Revista Adolescência e Saúde

INTRODUCTION

A global calculation estimate is that 5.2 million preschool children and 9.8 million pregnant women is a n affected by vitamin A deficiency (VAD), according to functional indicator - night blindness (XN, symptoms eyepieces of the DVA and first phase of xerophthalmia)¹. In Brazil, VAD has a high prevalence in the maternal-infant group². The XN of gestation on has negative health impacts, especially a higher incidence of infections^3.4.

The inadequate food intake is recognized as an important risk factor for disability². The association between characteristics demographic and the unfavorable disability is well described to international studies^3.4.

In Brazil, the conclusions about DVA and XN during pregnancy are scarce⁵, especially in pregnant adolescents. In addition, the available studies are conducted with a small sample size and there is no consensus on the factors associated with this deficiency in pregnant adolescents, however, prevalence rates are high as described^6.7. Gurgel et al.⁶ found that 75.5% of brazilian adolescents women studied showed retinol intake below the recommendation, reflecting a low level of vitamin A in human milk. The study of Garcêz et al.⁷ evaluated 89 teenagers, which had 34.8% retinol serum insufficient, whose average reduction suffered along pregnancy. In this last study⁷, the protective factors against DVA were the body mass index and adequate sanitation (BMI) pre-gestation.

The present study aims to describe the prevalence of VAD based on functional indicators ( XN of pregnancy ) and dietary (inadequate dietary intake), in addition to estimating the factors associated with pregnancy XN in pregnant adolescents in Rio de Janeiro .


METHODS

This cross-sectional study is part of research of the "Program of prenatal nutritional counseling for pregnant adolescents"⁸ developed in a public hospital in Rio de Janeiro, RJ. The unit studied is linked to the public health service and provides assistance to pregnant women/pregnant adults and adolescents and also newborns.

The study population included database of this study was to Accompany pregnant teenagers as in the periods 2004-2006 (Group I - GI) and 2007-2010 (Group II - GII)⁸, which met the inclusion criteria: adolescent (age <20 years), single-fetus pregnancy, healthy .

The GI received routinely a prenatal standard adopted in maternity, including visualization with the nutritionist⁸. The GII received a minimum calendar of four consultations with the nutritionist in the prenatal period. Both groups also received three group consultations with a multidisciplinary team that includes nutritionist⁸. From the database study⁸ (n = 746), were selected 303 teenagers were accompanied by a nutritionist in prenatal diagnosis and had XN of gestation (Figure 1).




The data collection of the original study was done by interview and consultation with the records. The XN of pregnancy was diagnosed with the implementation of the interview standardized by the World Health Organization (WHO) and validated⁹.The diagnosis was made by the nutritionist, for both groups, and recorded in the records. The investigation of the pregnancy XN occurred in a standardized manner.

In the anthropometric evaluation, the following were considered: pre weight gestacional updated or measured in the 1^st quarter, height and weight before birth or from the last prenatal visit up to 7 days before delivery. The BMI pre-pregnancy was evaluated according to the WHO¹⁰ curve. The adequacy of the weight gain was evaluated as the ranges of recommended weight gain¹¹.

The dietary intake of vitamin A in GII was assessed by the semi-quantitative frequency consumption¹² in the first and second trimester of pregnancy. It was research the amount and frequency of consumption (daily, weekly, biweekly or monthly) of food source of vitamin A. Adequate intake of vitamin A was considered when ingested more than 800 micrograms RE/¹³.

The pregnancy complications evaluated were Mellitus diabetes Gestational (D G M), hypertension syndromes going of pregnancy (SHG), urinary infection¹⁴, pica malacia, identified s in the records. The concentration of hemoglobin less than 11g/dl was considered to anemia¹⁴.

The prescription of multivitamin supplements containing vitamin A was identified in the medical records. In both study groups for prevention and treatment of XN, the consumption of food and the increase of those containing vitamin A¹ were stimulated, in particular, the weekly consumption of liver steak, in addition to the vitamin A supplement prescribed by the doctor.

