coagulopathy, impaired immunity. But it is said that it's difficult to achieve the vitamin E toxicity [5].
Deficiency of any one of these micronutrients is now becoming a global problem. More over this is mostly common in the population of low socioeconomic status, undeveloped parts of world and place having different climatic state and cultural belief. Heilongjiang province lies in northeast part of china which is having less sunshine, heavy snow fall, low socioeconomic status, backward, remote and less developed than other parts of China. Some of study has shown high prevalence of Vitamin D deficiency. At present there lacks large samples data of vitamin A, D, E in eastern Heilongjiang. This study is aimed to see the prevalence of vitamin A, D and E in Jiamusi and differences with age, gender and season. It plays a guiding role for children's health in Jiamusi area.

Study participants
This study was done in first affiliated hospital of Jiamusi University which lies in north east of China. The children from the nearby cities and villages of Jiamusi city were included. There were 3365 children who participated in the analysis of vitamin A, D, Ewho came for regular heath check up from September 1, 2016 to August 30, 2017.

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Children with known diseases of rickets, calcium metabolism, renal and liver diseases were excluded. Ethics approval was obtained from the first affiliated hospital of Jiamusi University.

Methods
The study was done to find the levels of vitamins. We categorized the samples taken according to age where children were divided into four sub classes; 0~1year, 1~<3years, 3~<6years, 6~14years of age, according to the season into four subgroups; autumn (September to end of November), winter (December to end of February), spring (March to end of May) and summer (June to the end of August), according to gender into two subgroups; male and female child. Those children who came for normal health check up were used for our study. The children who did not follow the inclusion criteria were not used in this study.

Blood samples and biochemical measurements
Samples were collected from the children visiting first affiliated hospital of Jiamusi University. 2 ml of venous blood was collected for the test and collected in the test tube. The blood was collected in the heparin added test tube and kept away from the light. The test tube was marked with the name of the children and the special code and stored in ice bag. The levels of vitamin were measured by reverse phase high performance liquid chromatography (FT-HPLC) and liquid chromatography-tandem mass spectrometry from sigma company (USA).

Statistical Methods
Statistical computations were performed using SPSS for windows statistical software package version 23 (SPSS Inc., Chicago, IL, USA). Mean serum levels of vitamin A, D, E were compared between groups by using the t test or analysis of variance where appropriate. Difference between proportions was elevated by Pearson's X 2 test.

General characteristics
The study was done in First affiliated hospital of Jiamusi University (JUH) from September 2016 to end of August, 2017. The frequency of distribution of vitamin A, D, E is shown in the figure no.

Serum vitamin A levels and prevalence of low vitamin A status
There were 2876 cases (male 1701 and female 1175) for vitamin A sampled in Jiamusi city area. There was prevalence of vitamin A deficiency (n=1658, 57.6%) with Male (n=1004, 34.9%) and female (n=654, 22.7%). The study showed that there was no significant difference in male and female children being p>0.05. There was more prevalence of vitamin A deficiency with increasing of age; maximum deficiency was found in 6-14 years child (n=708, 24.6%) least deficiency was found in 0-1 year (n=180, 6.3%). There was more prevalence of vitamin A deficiency in summer season (n=552, 19.2%). The study showed that difference according to Age group and season being p<0.05. This result was made with the cutoff limit of 0.3mg/L for vitamin A deficiency.

