Angular stomatitis and riboflavin status among adolescent

Bhutanese refugees living in southeastern Nepal13

Heidi Michels Blanck, Barbara A Bowman, Mary K Serdula, Laura Kettel Khan, William Kohn, Bradley A Woodruff, and the
Bhutanese Refugee Investigation Group

KEY WORDS
Stomatitis, folic acid, Nepal, refugees,
riboflavin, riboflavin deficiency

INTRODUCTION
Between 1990 and 1993, 83 000 ethnic Nepalese fled their
homes in Bhutan because of fear of new citizenship laws and consequent ethnic persecution. Ultimately, these refugees were settled in 7 camps in the Jhapa and Morang districts of southeastern
Nepal. In July 1992, the office of the United Nations High Commissioner for Refugees, Save the Children United Kingdom, and
the Centers for Disease Control and Prevention helped establish a
surveillance system to monitor morbidity and mortality (1). Workers at each of the major camp health centers recorded clinical signs
430

of diarrhea, malaria, worm infection, acute respiratory infections,

and deficiencies in micronutrients. In response to sporadic signs
of possible micronutrient deficiency, including beriberi, a vitaminfortified cereal blend was added to the general ration in June 1994.
The blend was withdrawn in January 1999 because of program
constraints. After this withdrawal, the number of reported cases
of angular stomatitis (AS), ie, thinning or fissuring at the angles
of the mouth, increased quickly and dramatically from 5.5 per
1000 refugees per month in December 1998 to 35.6 cases per 1000
refugees per month in March 1999 (2). The highest rates were
found in children and adolescents.
A nonspecific condition possibly exacerbated by infection, AS
has classically been linked with deficiencies of riboflavin, other
B vitamins, and iron (3, 4). For riboflavin deficiency specifically,
a purplish-red or magenta tongue and cheilosis (vertical fissuring
of the lips) are also regarded as clinical signs. Examination for AS
has been advocated for nutrition surveys since the 1960s (5, 6),
and AS status has been useful in diagnosing riboflavin deficiency
in populations (7). The possible functional consequences of
riboflavin deficiency in humans include decreases in motor skills
and attention span (8) and in the absorption or utilization of iron
(9), and those in animals include decreased growth (10, 11). To
date, however, the impact of marginal B-vitamin concentrations
during the intensive growth period of adolescence has not been
well documented.
We are unaware of any previous investigation of an outbreak of
AS and riboflavin deficiency in a refugee population. The possibility that the dramatic increase in AS among these Bhutanese
1
From the Divisions of Nutrition and Physical Activity (HMB, MKS, and
LKK), Diabetes Translation (BAB), and Oral Health (WK), National Center
for Chronic Disease Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta; the Epidemic Intelligence Service, Division
of Applied Public Health Training, Epidemiology Program Office, Centers for
Disease Control and Prevention, Atlanta (HMB); and the International Emergency and Refugee Health Branch, Division of Emergency and Environmental
Health Services, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta (BAW).
2
Supported in part by the World Food Programme, the United Nations High
Commissioner for Refugees, and the Centers for Disease Control and Prevention.
3
Address reprint requests to HM Blanck, Division of Nutrition and Physical Activity, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-26, Atlanta, GA 30341. E-mail: hblanck@cdc.gov.
Received June 19, 2001.
Accepted for publication September 5, 2001.

Am J Clin Nutr 2002;76:4305. Printed in USA. 2002 American Society for Clinical Nutrition

