Tóm tắt Luận án tiến sĩ Y học: Nutritional status and effectiveness of iron and zinc fortified rice in children aged from 36 to 2 under 60 months in Vu Thu district, Thai Binh province

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Therefore, we conducted the topic: "Nutritional status and effectiveness of iron and zinc fortified rice in children aged from 36 to 2 under 60 months in Vu Thu district, Thai Binh province" with the following objectives: To determine the rate of malnutrition, the prevalence of anemia, in children aged from 36 to under 60 months and some related factors in Vu Thu district, Thai Binh province. To analyzie characteristics of diets and prevalence of iron and zinc deficiency in children aged from 36 to under 60 months;

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Nội dung Text: Tóm tắt Luận án tiến sĩ Y học: Nutritional status and effectiveness of iron and zinc fortified rice in children aged from 36 to 2 under 60 months in Vu Thu district, Thai Binh province

1 INTRODUCTION Children’s growth is governed by many factors: genetic and external factors including nutrition. Proper nutrition is an important environmental factor for the growth and control of health and disease in the life cycle stages. Investing in nutrition and diet throughout the life cycle brings about not only economic benefits but also practical social meaning such as saving the cost of medical care, increasing the intellectual capacity and productivity of adults. Nutrition is the foundation for the development of strength, health, wisdom, stature of children. When it comes to malnutrition, experts say it's not just about hunger but also implies the notion of "latent hunger" or lack of essential micronutrients such as Vitamin D, A, iron and zinc. This is a meaningful public health issue, in which high-risk groups of getting malnutrition are women and children, especially children under 5. Survey data from the National Institute of Nutrition show that the rate of micronutrient deficiency in children is over 30%. Micronutrient deficiencies can be completely prevented and eliminated if those with high risk of malnutrition are constantly exposed to a small amount of micronutrients. To prevent micronutrient deficiency, many solutions can be implemented including solutions to enhance the micronutrients in food. Foods that are fortified with micronutrients are often foods that are often used by people. Micronutrient Intake is a viable and sustainable intervention to improve micronutrient deficiency. Thai Binh is an agricultural province and rice is the main source of food for the people. So far, there have been no studies to evaluate the effect of multi-micronutrient fortified rice on the health status of people in general and children in particular. The assessment of the effectiveness of multi- micronutrient fortified rice use for children is essential as a basis for the development of appropriate policies on multi-micronutrient enhancement in rice in Vietnam. Therefore, we conducted the topic: "Nutritional status and effectiveness of iron and zinc fortified rice in children aged from 36 to
2 under 60 months in Vu Thu district, Thai Binh province" with the following objectives: 1. To determine the rate of malnutrition, the prevalence of anemia, in children aged from 36 to under 60 months and some related factors in Vu Thu district, Thai Binh province. 2. To analyzie characteristics of diets and prevalence of iron and zinc deficiency in children aged from 36 to under 60 months 3. To evaluate the effectiveness of iron and zinc fortified rice to improve nutritional status in children aged from 36 to under 60 months. NEW CONTRIBUTIONS OF THE DISSERTATION - The dissertation has provided additional data on child malnutrition situation in Thai Binh province and identified the prevalence of zinc, iron deficiency and low iron stores in children aged 36-60 months, which are the basis for proposing interventions to improve childhood micronutrient deficiencies. - Rice is the staple food of Vietnamese people. Iron and zinc fortified rice is a solution that can accessible to all populations. - Research has shown that the use of iron and zinc fortified rice in children's diets has improved their diets, increased serum zinc levels, increased iron status and reduced the incidence of iron and zinc deficiency. These factors contributed to the rapid improvement of the child's physical development and served as a basis for confirming the Government's Regulation No. 09/2016 ND-CP dated January 28, 2016 on the promotion of micronutrient fortified in food is very important and needs to be developed on a nationwide scale. LAYOUT OF THE DISSERTATION The dissertation consists of 115 pages, 31 tables, 4 charts, and 139 references including Vietnamese ones and foreign ones. There are 2 page backgound, Literature review 31 page, Research methodology 23 pages, research results 28 page, discussion 28 pages, conclusion and 3 page recommendations.
