ACTUAL STATUS OF STUNTING AND DIETARY INTERVENTION EFFECTIVENESS FOR CHILDREN UNDER 5 YEARS OF AGE IN THE COASTAL AREA OF TIEN HAI, THAI BINH Author: Tran Quang Trung BACKGROUND Statis
Trang 1ACTUAL STATUS OF STUNTING AND DIETARY INTERVENTION EFFECTIVENESS FOR CHILDREN UNDER 5 YEARS OF AGE IN THE COASTAL AREA OF TIEN HAI, THAI BINH
Author: Tran Quang Trung
BACKGROUND
Statistic data from many countries show that the malnutrition in children in the world has changed markedly, the underweight rate has decreased rapidly but the stunting rate has been still high and combined with micronutrient deficiencies
In 2011 the stunting rate of the world was 27.5%; the average of the Asian countries was 26.8% The stunting rate in Vietnam in 2012 was still high, accounting for one quarter of children under 5 years old
Cause of malnutrition are very diversified and complicated, many studies indicate that animal protein and dietary micronutrients only reached 30-50% of the demand of children The environment pollutions, infections in children, awareness
of mothers and caregivers, customs, socioeconomic conditions also have significant impact on child malnutrition Prevention of malnutrition has been deployed nationwide; studies on multi-micronutrient supplementation with zinc have achieved good results A study trend on improvement of supplementing food
to ensure the nutritional requirements from food sources available at localities is a good approach to improve the nutritional status of children Tien Hai district has been raising many types of clam with a high rate of nutrients such as protein and fat, vitamins and minerals like calcium, iron, and especially zinc with a concentration much higher than the other foods
Believing in the hypothesis that using clams supplemented to children's diets might increase the important micronutrients protein considerably to recover
malnutrition, especially the stunting, we conducted the study on "Actual status of stunting and dietary intervention effectiveness for children under 5 years of age
in the coastal area of Tien Hai, Thai Binh"
Trang 23 New contributions of the thesis
- Combined some anthropometric indices with biochemical comprehensive assessment on the current state of stunted children under 5 years old in the coastal areas of Thai Binh Fist time to figure out the stunning rate assessed via multiple anthropometric indices in children under 5 years old is that the stunting rate was the highest, and determined the status of multi-micronutrient deficiency in the stunted children
- Via the multivariate analysis, the study identified that the factors related to the stunting rate have changed and different from previous epidemiological findings on malnutrition in which the economic, culture and occupation of the mother are currently less related to the stunning, key ones at the present are mostly the hygiene factors and personal characteristics
- It has shown that supplementing clams for daily diets of the stunted children aged 25-48 months at kindergartens together with counseling the mothers on children's diet increased the concentration of zinc, IGF1 in the serum, reduced the anemia, zinc deficiency, reduce the incidence and increased the recovery rate of stunting to increase the growth in height and weight of children (p<0.05)
4 Structure of the thesis
The thesis has 129 pages, 28 tables, 10 figures, 150 reference documents including 83 English ones The Background part: 2 pages; Literature review: 32 pages; Study subjects and methodology: 27 pages; Study results: 33 pages; Discussion: 32 pages; Conclusions and recommendations: 3 pages
Chapter 1 LITERATURE REVIEW
1 - Stunting situation of children in the world and Vietnam
- Stunting malnutrition in the world:
Statistics from countries show that from 1990 to 201 0 the rate of stunted children in the world decreased from 39.7% to 26.7%, the average reduction was 0.7%/year The reduction of malnutrition was not in parallel with economic growth The decrease of the stunting rate in the last 2 decades in some areas achieved a remarkable progress such as in Asia In Africa, the stunting rate hardly changed After 20 years, the stunting rate fluctuated around 40% Approximately 80% of children under 5 in the world were in 14 countries, of which four ones including East Timor, Burundi, Niger and Madagascar had the stunting rate of children under
5 the highest (more than half of children under 5 are stunted)
Trang 3- Stunting malnutrition of children in Vietnam: Domestic researches show
that Vietnam is one of 20 countries suffering the most from the severe consequences of child malnutrition In recent years, severe malnutrition has decreased a lot, but stunting rate is still very high In 199, in Thai Binh province, the underweight rate was 58.5%, and stunting rate was 59.9%; in 2012, the underweight rate decreased to 16%, the underweight rate in Tien Hai district was 15.7%
2 Causes of malnutrition
- Inadequate food in both quantity and quality, and infectious diseases:
Many studies indicate that the diets of children in rural Vietnam only meet about 30-50% of their demand for animal proteins, and the children face the multi-micronutrient deficiency It is estimated that the infection affects 30% of the reduction in the height of children The prevalence of child malnutrition increases markedly in the seasons when parasite infections are common, such as diarrhea, respiratory infections, malaria
Researches of other authors show that the pre-clinical deficiency of vitamin A affects 140-250 million children in developing countries, including Vietnam Diarrhea causes dehydration and some important nutrients such as zinc and copper Other diseases such as congenial malfunction, heart diseases, and diseases of other organs also affect the development of children and make children malnourished
- Lack of maternal and child health care services, knowledge of the caregivers, clean water and environmental sanitation
It has been shown that the lack of health care services, poor environmental sanitation, no clean water system leads to diseases arise and not be controlled to lead to malnutrition in children The difference in the rate of malnutrition, especially stunting, in various socio-economic areas reflected that food status of households affect the status of child malnutrition Although the knowledge and practice on child caring of the mothers was rather good, there is a gap between their knowledge and practice
- Low socio-economic conditions, poverty, backwardness and unequal economic status
According to some authors, the poor social and political structure and economic conditions are a main cause of malnutrition Economic crisis makes difficult to ensure the food security and health care service in developing countries According to the Demographic and Health Survey on 11 countries, in most of these countries, the children of the poor class have the stunting rate twice higher than that of the children of the wealthy class
Trang 43 Some intervention solutions to improve the stunted children
- Communication and education on nutrition and health care: Education on
nutrition and hygiene for prevention of diseases to the children in kindergartens and to their mothers demonstrated a great effect to the practice on eating and prevention of diseases, especially infectious diseases, thus it could prevent nutritional diseases, infections, parasites and diseases due to living and learning conditions
- Medical intervention to children's nutrition status: Through periodic
health check-ups, early detection of diseases of infection, parasites, nutrient deficiencies/excess, ones found that this intervention also helped children prevent complications of the diseases, improve the nutritional and health status, and thereby, prevent infectious, parasite and other chronic diseases
- Intervention studies to improve children's diets: The best measure to
improve the micronutrient deficiency is through the use of food available at the locality Ones also are very interested in seafood, especially clams which contain high levels of micronutrients, especially zinc, iron and vitamin B12 Some authors suggest that the enhancement of technical guidelines for processing these types of food at community helped to improve the nutritional status of children The fortification of nutrients to foods is a specific intervention which has been successful in many countries
Chapter 2 STUDIES SUBJECTS AND METHODOLOGY 2.1 Study subjects
- Phase 1: baseline survey on the children under 5 years old in July 2011 at 6 communes in Tien Hai District
- Phase 2: Intervention study for 12 months (from September 2011 to September 2012) on children 25-48 months The control group (Control) was performed at 2 communes: Dong Minh and Nam Ha; and the Intervention group (Intervention) were 2 ones: Dong Co and An Ninh communes
2 2 Methodology
2 2.1 - Study design: two successive stages
Phase 1: A descriptive and analytical epidemiological study via a sectional survey on 3,042 children under 5 years of age (M0) to assess their nutritional status through anthropometric indices and micronutrient testing of Hemoglobin (Hb) for 303 children 25-48 months old who are stunted through anthropometric examination
Trang 5cross-Phase 2: Intervention study with a control group for 12 months
Intervention group: Supplemented clams for the meals at the kindergartens
(40g clams/2 meals/week for normal children, and 120g clams/6 meals/week for the stunted children), combined with communication on nutrition, periodic health check-up once every 3 months for children
Intervention group: Did communication on nutrition, periodic health
check-up once every 3 months for children
Variables assessed before intervention (M0) and after 12 months of intervention (M12) include: weight/age, height/age, Hb, IGF1, zinc, frequency of food consumption in a month, 24 hours diet recall, prevalence of current diseases and history of diseases in the previous month
2 2.2 Sampling and sample size