Downloaded from ajcn.nutrition.org by guest on August 25, 2014

ABSTRACT
Background: Between 1990 and 1993, fear of ethnic persecution
led 83 000 ethnic Nepalese to flee from Bhutan to refugee camps
in Nepal, where they remained at the time of this study. Reported
cases of angular stomatitis (AS), ie, thinning or fissuring at the
mouth angles, increased 6-fold from December 1998 to March
1999, from 5.5 to 35.6 cases per 1000 per month. This increase
came after the removal of a fortified cereal from rations.
Objectives: The main objectives were to assess the prevalence of
AS and of low concentrations of riboflavin, folate, vitamin B-12,
and iron by using biochemical measures; to determine whether
riboflavin status was associated with AS; and to assess the
potential of AS as a screening measure for low riboflavin
concentrations.
Design: In October 1999, we performed a survey among a random sample of 463 adolescent refugees in which we conducted
interviews and physical examinations and obtained blood specimens for riboflavin assessment. Riboflavin status was assessed
with the erythrocyte glutathione reductase (EC 1.6.4.2) activity
coefficient. After we excluded those adolescents who had taken
vitamins during the past month, 369 were eligible for analyses.
Results: AS was common (26.8%; 95% CI: 22.3, 31.3), the prevalence of low riboflavin concentrations was high (85.8%; 80.7,
90.9), and riboflavin status was associated with AS. Adolescents
with AS had significantly lower riboflavin concentrations than did
adolescents without AS (P = 0.02). The adjusted odds ratio for AS
and low riboflavin concentrations was 5.1 (1.55, 16.5).
Conclusion: Globally, riboflavin deficiency is rare. Its emergence in food-dependent populations can be a harbinger of other
B-vitamin deficiencies.
Am J Clin Nutr 2002;76:4305.

ANGULAR STOMATITIS AND RIBOFLAVIN AMONG REFUGEES

refugees had a nutritional cause and the concern that similar
refugee populations may be at risk led to this investigation.
Because adolescents exhibited the highest rates of AS, we focused
on that high-risk subgroup. The main objectives of this study were
1) to assess the prevalence of AS and associated symptoms; 2) to
assess the prevalence of low concentrations of riboflavin, folate,
vitamin B-12, and iron by using biochemical measures; 3) to
determine whether riboflavin status was associated with AS; and
4) to assess the potential of AS as a screening measure for low
riboflavin concentrations.

SUBJECTS AND METHODS

Study design
This cross-sectional survey was carried out in October 1999 in
the 7 Bhutanese refugee camps in Nepal. The total camp population in September 1999 was 99 044 persons, including 26 235 adolescents (those aged 1019 y; 26.5% of the total population).

Potential participants were chosen by simple random sampling

from computerized registration data. To estimate prevalence 5
percentage points, we assumed point estimates of 30% and 50%
for the prevalence of AS and low hemoglobin, respectively, which
resulted in samples of 321 and 400 adolescents, respectively (12).
To allow for expected refusals and attrition, we needed to enroll
495 subjects; thus, we chose every 53rd subject from a randomized enumeration of all registered adolescents. Of these 495 adolescents, 463 (93.5%) provided informed consent to participate.
Of the 32 who did not enroll, 14 (2.8%) resided outside the camps,
13 (2.6%) were aged < 10 y or > 19 y, 3 (0.6%) refused, 1 (0.2%)
could not be found, and 1 (0.2%) had died. The study underwent
Human Subjects Review by the Centers for Disease Control and
Prevention Institutional Review Board.
Data collection
Participants were asked about their recent medical history,
vitamin use in the previous month, tongue pain, duration of the
current AS episode, treatment of AS, illness (diarrhea, pneumonia, fever) in the previous month, and demographic and household characteristics. We also asked about food consumption during the previous week, including that of lentils, potatoes, green
vegetables, fruit, dairy products, eggs, and meat or fish. Parents
were encouraged to accompany younger participants. All participants were weighed and heights were measured without shoes.
Local Nepali camp medical assistants who had completed 2 y
of medical training performed a limited physical examination of
the face and neck to assess for clinical signs of micronutrient
deficiency, including AS, cheilosis, and goiter. Because there is
no published classification system for the severity of AS, we first
classified the AS cases in photographs taken in the spring of 1999
in the Nepali camps as mild-to-moderate, severe, or scarred. The
photographs were used to train survey workers to standardize the
diagnosis of AS and the grading of its severity; these photos were
similar to those included by McLaren (13). We defined a mildto-moderate condition as a thin and mottled surface epithelium
with superficial fissuring, a severe condition as a cracked surface
epithelium with well-developed fissuring, and a scarred condition as a white or pink surface epithelium. Cheilosis was defined
as vertical fissuring of the lips complicated by redness and

