Assessment of nutritional status among ethnic minority university students, thai nguyen province, vietnam

FOR MASTER OF PUBLIC HEALTH IN NUTRITION FOR HEALTH Thesis title: Assessment of nutritional status among ethnic minority university students, Thai Nguyen province, Vietnam Author: Mrs

THAI NGUYEN PROVINCE, VIET NAM

MRS TRAN THI HUYEN TRANG

A THESIS FOR THE DEGREE OF MASTER OF PUBLIC HEALTH

KHON KAEN UNIVERSITY

2018

MRS TRAN THI HUYEN TRANG

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE DEGREE OF MASTER OF PUBLIC HEALTH

IN NUTRITION FOR HEALTH GRADUATE SCHOOL KHON KAEN UNIVERSITY

2018

FOR MASTER OF PUBLIC HEALTH

IN NUTRITION FOR HEALTH

Thesis title: Assessment of nutritional status among ethnic minority university

students, Thai Nguyen province, Vietnam

Author: Mrs Tran Thi Huyen Trang

Thesis Examination Committee:

Prof Dr Sastri Saowakontha Chairperson Assist Prof Dr Pattara Sanchaisuriya Member Assist Prof Dr Suwalee Lowirakorn Member Assoc Prof Dr Pongdech Sarakarn Member

Thesis Advisor:

Assist Prof Dr Pattara Sanchaisuriya

Copyright of Khon Kaen University

Tran Thi Huyen Trang 2561

การประเมินภาวะโภชนาการของนักศึกษาชาติพันธุ์มหาวิทยาลัยใ นจังหวัดไทยเหงียนประเทศเวียดนาม

ที่ ม ห า วิ ท ย า ลัย เภ สัช ศ า ส ต ร์ แ ล ะ แ พ ท ย์ ศ า ส ต ร์ ไ ท ย เห งี ย น เก็บรวบรวมข้อมูลโดยการสัมภาษณ์นักศึกษาตามแบบสอบถามกึ่งโครง สร้างที่ออกแ บ บ ไว้ล่วงห น้ าป ระก อบ ด้วยข้อมู ลลัก ษ ณ ะบุ ค ค ล ข้ อ มู ล โ ภ ช น า ก า ร ข้ อ มู ล ก า ร วั ด สั ด ส่ ว น ร่ า ง ก า ย และปัจจัยที่มีผลต่อสถานะทางโภชนาการ ผลการศึกษา พบว่า ความชุกของนักเรียนที่มีน ้าหนักต ่ากว่าเกณฑ์อยู่ในระดับสูง (ร้อยละ 25.4) แต่น ้าหนักเกินและอ้วนมีค่อนข้างน้อย (ร้อยละ 4.3 และร้อยละ 0.5, ตามล าดับ) เพศหญิงมีภาวะน ้าหนักต ่ากว่าเกณฑ์สูงกว่าเพศชาย (Adjusted OR = 3.2, 95% CI: 1.55-6.80) ด้ า น พ ฤ ติ ก ร ร ม สุ ข ภ า พ พ บ ว่ า

ม า ก ก ว่ า ค รึ่ ง ห นึ่ ง ข อ ง นั ก เ รี ย น ไ ม่ ไ ด้ อ อ ก ก า ลั ง ก า ย หนึ่งในสามของนักศึกษากลุ่มตัวอย่างดื่มเครื่องดื่มแอลกอฮอล์ ส่ ว น อั ต ร า ก า ร สู บ บุ ห รี่ ต ่ า (ร้ อ ย ล ะ 4) เ กื อ บ ร้ อ ย ล ะ 40

ข อ ง ผู้ ต อ บ แ บ บ ส อ บ ถ า ม รับ ป ร ะ ท า น เพี ย ง ส อ ง มื้ อ ต่ อ วัน การบริโภคพลังงานและปริมาณธาตุอาหารที่มีธาตุอาหารเสริมบางอย่าง