The dependent variable - pregnancy XN , was analyzed in a dichotomous way (yes, no). The independent variables studied were: characteristics of the partner demographic prenatal care, dietary vitamin intake A, social habits; maternal characteristics (biological, obstetric and clinical), analyzed as dichotomous variables. It was considered as inadequate sanitation conditions of the dwelling when one of the services (regular garbage collection, drainage, drinking water) was absent and adequate conditions when all the services were present. The use of alcohol/cigarette in pregnancy identified by the professional in the consultations, at any gestational age, was recorded in the records. The amount and frequency of alcohol/cigarette use were not available. With the aim of characterizing the sample, maternal age was also analyzed as a continuous variable and maternal inter-occurrences were estratified (yes, no).

The dietary consumption of vitamin A was transformed into daily consumption and was described with data adjusted by the total energy consumption, according to the waste method. The variable consumption of vitamin A was also analyzed as a continuous variable.

In the statistical analysis was used the t - Student and the Chi-square test. The level of significance adopted was p<0.05. In the univariate analysis was use simple logistic regression, using the odds ratio (OR) brut and 95% confidence intervals (CI). Multivariate logistic regression models were evaluated, adopting the p<0.25 value obtained in the bivariate analysis as a criteria for inclusion in the models and, also, variables based on the literature review were included. The stepwise method was used for the adjustment of the model, with input and output criteria of variables of 0.05 and 0.10, respectively. In the final model, adjusted OR and 95% CI were estimated. For this, the statistical package SPSS version 21 was adopted.

The calculation of the sample size was used post-hoc considering a 14% prevalence of XN gestation and a significance level of 5% in the sample of 303 women, with 80% power to detect differences of at least 9% in the prevalence of XN gestation between groups, with a minimum estimated sample of 300 adolescents.

The study was approved by the Research Ethics Committee of the Federal University of Rio de Janeiro (CAAE - 1758.0.000.361-07).


RESULTS

The pregnant teenagers had n a average age of 17.8 years (+ 1:58) and most had an age ≥ 16 years. The prevalence of pregnancy XN was 13.2% (n=40). The demographic characteristics; the data on prenatal care and social habits are in Table 1. The use of cigarettes and alcohol in pregnancy was reported by 11 pregnant women (3.6%, Table 2). The biological, obstetric and clinical characteristics of the pregnant women are described in Table 3. It was verified that 36.5% of the adolescents developed anemia, 24.8% presented some inter or degree, among them, 1.0% of GDM, 7.3% SHG (hypertension gestational- 66,7%, pre-eclampsia - 28.6% and eclampsia - 4.8%), of the urinary tract 6.6% and; picamalacia was inform by 27.8%. The inadequacy of the total gestational weight gain was observed in 68.3% of the adolescents (Table 3).




It was considered for the composition of the present sample, data used two from a study previously developed by the research group (n=746). Of this, 303 participants were selected from two different periods, analyzing the similarity of the characteristics of adolescents as study groups and check the similarity in terms of: maternal age (p=0.96); schooling (p=0.42); skin color (p=0.26); housing sanitation conditions (p=0.07); (p=0.97) and use of l cigarette and alcohol in pregnancy (p=0.06). The differences verified were: higher proportion of adolescents living with the partner in the GII (p=0.001); Most proportion of XN (P=0.02) and Picamalacia (p=0.001) in the GII; and a higher proportion of adolescents residing in the South Zone in the GII (p=0.007). The differences were considered in the multivariate analysis.

The average dietary intake of vitamin A by the members of the GII was from 1391.9 micrograms RE (n=211; + 1917.8) and 1417,7 micrograms RE (n=155; + 1605.8), in the 1^st and 2^nd trimester, respectively. Dietary intake is inadequate like observed in 44.1% (n=93) and 38.1% (n=59) of the adolescents in the 1st and 2nd trimesters , respectively, but there was no significant association to the XN of pregnancy (Table 2).

Information was obtained on the use of multivitamin supplement of 272 adolescents, and all received medical guidance for its use. Most prescribed supplements (92.3%) containing ferrous sulphate, folic acid and C vitamin, and 7.7% were multivitamin containing A vitamin. For the majority (57.1%) of pregnant with XN was prescribed supplement multivitamin with A vitamin.