3 CHAPTER 1. LITERATURE REVIEW 1.1. Current situation of child malnutrition and some related factors 1.1.1. Malnutrition status of children in the world From 576 representative surveys of the countries and territories between 1990 and 2010, it is shown that in 1990 the world rate of stunted children under age 5 accounted for about 40%. This rate in Latin America and the Caribbean was 24.6%. The stunting rate in Asia in 1990 was 48.4%; developing countries 44.6%; developed countries 6.1%. By 2010, the stunting rate in children worldwide has dropped from 39.7% to 26.7% However, there is a significant difference in the rate of stunting among regions. In Africa, the stunting rate is almost unchanged that after 20 years, the stunting rate has fluctuated around 40%, while Asia has experienced dramatic changes, the stunting rate reduced significantly 49% in 1990 to 28% in 2010. However, in most developing countries, stunting rate remains a significant public health problem in the present. About 80 percent of stunting children under the age of five are in 14 countries, of which the countries with the highest rate of stunting children under five are East Timor, Burundi, Niger and Madagascar, Bangladesh, Cambodia, Camarun, Ethiopia. By 2012, the overall stunting rate worldwide was around 25.0%, of which 56% is in Asia and 36% in Africa. By 2015, 156 million children suffered from stunting, accounting for 23% of all children under 5 years of age. There is evidence that although the number of under-five children with stunting is high, the rates are unevenly distributed across regions of the world. Stunting is more severe than underweight. In developing countries, rural children are 1.5 times more likely to develop stunting than urban children. It is predicted that by 2020, stunting worldwide will continue to decline. 1.1.2. Malnutrition status of children in Vietnam Research results of the National Institute for Nutrition until 2014 showed that: Distribution of malnutrition in our country is uneven among ecological regions; many mountainous areas have higher rates of malnutrition than delta areas. The highest malnutrition rate was in the Central Highlands (22.6% for underweight and 34.9% for stunting). In the South East, the prevalence of malnutrition was lower than in other regions (8.4% for underweight and 18.3% for stunting), lowest among ecological regions of the
4 country. The highest rate of stunting was recorded in the Central Highlands (34.9%), the Northern Midlands and Mountains (20.3%). The stunting rate was uneven among ecological regions. The Northern Highlands and Mountains and the Central and North Central Coast remained at a high level of public health significance (> 30%). Results of the study by Nguyen Thanh Ha on the micronutrient status of stunting children aged 6-36 months in Gia Binh district, Bac Ninh province showed that anemia, vitamin A deficiency and zinc deficiency in stunting children was all severe according to the WHO classification. Stunted children have high rates of micronutrient deficiency. 37.6% of stunted children are lack of 1 kind of micronutrient, 23.5% of children lack 2 combined micronutrients and 8.2% of total stunted children are deficient in the combination of 3 micronutrients. 1.1.3. Several factors related to malnutrition The three most important factors that affect malnutrition are food security, poor nutrition practices and illnesses, which are largely influenced by poverty. 1.1.3.1. Household food insecurity: That the food security of households do not guarantee is the key factor leading to food shortages in both quantity and quality - including lack of energy, protein and micronutrients. At present, the rate of poor households in remote and disadvantaged areas remains high. This is a potential cause of individual malnutrition. In addition, the level of influence of each factor depends on the accessibility of food in each household, and depends very much on nutrition knowledge, customs and habits of each ethnic group. 1.1.3.2. Poor nutritional practice: Poor nutritional practices related to food imbalances and preference for children and pregnant mothers. Even if the household ensures food security, there may be food shortages for individuals, especially for high risk individuals such as children under 5 or pregnant women etc. which is mainly due to poor nutritional practice. 1.1.3.3. Role of illnesses: Illness is considered to be one of two direct causes of child malnutrition. Infections increase the loss of nutrients, anorexia and eating in smaller amounts due to decreased appetite. Studies estimate that infection affects 30% of the decrease in height in children.
