Hiệu quả bổ sung đa vi chất đến tình trạng dinh dưỡng, thị lực và thể lực của nữ vị thành niên 15 17 tuổi miền núi thanh hóa TT TIENG ANH

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTHNATIONAL INSTITUTE OF NUTRITION LUU KIM LE HANG EFFICACY OF MULTI-MICRONUTRIENT SUPPLEMENTATION ON NUTRITIONAL STATUS, VISUAL ACUITY

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH

NATIONAL INSTITUTE OF NUTRITION

LUU KIM LE HANG

EFFICACY OF MULTI-MICRONUTRIENT SUPPLEMENTATION ON NUTRITIONAL STATUS, VISUAL ACUITY AND PHYSICAL FITNESS OF ADOLESCENT GIRLS AGED 15-

17 YEARS OLD IN MOUNTAINOUS AREAS OF

THANH HOA PROVINCE

Specialization: Nutrition

Code: 9720401

SUMMARY OF DOCTORAL THESIS IN NUTRITION

HA NOI, 2022

THE WORK WAS COMPLETED AT THE NATIONAL INSTITUTE OF NUTRITION

Science instructor:

1 Asoc Prof PhD Nguyen Xuan Hiep

2 Asoc Prof PhD Tran Thuy Nga

INTRODUCTION

Adolescence is a critical period of nutritional vulnerability due to anincreased need to meet growth and development of the body Anemia and multi-micronutrient deficiencies are still common worldwide and often occur from infancy

to adulthood If not intervened, it will negatively affect the overall physical andcognitive development Therefore, the research of micronutrient status duringadolescence has become an important area of interest

Many domestic and foreign researches have shown that the efficacy ofmicronutrient supplementation not only improves nutritional status andmicronutrient deficiency, but also improves cognitive and physical development inadolescents However, there have not been many multi-micronutrient interventionresearches on adolescents aged 15-17 to evaluate the efficacy on nutritional status or

physical fitness Therefore, the research team conducted the topic: "Efficacy of

multi-micronutrient supplementation on nutritional status, visual acuity and physical fitness of adolescent girls aged 15-17 years old in mountainous areas of Thanh Hoa Province" to evaluate the efficacy of multi-micronutrient

supplementation interventions on adolescent girls and make recommendations formulti-micronutrient supplementation interventions to prevent and control anemiaand micronutrient deficiency

THE OBJECTIVES OF THE TOPIC

1 To describe nutritional status, visual acuity and physical fitness of adolescentgirls aged 15-17 years old in mountainous areas of Thanh Hoa

2 To evaluate the efficacy of weekly multi-micronutrient supplementation onimproving anthropometry, visual acuity and physical fitness of adolescent girls aged15-17 years old in mountainous areas of Thanh Hoa after 9 months of intervention

3 To evaluate the efficacy of weekly multi-micronutrient supplementation onimproving hemoglobin and micronutrient levels of adolescent girls aged 15-17 yearsold in mountainous areas of Thanh Hoa after 9 months of intervention

New contributions of the thesis:

The research was conducted to intervene on adolescent girls aged 15 - 17years, who are at risk of anemia and micronutrient deficiency The interventionmodel is based on schools, health workers and homeroom teachers who directlydistribute multi-micronutrient tablet in class and ensure students take them in class

The content of multi-micronutrient tablets includes 23 vitamins and minerals,however, focus on iron (60mg), folic acid (2.8mg) as recommended by WHO 2011for subjects at risk of anemia, iron deficiency with supplemental dose of one tabletper week

In addition to evaluating the effectiveness of improving the anthropometric,biochemical and hematological indicators, the research also evaluated the efficacy

on improving on visual acuity and physical fitness The results of micronutrient supplementation significantly increased levels of hemoglobin, ferritin,serum zinc and serum vitamin A, gave effective prevention and improved anemiaand iron deficiency in adolescent girls aged 15 - 17 years The physical fitness level

multi-of adolescent girls also increased significantly compared to the control group

Thesis structure: The thesis consists of 121 pages (excluding references and

appendices), 3 pages of introduction and objectives of research, 33 pages ofoverview, 22 pages of research methods, 30 pages of research results, and 30 pages

of discussion, 2 pages of conclusion, 1 page of recommendation The thesis has 36tables, 10 pictures and 175 references (44 documents in Vietnamese, 131 documents

in English)