Although a significant association was found between the use of A vitamin supplement and pregnancy XN (p <0.001), this variable was not included in the multivariate analysis, since all pregnant women used supplements. In addition, there was no record in the records regarding the adherence and the dose used by the pregnant women, only the prescribed doses.

In the multivariate analysis it was found that the probability of pregnancy XN for adolescents who used cigarettes and alcohol in pregnancy went from 4.06 (95% CI 1.13-14.57) pair to 3.94 (95% CI 1.01 - 15.41, Table 4), in the final model .The other variables tested remained in the model, but were not associated with the pregnancy XN (Table 4).


DISCUSSION

The prevalence of pregnancy XN and inadequate dietary intake of vitamin A among the adolescents studied were significant. The prevalence of gestational XN was similar to l or described in another study in the same public hospital in Rio de Janeiro, where he found that 18% of adults had gestational XN⁹. There was a significant reduction in pregnancy XN in adults of the same motherhood after prenatal nutritional surveillance, from 18.7% to 6.2%¹⁵. The results of this high prevalence of VAD in Rio de Janeiro corroborate the data practices described in Brazil², referred to the region of southeast as most relevant affected, with 15.5% of the women of childbearing age (15-19 years) with inappropriate or serum retinol².

In another study carried out in Brazil, it was found that 8.7% of adult pregnant women who attend a health center in the city of Diamantina - Minas Gerais presented XN⁵. This region was considered a risk and a priority for the actions of the National Program for the administration of A vitamin supplements in Brazil¹⁶ . Therefore, by 2016, mothers received prophylactic supplement with mega dose of A Vitamin in the immediate postpartum period, before hospital discharge, as well as guidance on healthy eating and encouraging the consumption of foods rich in A vitamin, which may explain the lower prevalence of DVA described like intervention that occurred in women of reproductive age¹⁶.

In the study Pathak et al.¹⁷ developed in India, revealed prevalence of similar VAD as in the present study in that 16% of pregnant adolescents presented XN gestation associated with anemia, goiter and low consumption of retinol and iron. However, the greater biological vulnerability of adolescents to DVA is not evidenced by other researchers. In another study conducted in India³ there was a higher prevalence of pregnancy XN among older women compared to younger women³. In a study in Ethiopia¹⁸, there was as well more vulnerable to VAD among older women l a s. A possible explanation for this finding is lifetime exposure to periods of nutritional depletion of maternal reserves associated with prolonged lactation and during periods of drought and multiple births. It was also found that 10% of pregnant women reported XN of pregnancy, and the highest vulnerability was indicated among older women (30-34 years), without formal education and in the third trimester¹⁸.

The high proportion of the inadequate dietary intake of vitamin A that is described in the present study suggests that the consumption of food supply may have been insufficient against the increase in the physiological demands of adolescents¹³. However, this hypothesis can´t be proven, since the data on dietary consumption were only available for the GII.

In the context of adolescence, the concern for adequate nutrition to the nutritional needs of pregnancy interferes with their social life and their daily lives, since food is the central element of meetings and commemorations, including meanings that go beyond the nutritional dimension. Thus, the alimentary guidelines don´t consider other dimensions that make up the complexity of adolescent alimentary little practiced. This is usually the reason for the incorporation of new eating habits in adolescence that requires an effort to combat the influence of friends, the media and the social context that surround¹⁹.

The high prevalence of inadequate consumption of vitamin A described suggests the need to review the nutritional assistance oriented to the pregnant woman, so that it is offered from the beginning of the prenatal period and that it extends throughout the gestation, to offer the necessary support the teenager to the co - Responsibilit ization of choosing healthier foods¹⁹. The WHO 1 It recognizes the importance of prenatal nutritional care to treat nutritional deficiencies that affect birth weight in the 1.000 first days of life. In 2013, WHO began recommending the prevention and treatment of maternal VAD as a strategy to improve the health of children in the first 1,000 days of life²⁰. Vitamin A supplements are recommended in the third trimester of pregnancy, when the needs are alt a s and the food supply intake does not reach the recommendation of 800 micrograms/day²⁰ . In another publication, WHO reinforces the intervention with vitamin A supplements during pregnancy in areas where VAD is a serious public health problem and when the prevalence of XN pregnancy is ≥ 5% or if the prevalence of serum retinol < 0.70 μmol/L for 20% 21≥ . However, such intervention is not yet adopted in Brazil.