5 1.2. Micronutrient deficiencies in children Results of the national micronutrient census in 2014 and 2015 showed that the younger the child, the higher the risk of anemia: children in the groups of 0-12 months and 12-24 months had the highest rates of anemia with 45.0% and 42.7%, respectively; whereas in the group of children aged 24-35 months this proportion was 23.0%; the group of 36-47 month children was 18.8%; the group of 48-60 months 14.3%. The prevalence of anemia in urban children was 22.2%; in rural areas: 28.4%; in mountainous areas was 31.2%. A study on micronutrient deficiencies in six northern mountainous provinces showed that the prevalence of anemia in children was 29.1%, which was in the mean of public health significance. The low iron stores ratio (Ferritin
6 2.2.1.2. Community interventional study with control Children aged 36 to under 60 months were divided into two groups: the intervention group and the control group. Prior to the intervention, children in both groups were tested for the following indicators:- Weight, height. - Tests: Hb, serum zinc, serum ferritin (SF), TfR, CRP. - An interview with the mother about the child's diet Intervention group: Children from 36 to under 60 months of age living in Minh Khai commune and are fed with iron and zinc-fortified rice for 12 consecutive months. Control group: Children aged 36 to under 60 months living in Nguyen Xa commune and were served daily with normal rice, not zinc and iron- fortified rice. Children participating in the intervention were divided into two age groups at the beginning of intervention: + Age group 1: children aged 36-47 months. + Age group 2: children aged 48 to under 60 months. Both groups were evaluated by survey at the time points of M0; M12 and there was the comparison between the two groups. 2.2.2. Sample selection and sample size p (1 − p ) - Sample size for assessing children’s nutritional status n = Z 2 (1− α / 2 ) d2 According to the calculations, n = 461 children, but in this study, we selected clustered sampling, so we doubled the sample size; this is why the sample size was 922 children but in fact we surveyed 938 children. - Sample size for determining anemia: The total number of children participating in the assessment of anthropometric indicators (938 infants) were selected. Z 2δ 2 N - Sample size for Phase 2 - Intervention study n = 2 (e N ) + ( Z 2δ 2 ) According to the calculations, n = 71 children for each group, together with 10% of those who gave up, so the number of children for diet surveying was 80 children. Sample size for testing δ 12 + δ 22 n = ( Z 1− α + Z 1− β ) 2 (µ1 − µ 2 ) 2
7 Sample sizes were calculated for each of the criteria as follows: Serum hemoglobin was 130 samples; The serum ferritin test was 136; The serum Zn test was 135 samples. Sample size for intervention effectiveness evaluation was 136 children per group, which was sufficient to cover the monitoring of all indicators of concern. In fact, there were 324 children in the two intervention groups including 167 children in the intervention group and 157 children in the control group. Sampling: + Phase 1: Research site selection: purposively selected Vu Thu district. - Select communes: 4 communes to study were randomly selected including Minh Khai commune, Song Lang commune, Nguyen Xa commune and Song An commune. - Select the target population: Select all children aged 36 to under 60 months in accordance with sampling standards and sample size to have enough calculated sample size. + Phase 2: Select the subjects in the intervention study - Intervention site selection: In the four study communes in the first phase, we randomly selected 2 communes. The randomly selected communes were Minh Khai Commune as the intervention commune and Nguyen Xa Commune as the control commune. The total number of children aged between 36 and under 60 months of 2 communes were selected to participate in the second phase. 2.2.3. Techniques applied in the study: - Techniques for anthropometry, age, classification of child malnutrition according to WHO 2007. - Interview technique, survey and analysis of the last 24 hours - Clinical examination technique - Biochemistry, Hematology tests: Hb, Zinc, Ferritin, CRP and TfR 2.3.4. Data processing: Data was analyzed using SPSS 16.0 software at Thai Binh University of Medicine and Pharmacy. Statistical tests applied in biomedical research were used to analyze the results.
