The vitamins have been identified since the early 20^th century and occur naturally and mostly in diets. Thirteen vitamins exist that are classified as fat-soluble (easily dissolvable in fats) and water-soluble (easily dissolvable in water). The fat-soluble vitamins are Vitamin A, D, E and K.

Vitamin A, also known as retinal, retinol or retinoic acid, is important organic nutrient integral to visual system, maintenance of immune system and development. It is a component of B-carotene, which is found in plants, algae and fungi.  Typical vegetables and fruits with increased contents are carrots, cauliflower and tomatoes.  Those with vitamin A deficiency, especially children, are afflicted with xerophthalmia (dry eyes), corneal ulceration, blindness, and increased mortality¹.  In Sub-Saharan Africa, and other developing countries, it is postulated that 1/3 of children under the age of 5 suffer from vitamin A deficiency.

Another fat-soluble vitamin is calciferol (Vitamin D), which is present in both plants and animals.  About 50-90% of it is produced when sunlight strikes the skin and converts a precursor to calciferol. Its presence is necessary for the calcium equilibrium in order to prevent osteopenia and osteoporosis. Adequate vitamin D level has also been associated with enhancement of the immune system, control of diabetes mellitus, prevention of cardiovascular conditions and cancer.  Fatty fish, such as mackerel, tuna are abundant in vitamin D as well as dairy products, egg yolks, beef liver, and soymilk.  Vitamin D deficiency is not as prevalence as vitamin A but has a host of complications, with approximately 1 billion of people suffering from diminished stores. Obesity, hypertension, rickets, osteoporosis, depression, fibromyalgia and certain cancers have all conditions that are linked to low calciferol levels.

Alpha tocopherol, the only human nutritious part of 8 components of Vitamin E, is the third fat-soluble vitamin. It is typically absorbed in the small intestine. It has important implications as an anti-oxidant, immunomodulator and anti-platelet agent. It is one of the fat-soluble vitamins that are least likely to be deficient in human; its deficit is typically due to malabsorption of fats in developed countries.  In developing countries, the lack of Vitamin E is due to dietary insufficiencies. Tocopherol is found in leafy vegetables, whole grains, nuts, seeds, vegetable oils and fortified cereals.  Individuals who are low chronically with Vitamin E suffer from gait abnormalities (ataxia), difficulty with upward gaze and diminished reflexes.  More severe problems include cardiac arrhythmias, blindness and dementia. As well, low tocopherol levels have also been associated with increased rates of ischemic heart diseases and atherosclerosis (deposits of fat plaques in arteries).

Vitamin K , also known as naphthoquinone, exist as two subcategories, K₁ and K₂, that will not be discussed here. In short, they naturally occur in green leafy fermented foods.  Population that are at risk for deficiency are newborns, as they are depleted from their maternal storage as soon as they are born, patients with liver cirrhosis and those with inflammatory bowel disease.  In developing countries, where access to nutritious food is sparse, complications are readily observed. Deficiency can causes easy bruising, nonfatal and fatal bleeds, and subsequent anemia. Osteoporosis and heart disease are associated with Vitamin K₂ deficiency.

The complications of these fat-soluble vitamins could readily reversed in most cases by readily administering supplements and appropriate nutrition support. If support could be obtained early in childhood, in certain cases, in the neonatal period, neurological deficits could be avoided.  If we could aid developing countries in the acquisition and sustainability of appropriate nutrients and agriculture, then these complications would be eradicated.

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Bird JK, Murphy RA, Ciappio ED, McBurney MI. Risk of Deficiency in Multiple Concurrent Micronutrients in Children and Adults in the United States. Nutrients. 2017;9(7):655. Published 2017 Jun 24. doi:10.3390/nu9070655

Fitzpatrick TB, Basset GJ, Borel P, et al. Vitamin deficiencies in humans: can plant science help?. Plant Cell. 2012;24(2):395-414.