Discussion:-
Micronutrients plays crucial role in health and well being of any individual. These have even more special importance in children as they are growing and developing. The need for vitamin is different for different age group, different for different gender. Our study showedthe prevalence of vitamin A deficiency of 57.6% showing more than half children deficit of vitamin A. This was coinciding with the study done by Chun yang et al [6] where it was found that most of part of china was having more prevalence of vitamin A deficiency. This could be due to the changing pattern of feeding habit. There is increasing trend of consumption of junk foods among children. There have been vast changes in the food and beverage. This diversity of food habit was also explained by the study done by wang x et al [7] where he explained about the changing trend of feeding habit among Chinese children. This could explain the same result we had in our study. Western world children are also having similar changes in vitamin level which was explained in study done by mensrik et al [8] in children of UK, Poland and some western countries. They also have such change of feeding habit. Generally boys are more active in growing phase. They are more sports lovers and enjoy outdoor activities. This makes the boys needing more micronutrients. One of the study showed that the boys would need more vitamin A than girls as growth rates are higher before 10 years of age [9], which was coinciding with the result shown in male children of our study. Our study revealed that vitamin A deficiency is more common in younger children. The children from transition of breast feeding to other food had shown this pattern of vitamin A deficiency and the level is not fulfilled as children grow rapidly [10] which were coinciding with the Meta analysis done by Peige Song et al [11] where prevalence of VAD in younger children was seen. This could be due to the fatty food pattern and lowering activities among children in present days.
Vitamin D intake in American children was below 21% in done by Mansbach et al [12], whereas the study done by Wang at el [13] in Wenzhou in china showed the prevalence of 38%. The study said that there was supply of vitamin D due to sea fish which have good amount of vitamin D. Our study showed 36.9% of vitamin D deficiency. This may be due to lack of fresh food in northern parts and lack of sea food throughout the year. Jiamusi has less fresh food. Vegetables and poultry are imported from the south part. Wang LL study also showed the similar scenario of vitamin D deficiency. This study reflects prevalence of vitamin D all over china. We had significant difference between male and female children which coincides with the study done by Saintonge et al [14]. This could be due to less outdoor activities of female than boys. Chances of osteoporosis in females are more which was shown in one of the study done in Beijing coinciding higher prevalence of VDD in females [15]. Our study found the difference in season was significant with higher prevalence in winter and lesser prevalence of VDD in summer. Such pattern of variation was shown in the study done in Shanxi province by Strand MA et al [16]. Probably due to low sunlight, wearing of more clothes due to longer winter and less outdoor exposure could explain the low levels of vitamin D in 171 northern part in winter season. More explanation matches with the result where vitamin D deficiency seen in summer is low and more vitamin D deficiency was prevalence in winter as extreme cold and longer snow covering remained for longer winter. Study done by Zhu et al [17] had shown that there was increasing vitamin D deficiency with increase of age. Study done by Schleicher et al [18] had shown that vitamin D was more common in 6-17 year children group than 1-11 years age group in US. Similarly study done by Sarafin k et al [19] in Canada had also shown more prevalence of vitamin D in 14-18 years of age group. Our study coincided with these two studies done out of China as we had similar older age group of children having more vitamin D deficiency. It may be due to more school work for children so that they won't get more time for physical activities. Older children generally take more junk foods which were relatively nutrients deficient. Infants were having high level of vitamin D. This may be due to supplementation of formula feed.
Vitamin E is an antioxidant which is very essential to human body. There was no clear cut trend of logics regarding the severity of vitamin E deficiency on basis of region, longitude, latitude and climate, prevalence was mostly affected by culture, life style of individual, nutritional pattern of children and presence of any infection in children during all time of sampling. When there was increased state of oxidative stress and lesser supply of antioxidants then patients showed bad prognosis [20,21]. Our study did not show the significance differences with age group and gender. Study done by Khatib IM et al [22] showed the prevalence of 17.1% of VED when cut off was 5mg/L and 89.2% of VED when cut off was 7.5mg/L in Jordan children. Farrell PM et al [23] showed Low vitamin E level in children ranging from 3-9 mg/L. Males supposed to have more vitamin E deficiency than females mostly due to PUFAs intake, alcoholic pattern and smoking pattern more in male. Females had higher level of tocopherol than males which was shown by the study done by Kang MJ et al [24]. The more the breast feeding, the lesser are the chances of having vitamin E deficiency. This was explained by study of Sinvichayakul et al [25] which showed that duration of breast feeding was having positive correlation with level of vitamin E. Study done by Winklhofer-Roob BM et al [26] showed that vitamin E had influence by age, sex and season of sampling. Season of sampling affected alpha tocopherol high in winter and gamma tocopherol higher in winter and spring than other season. Study done by Fares S et al [27] had shown that one fourth of children were having low vitamin E levels. Our study showed significance with season. It couldn't be explained why real significance exists in autumn season. Some researches done in animal has shown that there is decline of vitamin A and E in cow milk from autumn to winter [28]. One of the researches done in sheep has shown the prevalence of vitamin E was more in autumn due to deficiency of grass. These two can explain that the intake of this deficient food lead to vitamin E deficiency.