8 CHAPTER 3. RESEARCH RESULTS 3.1. Malnutrition and anemia rates among children aged from 36 to under 60 months old and some related factors in Vu Thu district, Thai Binh province Table 3. 1. Distribution of nutritional status of children by sex Malnutrition Underweight Stunting Wasting Overweight forms Sex Freq % Freq % Freq % Freq % Male (n=476) 68 14.3 140 29.4 25 5.3 17 3.6 Female (n=462) 51 11.0 106 22.9 14 3.0 11 2.4 Total (n=938) 119 12.7 246 26.2 39 4.2 28 3.0 p
9 Table 3.3. Percentage of stunting children by age group and sex Month Male Female p of age n Freq % n Freq % 36 - 47 246 62 25.2 236 48 20.3 > 0.05 48 -
10 Table 3.5. Prevalence of anemia in children by sex, age group n Frequency % p Sex Female 462 109 23.6 > 0.05 Male 476 115 24.2 Months of age 36-47 months of age 482 120 24.9 > 0.05 48-60 months of age 456 104 22.8 Nutritional status Got at least one malnutrition form 267 116 43.4 < 0.05 Non-malnourished children 671 108 16.1 The table above shows that the prevalence of anemia in female children was 23.6%, lower than that in males with 24.2%, but the difference was not statistically significant at p>0.05. The prevalence of anemia in children aged 36-47 months was 24.9%, higher than that in children aged 48 to under 60 months with 22.8%, but the difference was not statistically significant with p> 0.05. The prevalence of anemia in children with at least one malnutrition form was 43.4%, higher than that of non-malnourished children (16.1%). The difference was statistically significant with p 0.05. Male children and children aged 48-60 months were 1.4 times more likely to be malnourished than females in both univariate and multivariate analyzes (p
11 month group (95% CI: 1.1 - 1.9) in both univariate or multivariate analyzes. The difference was statistically significant with p 0.05 Other cereals and cereal processed products 38.95±38.8 33.6±30.5 > 0.05 Grease 10.9±4.4 11.1±3.25 > 0.05 Vegetables and ripe fruits 116.3±57.2 102.7±46.9 > 0.05 Meat and meat processed products 69.5±29.2 68.4±34.1 > 0.05 Fish and fishery products 25.4±15.9 26.2±13.2 > 0.05 Eggs and milk 34.9±20.8 35.7±23.6 > 0.05 The above table shows that there was no significant difference on children’s consumption level of food between the intervention group and the control group. The average consumption of rice was 162.8 g/d in the intervention group and 165.6 g/d in the control group. Table 3.7. Dietary energy value (Kcal per day) of children by age group and sex (n = 278) Total energy Dietary energy structure Variables %P %L %G Age 36-47 months 1116.9±189.6 16.1±2.6 27.4±9.2 56.7±10.7 group 48-
12 Table 3.8. Percentage of children got adequate amount of dietary energy producing substances as required (g /d) (n = 278) Percentage Dietary energy Freq % Male 32 22.1 Energy (Kcal) Female 46 34.6 Total 78 28.1 Male 145 100.0 Energy contributed by Female 133 100.0 Protein Total 278 100.0 Male 87 60.0 Animal protein / total Female 75 56.4 protein reached 60% Total 162 58.3 Male 62 42.8 Energy contributed by Female 71 53.4 Lipid Total 133 47.8 Male 30 20.7 Energy contributed by Female 54 40.6 Glucide Total 84 30.2 Table 3.8 shows that 28.1% of children met the recommended energy requirement, with 22.1% for boys and 34.6% for girls. 100% of children met the energy requirement of protein, but the rate of children got 60% animal protein out of total protein was only 58.3%. 47.8% of children got the energy requirement provided by lipid and 30.2% of children met the energy requirement provided by glucide. Table 3.9. The content of some minerals in the diet (n = 278) The rate reached the Some minerals X ± SD recommended demand n % Calci (mg) 477±204.5 67 24.1 Zinc 4.2±1.5 141 50.7 Phosphorus 669.7±192.3 228 82.0 Iron 4.9±2.3 132 47.5 Results of the above table show that the average content of calcium. Zinc, phosphorus and iron of children was: 477±204.5 mg; 4.2±1.5 μg; 669.7±192.3 mg; 4.9±2.3mg, respectively. The recommended rate for Calcium is 24.1%; zinc is 50.7%; phosphorus is 82% and iron is 47.5%.