swelling. To measure hemoglobin concentrations, nonfasting

blood specimens were obtained from all participants by finger
stick. To measure B-vitamin and transferrin receptor (TfR) concentrations, nonfasting blood specimens were obtained by phlebotomy from every second participant.
Biochemical assessment
Hemoglobin concentrations were measured with a Hemocue
hemoglobinometer (AB Addo, Malm, Sweden). Blood collected
by venipuncture was stored in plain (clotting) and EDTA-coated
tubes, which were kept in an insulated box containing ice packs
for 18 h until they were processed. For folate, vitamin B-12, and
TfR testing, clotted blood was centrifuged, and the serum was
removed by pipette, stored in cryovials, and kept frozen at 20 C.
Serum specimens were transported on ice to the Centers for Disease Control and Prevention (Atlanta), where they were kept frozen
until they were analyzed. The serum concentrations of folate and
vitamin B-12 were measured with a commercial radioimmunoassay kit (Bio-Rad Laboratories, Hercules, CA). Serum TfR testing
was done with a commercial kit (Ramco Laboratories, Houston).
For riboflavin testing, 0.1 mL whole blood collected in an EDTAcoated tube was added to a cryovial containing 0.9 mL distilled,
sterile water, and the mixture was frozen at 20 C (14). Diluted
whole-blood specimens were transported to Atlanta in a frozen
state on dry ice and subsequently shipped on dry ice to the laboratory of Philip J Garry (University of New Mexico) and stored at
20 C until they were analyzed. Riboflavin status was assessed by
a functional assay that measured the activity of a riboflavindependent enzyme, erythrocyte glutathione reductase (EC 1.6.4.2),
in whole blood. Laboratory testing measured the erythrocyte glutathione reductase activity coefficient (EGRAC), with a higher
coefficient reflecting lower riboflavin concentrations (14).
Control blood samples were collected from 3 supervisors in the
field during the survey and were processed, stored, and shipped
along with blood samples from the study subjects. All of the control samples had riboflavin EGRACs within the normal range
(0.681.70) for the assay (supervisor A: 1.09; supervisor B: 1.16;
supervisor C: 1.43) (14). Thirty samples were analyzed a second
time. The resulting EGRAC between-run CV was 6%.
Variable definition
An EGRAC > 1.7 was used to indicate low riboflavin concentrations (14). A folate concentration < 2.6 ng/mL and a vitamin B-12
concentration < 201 pg/mL were considered low; these cutoffs
reflect normal values for healthy US adults (15). A TfR concentration > 8.5 g/mL was used to indicate low tissue iron stores
(16). Low hemoglobin concentrations were established with the
use of World Health Organizationrecommended age- and sexspecific anemia cutoffs (in g hemoglobin/dL): both sexes aged
1011 y, 11.5; both sexes aged 1214 y, 12.0; females aged 15 y,
12.0; and males aged 15 y, 13.0 (17, 18). The prevalence of low
body mass index was determined by using the sex-specific World
Health Organization body mass indexforage cutoffs that are
based on data from US adolescents (19).
Statistical analysis
Data were entered with EPI INFO 6.04b (Centers for Disease
Control and Prevention, Atlanta), and the analysis was performed
with SAS software (20). Chi-square or Fishers exact test was used
to compare categorical data, and t tests were used to compare
means between subgroups of normally distributed continuous

Downloaded from ajcn.nutrition.org by guest on August 25, 2014

Subjects

431

432

BLANCK ET AL

TABLE 1
Prevalence of selected characteristics of survey participants aged 1019 y
(n = 369) in Nepali refugee camps1

ates that were meaningfully associated with the outcome (P <

0.10) or that altered the estimate for nutrient levels by more than
10% were retained in the model.

Characteristic

Exclusions

50.1 (45.0, 55.2)

46.9 (41.8, 52.0)
18.7 (9.5, 27.9)
22.0 (12.9, 31.0)
10.8 (1.2, 20.5)
16.8 (7.5, 26.1)
12.5 (2.9, 22.0)
10.0 (3.5, 19.7)
9.2 (0.0, 18.9)
4.1 (2.1, 6.1)
51.8 (46.7, 56.9)
88.3 (85.0, 91.6)
94.2 (91.8, 96.6)
41.3 (36.3, 46.3)
62.2 (57.3, 67.1)
26.8 (22.3, 31.3)
3.2 (1.4, 5.0)
49.9 (44.8, 55.0)
36.1 (31.2, 41.0)
35.4 (30.5, 40.3)
51.6 (46.5, 56.7)
0.6 (0.0, 1.3)
85.8 (80.7, 90.9)
35.3 (27.8, 42.8)
21.4 (14.9, 27.9)
51.1 (44.0, 58.2)
24.1 (19.7, 28.5)

1
95% CI in parentheses. EGRAC, erythrocyte glutathione reductase
activity coefficient; TfR, transferrin receptor.

