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   Table of Contents      
Year : 1981  |  Volume : 29  |  Issue : 4  |  Page : 467-472

Relative significance of protein calorie malnutrition and vitamin A and carotene level in the etiology of xerophthalmia in Indian children

Ravinder Nath Tagore Medical College, Udaipur, India

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M R Jain
Ravinder Nath Tagore Medical College, Udaipur
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Source of Support: None, Conflict of Interest: None

PMID: 6809615

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How to cite this article:
Jain M R, Tahiri B. Relative significance of protein calorie malnutrition and vitamin A and carotene level in the etiology of xerophthalmia in Indian children. Indian J Ophthalmol 1981;29:467-72

How to cite this URL:
Jain M R, Tahiri B. Relative significance of protein calorie malnutrition and vitamin A and carotene level in the etiology of xerophthalmia in Indian children. Indian J Ophthalmol [serial online] 1981 [cited 2021 Jan 25];29:467-72. Available from: https://www.ijo.in/text.asp?1981/29/4/467/30956

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Table 1

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Clinical entity of xerophthalmia has been recognised since ancient times by the Egyptians and it was attributed to inadequate diet. With the time, various teams of workers[1],[2],[3],[4] observed that Vit. A and Protein calorie malnutrition played a significant role in the clinical manifestation of xerophthalmia. It was also stressed that it is not only the deficiency of Vitamin A alone but an additional factor of protein calorie malnutrition is essential to cause xerophthalmia.

  Materal and methods Top

60 cases of either sex in the age group of I to 5 years were taken into this study Twenty of these cases were normal children which were taken as control (Group I) ; 20 children suffered from protein calorie malnutrition with­out any xerophthalmia (Group 11) and 20 cases suffered from Xerophthalmia with protein calorie malnutrition (Group III).

Each case was subjected to detailed external occular examination and a routine general systemic examination. Xerophthalmic mani­festation were graded[5]. Special note was made of the cases suffering from keratomalacia but rest of the cases involving conjunctiva and cornea were taken as one. The cases suffering from pulmonary, renal and gastrointestinal disorders or measles were excluded from the present study.

  Investigations Top

Following constituents of the serum were estimated in each case. (a) Vitamin A and Carotenes by Carr Price reaction[6] (b) Total proteins, albumin and globulin by Biuret method[7] In both tests, spectronic 20 photo­electric colorimeter was used.

  Observations Top

Age ranged from 1 to 5 years in our series [Figure - 1] and the average age in group I, II and III were 2.6, 3.2 and 2.6 years respectively. Males dominated with an over all incidence of 3:2.

Vitamin A : It was observed that the mean value of Vitamin A in control cases was 38.40 + 7.42 microgram/100 ml. P.C.M. cases showed mean value of 20.70 ± 5.75 microgram/100 ml. which is significantly less as compared to control cases. While mean level in xerophthalmic cases was much lower (14.65 ±5.45 microgram/100 ml). There was also statistically significant difference in between P.C.M. and Xerophthalmic cases. It was fur­ther noted that the cases who suffered from keratomalacia, had extremely low levels of vitamin A with a mean figure of 8 microgram/ 100 ml. [Table - 1].

Proteins : Total proteins were significantly less in P.C.M. and xerophthalmic cases as com­pared to control [Table - 2] and [Figure - 2] ; however, the proteins were slightly higher (value 2.44) in xerophthalmic cases as compared to P.C.M. cases. There was wide range of total proteins in xerophthalmic cases as compared to con­trols and P.C.M. cases [Figure - 3]

Albumins too were low in P.C.M. and xerophthalmic group [Figure - 2] [Table - 2] but there was no significant difference in cases of P.C.M. and xerophthalmia. Globulins were almost equal in all the three groups.

  Discussions Top

Serum content of vitamin A in normal children in the present study can be favour­ably compared to the figures put forward by various workers[8] in different countries as well as to an earlier study conducted in school children in Udaipur[9].

Xerophthalmic children in our study had extremely low Vitamin A content with a mean figure of 14.65 + 5.45 microgram/100 ml. with a range of 8 to 23 microgram/100 ml. Similar­ly, proteins too were significantly (PG0.01) decreased [Table - 3]. It is concluded from our observations that in cases with xerophthalmia, the proteins are reduced significantly and vita­min A is reduced drastically attaining a figure of approximately 33 percent that of control. It is also recorded by us that mean protein con­tent of P.C.M. cases without Xerophthalmia is significantly less (t value 9.25) as compared to controls and slightly less (t value=2.44) than Xerophthalmic cases. The cause of non development of xerophthalmia in P.C.M. cases is due to their comparative higher value of Vitamin A content as compared to xeroph­thalmic cases though the mean value was at the lower end of control range with figures of 14 to 32 microgram/ml.

The ratio of proteins and Vitamin A con­tent in our control cases as noted was 1:6; whereas, this ratio was extremely disturbed in Xerophthalmia with P.C.M. cases, attaining a figure of 1:2.6. In cases of P.C.M. without xerophthalmia, the ratio recorded was 1:4.75 though proteins and Vitamin A both are redu­ced to lower than normal level. It can be concluded that if this ratio is further disturbed and brought nearer to Xerophthalmic cases either by giving proteins alone or by reducing Vitamin A content in the diet, the cases are likely to clinically manifest Xerophthalmia and the severity shall depend upon the degree of decrease in ratio of Vitamin A to proteins. The fact is amply substantiated by our obser­vations in all the four cases of Keratomalacia where the ratio of proteins to Vitamin A was reduced to 1:1.2 as well as by another case of P.C.M. without Xerophthalmia in which at the time of admission, the protein levels were 5 gm/ 100 ml. and Vitamin A was 22 ttg/ 100 ml. forming a ratio of 1:4.2 When proteins alone were given for a period of about 45 days, the ratio was markedly disturbed and the child developed keratomalacia.