13 Table 3.10. Mean value of some test indicators in children before intervention Control group Intervention Test indicators p (n=154) group (n=143) Hb (g/dl) 114.3±8.6 114.5±8.4 > 0.05 Zinc (µmol/l) 8.4±2.9 9.0±2.8 > 0.05 Serum ferritin (µg/L) 45.1±26.7 57.9±31.2 < 0.05 TfR serum (µg/L) 2.76±0.63 2.79±0.81 > 0.05 Serum CRP 0.75±0.85 0.88±1.11 > 0.05 Results of the above table showed that there was no difference in average concentration of Hb, zinc, serum TfR, serum CRP in the control group and in the intervention group, there was no difference with p> 0.05. Serum ferritin levels in the intervention group were higher than those in the control group. The difference was statistically significant with p 0.05 Zinc deficiency 102 66.2 94 65.7 > 0.05 Both anemia and zinc 28 18.2 35 24.5 > 0.05 deficiency It is showed that the prevalence of children suffering from anemia, zinc deficiency, and both anemia and zinc deficiency in the control group was 28.3%; 65.9% and 19.5% respectively. The prevalence of anemia, zinc deficiency, combined prevalence of zinc deficiency among children in the intervention group was 27.1%; 60.7% and 20.0%, respectively. The difference between the two groups was not statistically significant with p> 0.05.
14 Table 3.12. Situation of iron stores in children before intervention Control group Intervention Indicators (n=154) group (n=143) p Freq % Freq % Depleted iron stores 9 5.8 0 0.0 - (Ferritin 34 22.1 40 28.0 (Ferritin 1 0.6 2 1.4 (TfR> 8.6 µg/L) 0.05 Table 3.12 showed that the percentage of depleted iron stores, low iron stores and tissue iron deficiency in children in the control group was 5.8%, 22.1%; 0.6%, respectively. The percentage of depleted iron stores, low iron stores and tissue iron deficiency in children in the intervention group was 0.7%; 28.0% and 1.4% respectively. The differences were not significant with p> 0.05. 3.3. Effectiveness of some interventions to improve the nutritional status of children aged 36-60 months at the study site Table 3.13. Effectiveness of interventions on weight and nutritional status of underweight children Indicators Control group Intervention p (n=167) group (n=157) Average weight (Kg. X ± SD) M0 14.5±1.95 14.7±2.3 > 0.05 M12 16.2±1.96 16.5±2.3 > 0.05 M12 - M0 1.67±0.23 1.77±0.43 Rate of underweight malnutrition W/Y: n (%) M0 21 (12.6) 20 (12.7) > 0.05 M12 21 (12.6) 12 (7.6) > 0.05 p before and after >0.05
15 Results of the above table showed that after intervention, the weight gain in the control group was 1.67 (kg), lower than that in the intervention group (1.77 kg), the difference was statistically significant at p 0.05 M12 102.7±5.3 105.4±5.99 < 0.05 M12 - M0 5.2±1.07 6.98±0.84 < 0.05 Rate of stunting malnutrition CC/T (Freq. %) New incidence 4 (2.6) 0 (0.0) < 0.05 Recovery 5 (3.3) 16 (10.2) < 0.05 M0 49 (29.3) 45 (28.7) > 0.05 M12 48 (28.7) 29 (18.5) < 0.05 p before and after >0.05
16 Table 3.15. Intervention effectiveness on serum Hb, serum zinc and ferritin, TfR over the intervention times Control Intervention Indicators Periods group p group (n=140) (n=151) M0 114.3±8.6 114.5±8.4 > 0.05 Average M12 118.6±13.5 120.3±7.6 > 0.05 Hb (g/L) M12 -M0 4.4 5.7 p 0.05
17 Table 3.16. Intervention effectiveness on reducing the incidence of anemia and zinc deficiency Control Intervention Indicators Periods group group p (n=151) (n=140) M0 40 (26.5) 42 (30.0) > 0.05 Anemia (%) M12 35 (23.5) 21 (15.0) < 0.05 Anemia reduction level (%) 3.0 15.0 < 0.05 Performance index (%) 12.5 50.0 < 0.05 Intervention effectiveness (%) 37.5 M0 99 (65.6) 92 (65.7) > 0.05 Zinc deficiency (%) M12 73 (48.3) 37 (26.4) < 0.05 Zinc deficiency reduction level (%) 17.3 39.3 < 0.05 Performance index (%) 26.3 59.8 < 0.05 Intervention effectiveness (%) 33.5 Results of Table 3.16 showed that the rates of anemia and zinc deficiency in both groups had a reduction, but the reduction in the intervention group was higher than the control group. The intervention effectiveness of reducing anemia and zinc deficiency was 37.5% and 33.5%, respectively. Table 3.17. Intervention effectiveness for children's iron stores over the intervention times. Control Intervention Indicators Periods group group p (n=151) (n=140) % Lack of iron stores (low M0 42 (27.8) 40 (26.8) > 0.05 and exhausted) M12 35 (23.2) 17 (12.1) < 0.05 Reduction (%) 4.6 14.7 < 0.05 Performance index (%) 16.7 57.5 < 0.05 Intervention effectiveness (%) 40.8 The table above shows that children's iron stores have improved significantly after intervention. Intervention effectiveness in improving children's iron stores is 40.8%.