variables. Correlations between nutrients and indexes of the utility of AS as a surveillance screening measure, including sensitivity, specificity, and positive predictive value (PPV), were also calculated (21). A P value < 0.05 was considered statistically
significant for all tests of association.
Logistic regression was used to model the prevalence odds
ratio for the occurrence of AS in relation to nutrient (B vitamin
and iron) concentrations with adjustment for potential confounders. The use of the US cutoff for low riboflavin concentrations designated a small group of adolescents (n = 26) as having
normal riboflavin concentrations and an even smaller group (n =
5) as having both AS and normal riboflavin concentrations.
Because of potential unstable estimates due to this small number
(22) and because a more appropriate population cutoff was not
available, we used the continuous EGRAC value in the multivariate analysis. Variables included in the models were marginally related to either AS or nutrient status in univariate analyses
and included age, camp of residence, household size, marital status, family member work status, and consumption of dairy products, lentils, and fruit. Collinearity was assessed by standard
methods (23), and age was centered (ie, the mean age in years
was subtracted from the age in years for each survey subject).
Effect modification was assessed by including biologically relevant interaction terms (eg, camp  nutrient status). Final models
were selected through a backward-elimination strategy; covari-

B-complex tablets (Royal Drugs Ltd, Kathmandu, Nepal) were

used in camp clinics to treat AS. Tablets containing iron and folate
were used to treat anemia. Such supplementation would render the
measured body concentrations of the corresponding vitamin
unrepresentative of usual status (8) and could affect current anemia and physical signs and symptoms. Of the 463 participants, 94
(20.3%) were excluded because they had taken a B-vitamin or iron
and folate supplement in the previous month; the result was a final
sample size of 369. There was no significant difference in supplement use by age, sex, or camp.
After the exclusion of enrollees who had taken vitamins in the
previous month, 154 serum samples (of 192 collected) remained
for folate and B-12 assessment, 190 serum samples (of 192 collected) remained for TfR assessment, and 183 blood samples (of
226 collected) remained for riboflavin assessment.

RESULTS
In our survey, one-half of the participants were male and
slightly less than one-half were 1014 y old (Table 1). Few were
married, and about one-half lived in a household with 7 or more
members. Less than one-half had family members who were
enrolled in supplemental feeding programs, and the families of
more than one-half had a kitchen garden. Mean SD reported
food consumption (times/wk) was 8.9 4.9 for lentils, 7.6 4.8
for potatoes, 1.6 2.0 for green vegetables, 1.2 1.5 for fruit,
1.5 2.1 for dairy products, 0.1 0.5 for eggs, and 0.2 0.5 for
meat or fish.
About one-fourth of the participants currently had AS (Table 1).
Of the AS cases, 47.4% were classified as mild-to-moderate,
23.7% as severe, and 28.9% as scarred. Most of the subjects
(n = 89; 89.9%) were affected bilaterally, and 4 (4.0%) had
accompanying perioral lesions. Participants with current AS
reported durations of 2180 d (mean: 18 d; median: 7 d). Few participants had cheilosis, but one-half reported tongue pain in the
prior month. Over one-third of participants had a low body mass
index at the time of the survey and over one-half had fever in the
prior month, but very few had goiter at the time of the study.
More than three-fourths of the 183 participants assessable for
riboflavin had low riboflavin concentrations (median and x SE
EGRAC: 2.0 0.30) (Table 1). More than one-third of the 154
participants assessable for folate and B-12 had low serum folate
concentrations (median: 3.1 ng/mL; x SE: 3.5 2.4 ng/mL), and
a smaller proportion had low serum concentrations of vitamin B-12
(median: 271 pg/mL; x SE: 307 150 pg/mL). Overall, just
under one-quarter of the 369 participants had low hemoglobin
concentrations (median and x SE: 13.0 1.7 g/dL), and one-half
of the 190 assessable for tissue iron had low tissue iron stores
(median TfR: 8.7 g/mL; x SE: 9.5 1.6 g/mL). Riboflavin
status was correlated with serum folate (Spearmans correlation
coefficient 0.31; P = 0.0001) and serum vitamin B-12 (Spearmans
correlation coefficient 0.19; P = 0.02).
Among the 183 adolescents who underwent riboflavin assessment, 68 had AS. This group of adolescents had a significantly
higher (P = 0.02, Students t test) mean (SE) EGRAC (2.2 0.4)
than did the adolescents without AS (2.0 0.3), which reflected