+ Identify the stunting rate: coordinate some sampling methods: randomly
selected 6 coastal communities of a district from 2 coastal districts of Thais Binh, then examined all the children under 5, the sample size is as the following:
n=Z 21 -α/2 p (1 - p) (Formula 1)
e 2 Calculating for 5 age groups in 6 communes, with cluster sampling, the sample size is 3,080 children
+ Determine the rate of micronutrient deficiencies in the stunted children 25-48 months of age: Using the formula 1, calculated the sample size is 303
children for zinc and Hb testing
+ Intervention study: purposeful sampling for the intervention study; chose
all the children 25-48 months of age who have meals at kindergartens of the communes Sample size for one intervention group is as the following:
12 0
2 12 12
1 0
0
p p
p p
Z p
p Z
n
−
−+
−
Accordingly, there should 342 children chosen for intervention
+ Formula for testing samples in the intervention study:
n = Z 2 (ααα,βββ) 2s
2
(Formula 3)
(µ1 - µ2)2Accordingly, the sample size for Hb and zinc testing is 112 stunned children, and that for IGF1 testing is 70 ones each group
2.2.3 Technique applied in the study: Classification of stunted children by
the indices of weight/age, height/age, and weight/height according to the 2006 WHO's classification scale Hemoglobin was tested by cyanmethemoglobin
Trang 6method Quantification of the serum zinc was done by using the Atomic Absorption Spectrometry method Quantifying the IGF1 (Insulin-Like Growth Factor I) under Chemiluminescence Immunoassay method
2.2.4 Data processing:
Data were analyzed by using the software Stata 10.0 at Thai Binh University
of Medicine and Pharmacy and the National Institute of Nutrition Calculated means, percentage; statistical tests applied in biomedical research were used to analyze the results Used the multivariate logistic regression analysis to identify related factors, eliminated confounding factors and interacting influences
+ Calculation of efficiency:
A
B A
+ Intervention effectiveness: IE = | H 1 - H 2 |
Trang 7
Chapter 3 STUDY RESULTS 3.1 Malnutrition in children under 60 months of age and some related factors in the coastal area of Tien Hai, Thai Binh
3.1.1 Stunting among children under 5 years old
Table 3.3 Rate of stunted children under 5 years old in the coastal area of
-0,98
-1,27 -1,41
-1,43 -1,37
-0,68
-1,45 -0,25
-1,6 -1,4 -1,2 -1 -0,8 -0,6 -0,4 -0,2
0
≤ 12 months 13-24
months
25-36 months
37-48 months
49-60 months
Figure 3 1 Distribution of HAZ score of each age group, by gender
Results in the Figure 2 show that all the mean HAZ scores of children in all age groups are below zero, the lowest was in the age groups 25-36 and 37-48 months The difference between the male and female children was most clearly in the group of less than 24 months old
Trang 823,7 13,1 5,3
29,3 18,1
11,8 13,4
8,7 8,3
0 10 20 30 40
Figure 3.4 Rate of 3 types of malnutrition, by age group
In the figure 2, both types of underweight and stunting tend to increase gradually in the age group 25-36 months, and then, decline until reaching the group of 60 months of age The wasting rate was not much different between the age groups
Table 3.6 Analysis of the stunting combined with the others
Male (n=477) Female (n=342) Total (n=819)
Stunting only 301 63.1 217 63.5 518 63.2 Combined
stunting
Underweight 123 25.8 98 28.7 221 27.0 Underweight
Trang 9Table 3.7 Regression model on relation of some family factors with the stunted
Trang 10Table 3.9 Regression model on relation of some individual factors with
3.2 Deficiency of micronutrients in stunted children aged 25-48 months
in the baseline survey
Table 3.11 Mean values of Hb, Zn in stunted children
Tests 25-36 months old 37-48 months old Total
Hb 1 7 0 12.1 ± 1.3 133 12.5 ± 1.2 12.3 ± 1.3 Zinc 170 6 ± 3.7 14.4 * 133 1 6 7.3 ± 1.7 * 65.3 ± 13.4
( * : P<0.05)
Table 3.11 shows the mean value of hemoglobin, zinc, IGF1 in stunted children aged 25-36 and 37-48 months; accordingly, only serum zinc is not different between the 2 age groups, p<0.05
Trang 11Table 3.12 Rate of anemia, zinc deficiency in stunted children
Tests Stunting only
(n=283)
Stunting + wasting (n=20)
Total (n=303)
p (χ2 test)
3.3 Effectiveness of dietary intervention on nutrition status of children 25-48 months of age in some kindergartens in Tien Hai, Thai Binh
Table 3.18 Intervention effectiveness to underweight status
Trang 12Z-score index and intervention effectiveness between the 2 groups were statistically significant, p<0.05
Table 3.19 Intervention effectiveness to underweight status, by age group
Indicators 25 -36 months (a) 37-48 months (b) p
Control (n=240)
Intervention (n=199)
Control (n=181)
Intervention (n=167)
eff (%)
Detailed analysis by each age group in Table 3.19 show that children aged 25-36 months improved in both intervention and control groups, so that intervention effectiveness of diet achieved more (p<0.05)
Table 3.20 Intervention effectiveness on stunting status
Indicators Control (n=421) Intervention (n=366) p