Kemnic TR, Coleman M. Vitamin E Deficiency. [Updated 2019 Feb 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519051/

Naeem Z. Vitamin d deficiency- an ignored epidemic. Int J Health Sci (Qassim). 2010;4(1):V-VI.

Monicka Felix

Dr. Monicka Felix, MD is an academic hospitalist in Internal Medicine with a passion for Global Health. Her focus is on healthcare disparities in both developed and developing countries. She is set to obtain a Master’s in Public Health with a concentration in epidemiology. She is originally from Montreal, Quebec Canada but now currently resides in the Tampa Bay area in Florida.

While the mystique and beauty of Uganda captures the attention of many outsiders as the ultimate travel destination, there’s no denying that if one were to visit the country, they would find evidence of malnutrition –  one of the single gravest threats to global public health that impacts one-third of the population in East Africa.

Malnutrition is “bad nutrition”. People can either lack nutrients because they do not consume enough food or they may eat too much of the wrong type of food. This lack of nutritious food and imbalance in diet can lead to vitamin deficiencies, stunting and anemia.

Uganda continue struggles with widespread malnutrition despite efforts by the Ugandan government and NGOs to ensure food and nutrition security in the country.

Here are 10 facts you should know about malnutrition in Uganda:

1. Uganda ranks as one of the least well-nourished countries in the world.
2. Staple, commonly eaten foods like cassava, posho, and matoke are poor in essential vitamins and minerals like iron, vitamin A, and zinc.
3. According to the most recent Demographic and Health Survey, inadequate and unbalanced diets are a root cause of persisting nutritional problems, which undermines the health, growth and development of the children in Uganda.
4. Between 2004 to 2009, around 110,220 children died of malnutrition. And large part of the problem is that 82 percent of cases of child malnutrition in Uganda go untreated.
5. Stunting (low height for age) affects 29 percent of children in Uganda under 5 and can lead to less educational attainment and a reduced likelihood of escaping poverty in adulthood.
6. Malnourished children are more likely to dropout of school or repeat academic years. An estimated 133,000 Ugandan children per year have to repeat grades, adding more burden to an already depleted educational system.
7. More than 4 million (53 percent) of Uganda’s children under the age of five are anemic (USAID). In children, anemia leads to a significant slowdown in cognitive development, decreased physical activity, and reduced resistance to disease.
8. Almost half of women of reproductive age are anemic. Anemia in women leads to chronic fatigue and impairs productivity, pregnancy complications, premature birth, low birth weight, and even maternal mortality
9. Vitamin A deficiency  is a serious issue, impacting at 38 percent of children and 36 percent of women
10. Malnutrition costs Uganda $899 million per year. Poor nutrition affects work productivity by reducing the physical capacities of the laborers.

Many past initiatives to combat food security and malnutrition in Africa have focused on increasing the availability of staple foods which are nutrient poor. But it’s clear that simply producing more low-cost, energy-dense foods does not solve the malnutrition problem.

Greater emphasis needs to be placed on foods that are high in protein and essential nutrients derived from animal-sourced foods, fish, fruit, legumes, and vegetables. Investments in sustainable opportunities should not only make more nutritious food available, but also increase employment, improve the local economy, and teach valuable skills.  Ideas include dairy from goats and cows, raising chickens for eggs, fruit and vegetable gardens, and aquaculture.

Additionally, education on nutrition practices and building the skills to put the educational content into action is a critical piece of the puzzle. The work currently being done in Uganda by USAID aims to educate families and caretakers on foods that protect their children (vitamin- and mineral-rich foods), foods that build their children’s bodies (protein-rich foods), foods that give their children energy (foods with carbohydrates).

Nutrition education programs can also provide cooking classes and teach households about the importance of meal frequency, hygiene and even gardening. Changing behaviors such as meal frequency and hygiene greatly contribute to children’s overall health. Teaching villagers about gardening improves their access to diverse foods.

These two key ingredients can help to alleviate the pains in Uganda’s malnutrition crisis in it’s road ahead to recovery.