Tóm tắt Luận án Nutritional status and effectiveness of iron and zinc fortified rice in children aged from 36 to2 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 <30ng/mL) was 49.1%. Similarly, the prevalence of iron deficiency anemia (both Hb and Ferritin) was 52.9%. 1.3. Measures to prevent micronutrient deficiencies - Dietary diversification: is the best and most sustainable option, but it takes the most time. - Enhancing micronutrients in food: brings about slower effectiveness but more effective and more sustainable. - Micronutrient supplementation effectively improves the micronutrient status of individuals and target populations. CHAPTER 2. SUBJECTS AND METHODOLOGY 2.1. Study subjects * Phase 1: Children aged from 36 to 60 months old and mothers with children aged from 36 to 60 months in 4 communes of Minh Khai, Nguyen Xa, Song An, Minh Lang, Vu Thu District, Thai Binh Province * Phase 2: Children aged from 36 to 60 months old and mothers with children aged from 36 to 60 months in 2 communes: Minh Khai (intervention) and Nguyen Xa (control). 2.2. Research methodology 2.2.1. Research design: include two successive phases. 2.2.1.1. Cross-sectional descriptive study: Determining malnutrition rate, anemia and some related factors in children from 36 to under 60 months of age. 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 - Sample size for assessing children’s nutritional status 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. - Sample size for Phase 2 - Intervention study 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 2)2/1( 2 )1( d ppZn -= -a )()( 222 22 d d ZNe NZn + = 2 21 2 2 2 12 11 )( )( mm dd ba - + += -- ZZn 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 forms Sex Underweight Stunting Wasting Overweight 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 0.05 The table shows that 12.7% of children was underweight, 14.3% of whom are males, higher in females with 11.0%, the difference was statitically significant with p <0.05. 26.2% of children was stunting, with 29.4% in males and 22.9% in females, the difference was statitically significant with p <0.05; 4.2% of children was wasting, with 5.3% in males, 3.0% in females, p <0.05 and 3.0% of children was overweight and obese. Table 3.2. Percentage of underweight children by age group and sex Month of age Male Female p n Freq % n Freq % 36 - 47 246 30 12.2 236 22 9.3 > 0.05 48 - 0.05 Total 476 68 14.3 462 51 11.0 > 0.05 The table above shows that malnutrition in males was 14.3% higher than in females with 11.0%, which was significant with p <0.05. The proportion of underweight male children in both age groups from 36-47 months and 48-60 months are higher than in female children, but the difference is not statistically significant at p> 0.05. 9 Table 3.3. Percentage of stunting children by age group and sex Month of age Male Female p n Freq % n Freq % 36 - 47 246 62 25.2 236 48 20.3 > 0.05 48 - <60 230 78 33.9 226 58 25.7 < 0.05 Total 476 140 29.4 462 106 22.9 < 0.05 It is shown that the rate of stunting male children was 29.4% higher than in female children with 22.9%, which was significant for p <0.05. The proportion of stunting male children in both age groups from 36-47 months and 48-60 months are higher than in female children. However, the difference was statistically significant (p <0.05) only in group 48-60 months. Table 3.4. Analysis of malnutrition by three anthropometric indicators Malnutrition forms Month of age 36-47 (n= 482) 48-60 (n= 456) Total (n= 938) Get at least one malnutrition form 26.7 30.2 28.5 Prevalence of each m alnutrition form s Merely underweight 5.2 6.3 5.7 Merely wasting 1.2 2.2 1.7 Merely stunting 15.7 18.4 17.1 Merely overweight 2.3 2.7 2.5 Combined 13.3 15.8 14.5 The table above shows that 28.5% of children had at least one form of malnutrition. Among them, children with stunting only accounted for 17.1%, and this percentage in the 48-60-month-old group was higher than that in the 36-47 month group with p<0.05. The proportion of combined malnourished children is 14.5%. 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. * Analysis of several factors related to nutritional status The education level and career of the mother were not significantly related to the nutritional status of the child in the univariate analysis. However, in the multivariate analysis, the group of children whose mothers were workers were 1.8 times more likely to be stunted (95% CI: 1.1-3.1) than children whose mothers were farmers. Children in the family with more than two children and children with birth order from the 2nd or 3rd or higher tended to be more malnourished than those in small families and the firstborn children but the difference was not statistically significant in either univariate or multivariate analyzes 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<0.05). For malnutrition condition of stunting, male children were 1.4 times more likely to be malnourished than female children (95% CI: 1.1-1.8), this risk increased by 1.5 times (95 % CI: 1.1-2.0) in the multivariate analysis. The children in the age group of 48-60 months were 1.4 times more likely to be stunted than those in the 36-47 11 month group (95% CI: 1.1 - 1.9) in both univariate or multivariate analyzes. The difference was statistically significant with p <0.05