These observations give ample strength to the theory[5],[7],[10],[11] that protein depletion may on one hand aggravate vitamin deficiency by interfering with absorbtion of Vitamin A and possibly with mobilisation of Vitamin A from liver and on the other hand mitigating Vitamin A deficiency by sparing the tissue requirement of Vitamin A by inducing growth retardation; however, when more proteins are given with­out the addition of Vitamin A, growth occurs, Vitamin A requirement increases leading to clinical manifestation of Vitamin A deficiency in the form of Bitot's spots, xerosis conjunc­tiva or cornea or even keratomalacia.

Higher incidence of xerophthalmia in males can be attributed to better growth in height and weight in male children necessitating higher protein and Vitamin A requirement. Sex incidence noted in our study is 7:3 which is exactly same as given by Oomen[3] and is at variance with others,[2],[4],[12]

It is at a common observation by most of the workers[13],[14],(15),(16) that the incidence of xerophthalmia is highest in the age group of 1 to 3 years. Our contention of higher incid­ence in the age group of 1 to 3 years in agree­ment to Sheila et al[5] is, that in India, most of the children are wholly breast-fed till the age of 9 to 12 months. Thereafter, children are given small amount of cereals and partial breast feeding is maintained until the age of 18 months or more. Animal food given is rare and vegetables and fruits too are scarce and hence the diet during weaning period from the age of 1 to 3 years suffers from poor calories, lack of proteins and vitamins. The deficiency is further aggravated by rapid growth during this period leading to P.C.M. with and without xerophthalmia.

Carotenes recorded in our cases of P.C.M with and without Xerophthalmia are approxi­mately 50 per cent of our controls. There appears to be no significant difference in cases of P.C.M. with and without Xerophthalmia [Table - 1][Table - 3]. There also appears to be definite relationship of the severity of Xeroph­thalmia to the carotene contents, since mean carotene content in cases of keratomalacia was 46.2 μg/ 100 ml. and in less severe cases 70.4 μg/100 ml. Different workers in the various parts of the world have reported extremely wide variations in normal carotenoid levels ranging from 49.9 ± 8.1 p.g/100 ml. to 149 μg/100 ml.

The study reveals that albumin globulirh ratio in our controls were 2.17:1. This ratio was disturbed equally in both conditions i.e. P.C.M. and Xerophthalmia with figures of 1.60:1 and 1.59:1 respectively. The distur­bance in ratio is mainly due to the fact that albumin levels were statistically significantly reduced in both conditions i.e. Xerophthalmia and P.C.M. whereas globulin levels showed almost no significant change in either condi­tion.

  Summary Top

Serum Vitamin A, carotene, total proteins, albumin and globulin have been estimated in normal, P.C.M. with Xerophthalmia and with varying degree of Xerophthalmia with P.C.M. children. Analysis of the results suggest that it is not only the reduction of Vitamin A or proteins alone but the disturbed ratio between serum proteins and Vitamin A content which decides the occurrence of xerophthalmia.

  References Top

Achar S.T., 1950, Brit. Med. J.1 : 701.  Back to cited text no. 1
Gopalan C., Venkatachalam P.S., Bhawani B. 1960. Amer Jr. of Clinic Nutr. 8 : 833.  Back to cited text no. 2
Oemen H.A.P.C. 1954. Brit J Nut. 8 : 307.  Back to cited text no. 3
Tiong Y.K., 1956, Brit. J. Ophthalmol 40 : 502.  Back to cited text no. 4
W.H.O. 1976, Technical Report, Vitamin A deficiency and Xerophthalmia. Series 590 (1976).  Back to cited text no. 5
Varley H. 1975 Practical clinical Biochemistry 4th Edition 607  Back to cited text no. 6
Wootton I.D.P., 1974, Micro analysis in Medi­cal biochemistry 5 Edition 156 Publisher Churchill Livingstone.  Back to cited text no. 7
Netelson S. 1977 Techniques of clinical chemi­stry 3rd Edition Pg. 751 Charles C. Thomas, Publisher.  Back to cited text no. 8
Kothari L,K., Lai K.B., Srivastav D.K. and Sharma R. 1971. Amer. Jr. of clinic Nutr. 24 : 510.  Back to cited text no. 9
Arroyave, C. 1969 Amer Jr. of Clinic Nutr, 22:1119.  Back to cited text no. 10
Kuming B.S., and Politzer W.M. 1967. Brit. Jr. of Ophthalmol. 51 :649.  Back to cited text no. 11
Mclaren D.S. 1958. Bull W.H.O. 19: 303.  Back to cited text no. 12
Sheila M.P., Begum A, and Marry E.D. 1966 Am. Jr. Clinic Nutr. 18.19 :182 (1966).  Back to cited text no. 13
Venkataswamy, G. 1967 Brit J. Ophthalmol 51 : 854.  Back to cited text no. 14


  [Figure - 1], [Figure - 2], [Figure - 3]

  [Table - 1], [Table - 2], [Table - 3]


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