Downloaded from ajcn.nutrition.org by guest on August 25, 2014

Demographic and household

Male
Aged 1014 y
Camp of residence
Beldangi I
Beldangi II
Beldangi extension
Sanischare
Khudunabari
Timai
Goldhap
Married
7 Family members in household
Father present in household
Currently attending camp school
Family members receiving supplemental food
Kitchen garden
Health
Angular stomatitis
Cheilosis
Tongue pain in prior month
Low BMI (19)
Diarrhea in prior month
Fever in prior month
Goiter
Biochemical status
Low riboflavin, EGRAC > 1.7 (14)
Low serum folate, < 2.6 ng/mL (15)
Low serum vitamin B-12, < 201 pg/mL (15)
Low tissue iron, > 8.5 g TfR/mL (16)
Low hemoglobin (17, 18)

Prevalence

ANGULAR STOMATITIS AND RIBOFLAVIN AMONG REFUGEES

DISCUSSION
AS was common among adolescent Bhutanese refugees. The
prevalence of AS was not appreciably different if prior-month

vitamin users were included in the analysis (28.7%; 133 of 463).

We found that AS was associated with other signs of riboflavin
deficiency, such as cheilosis and tongue pain. Despite the nonspecific nature of AS, we did observe a significant difference in
mean EGRAC value between those with and without AS. Furthermore, in a multivariate analysis, AS and EGRAC were significantly associated.
AS is a classic feature of riboflavin deficiency, but it is nonspecific and often is overlooked as a clinical sign. Although we
lacked data on the interobserver agreement in assessment of AS,
we did evaluate whether AS is a useful screening measure for low
riboflavin concentrations in community assessments or surveillance. In general, a screening measure should be both inexpensive
and easy to administer, should impose minimal discomfort on the
participants, and should be valid and reliable (21). As a screening
measure, AS easily meets the first 3 requirements. We found that
AS had high specificity and high PPV, but low sensitivity in
detecting low riboflavin concentrations. Because PPV increases
with the prevalence of the condition, the PPV found here is relatively high, whereas in populations in whom the prevalence of AS
is lower, the PPV would be expected to be lower (21). The high
PPV of AS in this survey (89%) shows that AS can be used in conjunction with other relevant nutrient data (eg, data on the nutrient
composition of the food basket) as a surveillance tool to indicate
marginal riboflavin concentrations in refugee or displaced populations. The low sensitivity of AS, however, limits its utility as an
individual screening measure for low riboflavin concentrations.
Low riboflavin concentrations were common in our study sample. With the use of an EGRAC cutoff of > 1.7, 86% of adolescents
were found to have low riboflavin concentrations. This prevalence
is similar to that found in a study of low-income urban schoolchildren in Hyderabad, India, in which 90% were determined to be
riboflavin deficient by use of an EGRAC cutoff of > 1.4 (24, 25).
Although the riboflavin values in our study may have been affected
by changes in storage temperature during the transport of the specimens from Nepal to the United States, the association between
EGRAC and AS should have been independent of the effects of
transport, because all specimens were treated similarly.
The intake of riboflavin-rich foods in the previous week was not
consistently related to low riboflavin concentrations. This is not surprising, because the dietary approach used was not intended to assess
individual micronutrient intakes or to quantify intakes of riboflavin,
but rather to obtain a crude measure of food consumption patterns and
food availability. Because AS probably results from chronically inadequate intakes of riboflavin, this crude measure of food consumption
during the prior week does not accurately assess the relation between
outcome and long-term diet. More detailed dietary nutrient intake
methods are time-consuming and were beyond the scope of this survey.
Withdrawal of the cereal blend from the general ration in January 1999 reduced the riboflavin content of the daily ration from
< 0.6 to 0.4 mg per person, far below the World Health Organizationrecommended amounts of 1.351.8 mg/d for adolescents (26).
The general ration food basket, which contains < 2100 kcal per
person per day, includes the bulk commodities (rice, vegetable oil,
lentils, sugar, and salt) and complementary foods [potatoes,
onions, green chili peppers, bananas (or, when available, pumpkin or cabbage), garlic, and turmeric]. Unfortunately, dairy products and meat and fish, good sources of riboflavin, are not part of
the general ration. Despite the lack of green vegetables in the
ration, 60% of adolescents reported consuming green vegetables
in the previous week; however, the green vegetables routinely