The National Program of Vitamin A Supplements in Brazil¹⁶ includes the distribution of mega dose vitamin A for kids 6 years and 59 months since 1980. The supplement or women in the immediate postpartum period was also an action implemented in the country since 2001, with the aim of reducing the VAD in mothers and children²². However, the supplement or mothers was completed in June/2016 by the lack of scientific evidence concerning the protection of vitamin A on the protective effect of supplement or of vitamin A in the morbidity and mortality of mothers or infants²².

Regarding the habits and behaviors of risk (use of cigarettes and alcohol) practiced by adolescents during pregnancy, it was verified that a small plot (3.6%) of pregnant women had that profile and, of these 36.4% presented XN of pregnancy. In national studies describing these habits during pregnancy²³, it was found that smoking during pregnancy in adolescents was increasing with the passage of age (<18 years 3.1% 3.8% 18-19 Years and > 35 years 14.9%). A study conducted with postpartum adolescents in public and private hospitals in Rio de Janeiro showed a decrease in prenatal consultations of those who smoked, consumed alcohol and/or drugs during pregnancy²⁴.

A systematic review of alcohol consumption in Latin America²⁵ revealed that 15.2% of brazilian women drank alcohol during pregnancy. It is further disclosed that 5.1% of l to s patients had compulsive alcohol and 0.9% excessive consumption during pregnancy²⁵.

The effect of alcohol consumption on the body's homeostasis of vitamin A has been demonstrated, and in the case of chronic alcohol consumption, there is a decrease in the levels of alcohol retinoid hepatic by increasing transport to extra-hepatic tissues²⁶. The XN is reported as a consequence of alcoholism and, with the persistence of this habit, the ophthalmological symptoms can evolve towards irreversible blindness. However, although it has been observed a complex interaction between alcohol metabolism and homeostasis vitamin A, the biochemical mechanisms have yet to be elucidated²⁶.

The effects of tobacco consumption on the nutritional status of the A vitamin in pregnant women is described by Titova et al.²⁷. The authors observed damage in the fetal development of the children of active and passive smokers, with shorter length at birth being observed. Another finding was the association between active smoking during pregnancy and the increase in serum levels of vitamins A and E in the umbilical cord. It was checked among the passive smoker women, highest concentrations of vitamin A in the cord blood. The authors suggest that the increase in these concentrations in the umbilical cord can be a stress - induced response oxidative as result the use of snuff, increasing the demand for fetal antioxidant compounds to neutralize the load oxidative caused by cigarette²⁷.

In the multivariate analysis, the association between cigarette use and alcohol with the XN outcome of pregnancy was evidenced in the final model. It was found that during pregnancy, the use of supplements containing vitamin A was negatively associated with the use of cigarettes and alcohol. It was found that among adolescents who reported the use of cigarettes and alcohol in pregnancy, only three (14.3%) reported the use of vitamin A supplementation. On the contrary, the use of vitamin A supplements was evidenced by the majority (85.7%, p=0.013) of adolescents who did not report these habits, which may explain, in part, the results of the study.

The results of the present study suggest that adolescents who used cigarettes and alcohol in pregnancy also had a lower degree of adherence to the guidelines provided in the prenatal, which include the reduction of smoke and alcohol; encouraging adherence alimentary plan; stimulation of the consumption of source foods fortified with vitamin A; and encouraging the use of supplement prescribed. However, to confirm this assumption, future studies must be developed.

As limitations of the study, we cite the transversal design; part of the casuistry obtained by consulting the records; differences observed between the groups; lack of information on adherence to the use of supplements containing vitamin A; in addition to the lack of quantitative information about the use of cigarettes and alcohol in pregnancy. In spite of this, it is worth mentioning that the study was of a significant sample size, carried out in reference maternity care for adolescent pregnant women.


CONCLUSION

The study revealed a significant prevalence of XN teenage pregnancy, suggesting that the investigation of the DVA must be part of prenatal care protocols at all levels of health care, especially for those who use cigarettes and alcohol. The data suggest that the DVA in adolescents may be an underestimated problem, requiring research in other regions of Brazil.


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