18 CHAPTER 4. DISCUSSIONS 4.1. Characteristics of malnutrition, anemia in children aged 36 to under 60 months and some related factors. The results of the study conducted in 4 communes of Vu Thu district, Thai Binh province showed that: The prevalence of underweight children among children aged 36 to under 60 months was 12.7% with 14.3% in male children, higher than in female children (11.0%), the difference was statistically significant with p
19 interventions to reduce malnutrition should focus primarily on preventing stunting and combined malnutrition forms. Micronutrient deficiencies are one of the leading causes of malnutrition, especially stunting. The overall prevalence of anemia in children was 23.9%. Anemia in children with at least one malnutrition form was 43.4% much higher than that of non-malnourished children with 16.1%, the difference was statistically significant at p
20 The prevalences of anemia, zinc deficiency and combined anemia and zinc deficiency in the control group were 27.3%; 66.2% and 18.2% respectively. In the intervention group, these were 30.1%; 65.7% and 24.5%. The difference between the two groups was not statistically significant with p> 0.05. The proportion of subjects with exhausted iron stores, low iron stores and tissue iron deficiency in the control group was 5.8%; 22.1%; 0.6% respectively. These proportions in the intervention group were 0.0%; 28.0% and 1.4% respectively. The differences were not significant with p> 0.05. Many studies have also shown similar results to our study results. Tran Thi Quynh Anh, a researcher in Thanh Son, Phu Tho, found that vitamin A content in the diet of 12-23 month children only met 65% of the child’s vitamin A requirement. Iron, zinc, calcium, and vitamin D levels in the diets were found to meet the requirement of children aged 6-11 months and 12-23 months with 50.0% and 29.1%; 68.3% and 70.7%; 46.5% and 47%; 9% and 6% respectively. It can be concluded that the prevalence of anemia among children aged 6-23 months was high. Supplemental dietary energy and micronutrient have not met the recommended needs. 4.3. Effectiveness of some interventions to improve the nutritional status of children aged 36-60 months at the study site The initial cross-sectional descriptive study showed that the prevalence of stunting in children aged 36 to under 60 months remained at a high level of public health significance. One of the direct causes of child malnutrition in this study was that the child's diet was not adequate. In order to prevent micronutrient deficiencies, diversification of meals and use of on-site food sources are considered one of the long-term, sustainable strategies to eliminate micronutrient deficiencies. Thus, from the analysis of the child's actual diet in the study, we conducted direct nutrition counseling sessions on the diet of infants for mothers, caregivers and nursing mothers of both control and intervention groups. All mothers were counseled directly about their child’s nutritional status, diet recommendations based on daily rations. In the intervention group, in addition to communication activities and nutritional counseling, children are served daily rice mixed with premix rice (iron and zinc fortified rice for 12 consecutive months). Results after 12 months of intervention, weight gain in the control group was 1.67 (kg), lower than that in the intervention group (1.77 kg), the