Downloaded from ajcn.nutrition.org by guest on August 25, 2014

the lower concentrations of riboflavin in the former group. Among

18 adolescents with mild-to-moderate AS, 83% had low riboflavin
concentrations (x SE EGRAC: 2.1 0.4; median EGRAC: 2.0);
all 9 adolescents with severe AS had low riboflavin concentrations
(x SE EGRAC: 2.3 0.3; median EGRAC: 2.3) (P = 0.10, chisquare for trend; P = 0.23, t test). Scarred AS may be more reflective of past AS episodes than of current nutritional status. Among
the 11 adolescents with scarring, 90% had low riboflavin concentrations (x SE EGRAC: 2.3 0.2; median EGRAC: 2.2).
The prevalence of AS and low concentrations of riboflavin by
demographic characteristics, food consumption in the previous
week, health characteristics, and biochemical status are summarized in Table 2. Age, sex, biochemical status, and variables that
were at least marginally related to the presence of either AS or low
concentrations of riboflavin (P 0.10) are shown. AS was not
significantly related to sex, but there were borderline relations
with age and with camp of residence. AS was significantly less
common in the adolescents who reported < 7 family members in
the household and in those who reported consumption of any dairy
products in the prior week. AS was significantly more common in
the adolescents with cheilosis or self-reported tongue pain in the
prior month. AS was slightly more common in those with low
riboflavin concentrations, but this relation was not significant. The
prevalence of AS did not differ significantly by consumption of
any other food item or any of the other health conditions listed in
the questionnaire.
Low riboflavin concentrations were not significantly related to
age, sex, or camp of residence (Table 2). They were slightly less
common in those who reported < 7 family members in the household, in those who were married, in those who reported that a family member worked, and in those who reported consumption of
any fruit in the previous week. They were significantly less common in those who reported consuming lentils 10 times/wk and
in those with normal serum folate concentrations. Riboflavin status was not related to other biochemical measures, demographic
characteristics, or health conditions.
We also used logistic regression to examine factors predicting
AS. In an unadjusted model (n = 183) using the EGRAC value for
riboflavin, we found that EGRAC was a significant risk factor for
AS ( = 1.50, SE = 0.53) and that, when an EGRAC of 2.0 (low
riboflavin concentrations) was compared with an EGRAC of 1.0
(normal riboflavin concentrations), the odds ratio was 4.5 (95%
CI: 1.58, 12.7). Because of missing data, the final adjusted multivariate models included only 154 adolescents. In the final model
adjusted for age, family-member work status, dairy product consumption, and serum folate and vitamin B-12 concentrations, we
found that EGRAC was still a significant risk factor for AS
( = 1.62, SE = 0.60) and that the odds ratio was still significant
at 5.1 (95% CI: 1.55, 16.5).
The sensitivity of AS as an indicator of low riboflavin concentrations was 22%: of the 157 adolescents with low riboflavin concentrations, 34 had AS. The specificity of AS in detecting the
absence of low riboflavin concentrations was 85%: of the 26 adolescents with normal riboflavin concentrations, 22 did not have
AS. The PPV for low riboflavin concentrations was 89%: of the 38
adolescents with AS, 34 had low riboflavin concentrations.

433

434

BLANCK ET AL

TABLE 2
Prevalence of angular stomatitis and low riboflavin concentration among adolescents in Nepali refugee camps by survey characteristics1
Characteristic

Low riboflavin (n = 183)

n
P

55 [30]
44 [24]

0.21

78 [85]
79 [87]

0.69

54 [31]
45 [23]

0.07

67 [86]
90 [86]

0.97

15 [22]
20 [25]
10 [25]
14 [23]
22 [48]
9 [24]
9 [27]

0.06

31 [86]
29 [81]
22 [92]
27 [96]
18 [78]
15 [79]
15 [88]

0.40

39 [22]
60 [32]

0.03

71 [81]
86 [91]

0.06

3 [25]
96 [27]

0.592

4 [57]
153 [87]

0.062

19 [26]
80 [27]

0.86

31 [78]
126 [88]

0.09

39 [20]
60 [35]

0.001

83 [86]
74 [85]

0.79

53 [27]
46 [27]

0.98

78 [80]
79 [92]

0.03

49 [27]
50 [27]