Chapter 1 OVERVIEW

1.1 Some related concepts

Adolescence is the period of life between childhood and adulthood, betweenthe ages of 10 and 19 The World Health Organization (WHO), the United NationsChildren's Fund (UNICEF) and the United Nations Population Fund (UNFPA)

agreed (1998) to classify this age group as adolescents and this age group isclassified into 3 phases: Early adolescence: from 10-14 years old; Middleadolescent: 15 - 17 years old; Late adolescence: 18-19 years old This is a period ofrapid physical, cognitive, and psychosocial development of people, an importanttime to lay the foundation for good health

Visual acuity is an important part of visual function, it includes manycomponents of which mainly the ability to distinguish light and the ability todistinguish space Vision examination is a fundamental and important part ofophthalmology Evaluation of visual acuity should always include distance vision,near vision, contrast and acuity

Physical qualities of a person are the sum of the qualities of the bodyexpressed in specific conditions of life, work, research and sports activities Mobility

is an external expression of physical qualities, and sport is a means (throughexercises) to improve mobility, contributing to the improvement of humanphysicality Physical qualities include: strength, speed, endurance, flexibility,dexterity

1.2 The role of micronutrients

Iron is an essential component of hemoglobin, myoglobin, enzymes,cytochrome and is necessary for oxygen transport and cellular respiration Irondeficiency anemia causes children to become less agile, slow in mental developmentwith cognitive delay, memory loss, poor concentration and results in a decrease incognitive function and learning ability and physical development Zinc plays animportant role in growth, immunity, and reproduction Zinc is important duringadolescence because of its role in growth and maturation in sexual function

Vitamin A has many roles in the body including vision, cell differentiation,immune function, reproduction, the formation and development of organs andbones, and keeping the skin and mucous membranes healthy Vitamin A participates

in increasing the concentration of Hb in the blood together with vitamins C, E, andB9, B12 Vitamin A deficiency is the cause of vision loss, dry eyes, is the maincause of blindness, while slowing down physical development, reducing the body'simmunity and increasing the risk of death Vitamin D is involved in promoting theabsorption of calcium, iron, magnesium, phosphate and zinc Vitamin D statussignificantly affects skeletal health during adolescent growth and plays an importantrole in female reproduction.

Vitamins, minerals, antioxidants and other key nutrients have been shown to

be essential for a good vision, able to protect eyes from conditions and diseases thatcause vision loss, prevent and delay the development of cataracts, maculardegeneration

1.3 Nutritional status of adolescent girls

Adolescence is a period of growth and development, characterized bytransformation In adolescent girls, this is the transitional period between childhoodand womanhood Adolescent malnutrition is a problem of public health significance

in Southeast Asian and African countries It is estimated that in Africa 22% ofschool children are stunted and 36% emaciated; Southeast Asia has 29% stuntingand 34% emaciation The percentage of stunting and emaciation among Indianadolescent girls is 39.4% and 33%, respectively;

In Vietnam, results from a number of researches on adolescent girls haveshown a worrying nutritional and health status, especially in rural and mountainousareas The status of stunting malnutrition in adolescents is still high due to the lack

of varied and adequate daily meals, insufficient energy, because children are stillskipping meals, due to lack of nutrition knowledge and practice, as well as theeconomic conditions of each family and each region, which affects the quality ofmeals and nutritional status

1.4 Anemia and micronutrient deficiencies in adolescent girls

Today in the world, iron deficiency anemia is still a problem of public healthsignificance During adolescence, iron requirements increase due to the peak ofpubertal development, characterized by an increase in total blood volume, anincrease in body mass, and the onset of menstruation in adolescent girls The highestrate of iron deficiency anemia is in developing countries such as Nepal 68.8%,Pakistan 65%, India 53%, Sri Lanka 52.3%, Indonesia 45%, China 37.9 %, Morocco35%, Philippines 31.8%