0.92

74 [81]
83 [90]

0.09

6 [86]
93 [26]

0.0022

4 [100]
153 [85]

1.02

74 [43]
25 [13]

0.001

70 [89]
87 [84]

0.34

43 [24]
56 [30]

0.16

77 [82]
79 [90]

0.29

34 [22]
4 [15]

0.172

15 [29]
23 [23]

0.37

49 [94]
83 [81]

0.03

4 [12]
34 [29]

0.06

31 [94]
101 [83]

0.13

22 [23]
31 [33]

0.10

66 [89]
66 [85]

0.40

28 [30]
71 [26]

0.41

39 [95]
59 [84]

0.64

Percentage in brackets. EGRAC, erythrocyte glutathione reductase activity coefficient; TfR, transferrin receptor.
2
Fishers exact test.

Downloaded from ajcn.nutrition.org by guest on August 25, 2014

Demographic and household

Sex
Male
Female
Age (y)
1014
1519
Camp of residence
Beldangi I
Beldangi II
Beldangi extension
Sanischare
Khudunabari
Timai
Goldhap
Number of family members in household
<7
7
Married
Yes
No
Family member works
Yes
No
Food consumption in prior week
Dairy products
Yes
No
Lentils
10 times/wk
< 10 times/wk
Fruit
Yes
No
Health
Cheilosis
Yes
No
Tongue pain in prior month
Yes
No
Fever in prior month
Yes
No
Biochemical status
Low riboflavin, EGRAC > 1.7 (14)
Yes
No
Low serum folate, < 2.6 ng/mL (15)
Yes
No
Low serum vitamin B-12, < 201 pg/mL (15)
Yes
No
Low tissue iron stores, > 8.5 g TfR/mL (16)
Yes
No
Low hemoglobin, age- and sex-specific cutoffs (17, 18)
Yes
No

Angular stomatitis (n = 369)

n
P

ANGULAR STOMATITIS AND RIBOFLAVIN AMONG REFUGEES

We thank the field survey teams and camp teachers and administrators for
their cooperation during the survey; the adolescent Bhutanese refugees and
their families for their participation; and Donald B McCormick, Abe Parvanta,
and Della Twite for their assistance with survey development, laboratory
analyses, and interpretation. The members of the Bhutanese Refugee Investigation Group were Rita Bhatia, Anne Callanan, Arabella Duffield, Philip J
Garry, Elaine Gunter, Dan Huff, Judit Katone-Apte, Mary Kay Larson, Joanne
Mei, George Montoya, Savitri Pahari, Rosemary Schleicher, Anne Sowell, and
Santa Tamang.

9.
10.

11.

12.
13.
14.

15.

16.

17.

18.

19.

REFERENCES
1. Surveillance of the health status of Bhutanese refugees Nepal, 1992.
MMWR Morb Mortal Wkly Rep 1993;42:147.
2. Save the Children Fund (United Kingdom), Bhutanese Refugee Programme. A report on nutrition survey conducted in Bhutanese refugee
camps. Jhapa, Nepal: Save the Children, 1999.
3. Sebrell WH, Butler RE. Riboflavin deficiency in man. Public Health
Rep 1938;53:22824.
4. Jolifee N, Fein HD, Rosenblum LA. Riboflavin deficiency in man.
N Engl J Med 1939;221:9216.
5. Jelliffe DB. The assessment of the nutritional status of the community
(with special reference to field surveys in developing regions of the
world). Monogr Ser World Health Organ 1966;53:3271.
6. World Health Organization Expert Committee on Medical Assessment of Nutritional Status. Expert Committee on Medical Assessment
of Nutritional Status report (meeting held in Geneva 2127 August
1962). World Health Organ Tech Rep Ser 1963;258:1825.
7. Buzina R, Brodarec A, Jusic M, et al. Epidemiology of angular stomatitis and bleeding gums. Int J Vitam Nutr Res 1973;43:40115.
8. Bates CJ, Evans PH, Allison G, et al. Biochemical indices and neuromuscular function tests in rural Gambian schoolchildren given a

20.
21.

22.

23.

24.