In Vietnam, the situation of anemia, iron deficiency anemia, zinc deficiencyand deficiency of other micronutrients is still high Anemia in women ofreproductive age by rural area is 26.3% and by mountainous area is 27.9%, zincdeficiency in women of reproductive age in rural areas is 60.3% and in mountainousareas is 73.4% In addition to iron deficiency anemia, adolescent girls also lack othercommon micronutrients such as zinc, calcium, magnesium, vitamin A, group B,vitamin D Thus, the percentage of common micronutrient deficiencies inadolescent girls is still high, the percentage and extent of deficiency are verydifferent in different countries, regions, and age groups, which affects the nutritionalstatus, physical and mental development of adolescent girls

1.5 Intervention researches evaluating the efficacy of multi-micronutrient supplementation on improving nutritional status, anemia, micronutrient deficiencies, visual acuity and physical fitness of adolescent girls.

Many researches evaluating the efficacy of interventions have shown theefficacy on improving iron-deficiency anemia when iron is supplemented alone or incombination with other micronutrients with daily or weekly doses, which increaseshemoglobin levels in the blood or improve the biochemical indicators ofmicronutrients added in the serum The fortification of multi-micronutrients,especially iron, zinc helps the body to grow, improve anemia, increase physical

development of children and adolescents When taken in a combination of vitamins

A, C and E with zinc, selenium, it will prevent cataracts, reduces the risk andreduces the progression of macular degeneration

In Vietnam, researches on iron deficiency anemia and micronutrientdeficiencies focus a lot on children under 5 years old, pregnant women, and women

of reproductive age More researches are needed on adolescent girls aged 15 - 17years on improving nutritional status or improving visual acuity and physical fitness,because this is the target group at a stage of strong physical development, with highbody's demands and also the pre-reproductive age, thereby we will have morescientific evidence to help prevent malnutrition, obesity as well as micronutrientdeficiencies in adolescent girls

CHAPTER 2 RESEARCH SUBJECT AND METHOD 2.1 Research subject

The research was conducted on female students from two high schools: NgocLac High School - Ngoc Lac District and Lang Chanh High School - Lang Chanh

District - Thanh Hoa province Inclusion criteria: Female students of the two

schools are from 15 to 17 years old Students and families agree to participate in theresearch Have a commitment to participate in the research and consent to do so asrequired by the intervention research

2.2 Research design

A community intervention trial research, randomized and double-blind, with

a control group, pre-intervention and post-intervention evaluation Phase 1:evaluating the nutritional status, anemia, micronutrient deficiencies, dietary intake,visual acuity and physical fitness of students Phase 2: controlled weekly multi-micronutrient supplementation intervention trial and post-intervention evaluation ofefficacy

Research design diagram

Evaluating the nutritional status.

- Anthropometric survey, general information

interview, optometry (n=740)

- Investigation of 24h rations, blood tests and

evaluation of physical fitness (n=300)

Phase 1: Evaluating the nutritional status

Intervention group (n=370)

Deworming before intervention

Take multi-nutrients once a week

Control group (n=370)

Deworming before interventionTake a placebo once a week

Phase 2: multi- micron utrient interve ntion for 9 months T0

2.3 Time and study sites

The research period was from June 2019 to December 2020 (in which themulti-micronutrient intervention period is 9 months)

Selected purposefully 2 mountainous and densely populated districts ofThanh Hoa province: Ngoc Lac district and Lang Chanh district Selected one highschool in each district, Ngoc Lac High School - Ngoc Lac District, Lang ChanhHigh School - Lang Chanh District to ensure a sufficient number of female students

of the sample size to participate in the research

2.4 Sample size

Applying the formula to calculate the sample size for communityintervention, to prevent the number of students giving up, the sample size according

to the indexes in the research was calculated as follows: sample size for each group

to evaluate anthropometric status, visual acuity was 350 subjects, evaluation ofhemoglobin and micronutrients was 150 subjects, evaluation of physical fitness was

120 subjects

Intervention group (n=370)

Deworming before intervention

Take multi-nutrients once a week

- Investigation of 24h dietaryrecall, blood tests and evaluation of physical fitness

(n=150)