25.
26.

riboflavin, or multivitamin plus iron supplement. Br J Nutr 1994;72:

60110.
Powers HJ. Riboflavin-iron interactions with particular emphasis on
the gastrointestinal tract. Proc Nutr Soc 1995;54:50917.
Agte VV, Paknikar KM, Chiplonkar SA. Effect of riboflavin supplementation on zinc and iron absorption and growth performance in
mice. Biol Trace Elem Res 1998;65:10915.
Baker DH, Edwards HM, Strunk CS, et al. Single versus multiple
deficiencies of methionine, zinc, riboflavin, vitamin B-6 and choline
elicit surprising growth responses in young chicks. J Nutr 1999;129:
223945.
Lwanga SK, Lemeshow S. Sample size determination in health studies: a practical manual. Geneva: World Health Organization, 1991.
McLaren DS. A color atlas and text of diet-related disorders. 2nd ed.
London: Wolfe Medical Publications, 1992.
Mount JN, Heduan E, Herd C, et al. Adaptation of coenzyme stimulation assays for the nutritional assessment of vitamins B1, B2 and
B6 using the Cobas Bio Centrifugal analyzer. Ann Clin Biochem
1987;24:414.
Gunter EW, Lewis BL, Konchikowski SM. Laboratory methods used
for the Third National Health and Nutrition Examination Survey
(NHANES III), 19881994. Hyattsville, MD: Centers for Disease
Control and Prevention, 1996.
Ferguson BJ, Skikne BS, Simpson KM, Baynes RD, Cook JD.
Serum transferrin receptor distinguishes the anemia of chronic disease from iron deficiency anemia. J Lab Clin Med 1992;119:
38590.
United Nations Childrens Fund, United Nations University, and
World Health Organization. Iron deficiency anaemia: assessment, prevention, and control: a guide for programme managers. Geneva:
World Health Organization, 2001:33-42.
Howson CP, Kennedy ET, Horwitz A, eds. Prevention of micronutrient
deficiencies: tools for policy makers and public health workers.
Washington, DC: National Academy Press, 1998.
Physical status: the use and interpretation of anthropometry. Report
of a WHO Expert Committee. World Health Organ Tech Rep Ser
1995;854:1452.
SAS Institute Inc. SAS stat users guide, version 6.12. Cary, NC: SAS
Institute Inc, 1990.
Hennekens CH, Buring JE. Epidemiology in disease control. In:
Mayrent SL, ed. Epidemiology in medicine. Boston: Little, Brown,
1987:3315.
Harrell FE. Regression modeling strategies with applications to linear models, logistic regression, and survival analysis. New York:
Springer, 2001.
Davis CE, Hyde JE, Bangdiwala SI, et al. An example of dependencies among variables in a conditional logistic regression. In:
Moolgavakar SH, Prentice RL, eds. Modern statistical methods in
chronic disease epidemiology. New York: John Wiley & Sons, 1986:
14017.
Prasad AP, Lakshmi AV, Bamji MS. Riboflavin and hemoglobin
status of urban school boys: relationship with income, diet and
anthropometry. Indian J Pediatr 1987;54:52933.
Prasad AP. Functional impact of riboflavin supplementation in urban
school children. Nutr Res 1990;10:27581.
World Health Organization. The management of nutrition in major
emergencies. Geneva: World Health Organization, 2000.

Downloaded from ajcn.nutrition.org by guest on August 25, 2014

found in the refugee camp markets (cabbage, okra, green beans,

and chili peppers) contain only marginal amounts of riboflavin.
Although periodic nutrition surveys of children aged < 5 y are
routinely carried out in displaced populations, nutritional assessment of adolescents is rare. The biochemical data presented here
suggest that the nutrient status of the adolescent Bhutanese
refugees is marginal with regard to riboflavin, folate, vitamin B12, and iron. Both continued surveillance for signs of micronutrient deficiency and an increase in food sources of micronutrients,
especially B vitamins, are needed in this population. Steps to
increase nutritional status include the addition of a fortified source
of micronutrients and the expansion of kitchen gardens and poultry raising. Since this investigation, vegetable production in camp
gardens has been expanded, and whole lentils have been added to
the ration. We are unsure of future health effects in the adolescents
if riboflavin deficiency continues, but low folate concentrations
and low tissue iron stores were also common. Along with marginal vitamin B-12 concentrations, low folate concentrations may
interfere with DNA synthesis and could lead to an increased
prevalence of anemia. The high prevalence of AS observed in the
adolescent Bhutanese refugee population is representative of the
precarious nutritional status of displaced populations and their
vulnerability to minor changes in rations.

435