Phase 2: multi- micron utrient interve ntion for 9 months T9

2.5 Methods of data collection and evaluation

At the times: T0 and T9, students in two groups were interviewed for generalinformation, the last 24 hour diet recall The indexes regarding anthropometricaspects, optometry and physical fitness, taking venous blood for testing wereevaluated

a) General demographic information group

b) Anthropometric index group: age, weight, height, nutritional status ofstudents: Based on WHO 2007 reference population

c) Hematological and biochemical indexes: hemoglobin, ferritin, serum zinc,serum vitamin A Normal and pathological values were according to WHOguidelines and the International Zinc Association

d) Group of visual acuity index: distance visual acuity, near visual acuity,contrast visual acuity and acuity with Helen Keller International's Snellen chart

e) Group of physical fitness index: squeeze force of the dominant hand, lying

on your back with stomach bent, turning on far in place, 5-minute running according

to own strength Evaluated physical fitness level for students according to Decision

No 53/2008-QD of the Ministry of Education and Training

2.6 Methods for data processing and statistical analyses

Used the questionnaire to collect data in the field All questionnaires weretransferred at the end of each survey to collect data to the National Institute ofNutrition to be entered and saved on the computer Biochemical test data, includingstandard sample and marked sample of the laboratory, are also stored in the databasefile on the computer Data were entered using Epidata 3.1 software Anthropometricdata were processed by WHO AnthroPlus software, 2006 Dietary data wereprocessed by ACCESS 2010 software Data were analyzed by SPSS 20.0 software.All data are cross-checked and cleaned before analysis

2.7 Ethics of research

The research outline was approved by the National Institute of Nutrition'sBiomedical Research Ethics Committee under Approval Certificate No 251/VDD-QLKH dated June 12, 2018 prior to implementation

Chapter 3 RESEARCH RESULTS 3.1 Status of nutritional status, visual acuity and physical fitness of adolescent girls aged 15-17 years old in mountainous areas of Thanh Hoa province

3.1.1 General information of students and their families

Table 3.1 General information of students and their families

Index n=705 Intervention n (%) Control n (%) Overall n (%)

Father's

education

level

Primary school orlower 124 (35.4) 117 (33.0) 241 (34.1)Secondary School +

High School 192 (54.9) 185 (52.1) 377 (53.5)Intermediate or higher 34 (9.7) 53 (14.9) 87 (12.4)

Mother's

education

level

Primary school orlower 133 (37.9) 131 (36.9) 264 (37.5)Secondary School +

High School 178 (50.9) 172 (48.5) 350 (49.6)Intermediate or higher 39 (11.2) 52 (14.6) 91 (12.9)

Family

economics

Near poor 55 (15.7) 56 (15.8) 111 (15.7)Normal 248 (70.9) 253 (71.3) 501 (71.1)

χ2 test compare the ratio of two groups at the same time.

3.1.2 Status of anthropometric status of adolescent girls

Table 3.2 Mean values of height, weight and BMI status

3.1.3 Status of visual acuity of adolescent girls

Table 3.4 Status of visual acuity of adolescent girls

Distance visual acuity of adolescent girls

Near visual acuity of adolescent girls

Contrast visual acuity of adolescent girls

Acuity

3.1.4 Physical fitness of adolescent girls

Table 3.5 Physical fitness of adolescent girls

No Test content

n

Test results (X±SD)

Number of students reaching the target

Percentag

e % 1

strength (m)

Table 3.6 Results of the overall physical fitness rating of adolescent girls

Overall physical fitness rating Total

3.1.5 Status of anemia, iron deficiency, micronutrient deficiencies

Figure 3 1 Situation of anemia, micronutrient deficiencies in adolescent girls 3.2 Efficacy of multi-micronutrient interventions on improving

anthropometric, visual acuity and physical fitness status of adolescent girls

3.2.1 Effect of intervention on the change of anthropometric index after

intervention

Table 3.7 Efficacy on weight change and average height after intervention

Zinc deficiency

Vitamin A deficiency

(p a ) T-test, comparing the means of two groups at the same time.

(p b ) Paired samples t-test , comparing the means of the same group before and after the intervention.

3.3.2 Efficacy of multi-micronutrient interventions on improving visual acuity

Table 3.8 Efficacy of multi-micronutrient interventions on improving visual

acuity

Index

Interventio n