ไ ม่ เป็ น ไ ป ต า ม ข้ อ ก า ห น ด ร า ย วัน ที่ แ น ะ น า ข อ ง เวี ย ด น า ม โดยเฉพาะอย่างยิ่งวิตามินเอ วิตามินบี 12 โฟเลต เหล็ก แคลเซียม

การวิเคราะห์ปัจจัยที่มีความสัมพันธ์กับภาวะโภชนาการพ บว่า เพศหญิงและการประเมินค่าน ้าหนักตัวสูงเกินไปเป็นปัจจัยที่สัมพันธ์กับ

ค ว า ม ชุ ก ข อ ง น ้ า ห นั ก ต ่ า ก ว่ า เ ก ณ ฑ์ ส รุ ป ไ ด้ ว่ า ภาวะการมีน ้าหนักต ่าในกลุ่มชาติพันธุ์ชนกลุ่มน้อยเป็นภาวะที่น่าตกใจโ

ด ย เ ฉ พ า ะ ผู้ ห ญิ ง จากผลการวิจัยมีข้อเสนอแนะว่าควรให้การศึกษาด้านโภชนาการมากขึ้ นโดยมุ่งเน้นที่แหล่งสารอาหารที่เหมาะสมและประโยชน์ของพฤติกรรม

ก า ร กิ น เ พื่ อ สุ ข ภ า พ ร ว ม ถึ ง ก า ร อ อ ก ก า ลั ง ก า ย เพื่อให้มั่นใจว่าเมื่ออายุมากขึ้นสุขภาพไม่มีปัญหา

Tran Thi Huyen Trang 2018 Assessment of nutritional status among ethnic

minority university students, Thai Nguyen province, Vietnam

Master of Public Health Thesis in Nutrition for Health, Graduate School, Khon Kaen University

Thesis Advisor: Asst Prof Dr Pattara Sanchaisuriya

ABSTRACT

Malnutrition has been a critical health problem in developing countries It is also becoming a serious health problem among ethnic minority groups The research was conducted among 351 ethnic minority students aged 17-29 years old at Thai Nguyen University of Pharmacy and Medicine The semi-structured pre-designed questionnaire was used to directly interview students to gather information about characteristics of individuals, dietary data, anthropometric data and a number of factors affecting the nutritional status The results showed that the prevalence of underweight students was high (25.4%); in contrast, that of overweight and obesity were relatively low (4.3% and 0.5%, respectively) Females students were statistically significant underweight than male students (AOR=3.2, 95%CI: 1.55-6.80) A questionnaire on life style and nutrition concerns indicated that nearly half of students did not exercise, more than one-third of students drank alcoholic beverage, and smoking was low in this population (4%) Nearly 40% of participants only consumed two meals per day The energy intake and some micronutrient intake did not meet two-thirds of the Vietnamese Recommended Daily Allowances, especially vitamin A, vitamin B2, B12, folate, iron, calcium, and fiber Females and overestimating the body weight were factors related to underweight prevalence In conclusion, underweight status in ethnic minority students was an alarming condition, particularly among females More nutrition education, focusing on selective nutrient sources and the benefits of healthy eating habit as well as physical activity, should be provided to ensure good health in their adult life

ACKNOWLEDGEMENTS

First of all, I would like to express my gratitude to my advisors, Assistant Professor Dr Pattara Sanchaisuriya Thank you for all constructive guidance and statistical advice in doing this work, and constant support not only for doing this thesis but also for the whole time I was studying in Khon Kaen Thank you for tirelessly supporting my work, without ongoing encouragement, interest, and enthusiasm, I could not have completed this thesis

Sincere thanks to the Faculty of Public Health, Khon Kaen University for granting the scholarship that makes my study here feasible and convenient

I would also like to give my special thanks to Associated Professor Dr Kanokwan Sanchaisuriya, and all the professors and lecturers in the Department of Nutrition for providing me valuable knowledge and experience during my study

I would also like to express my extremely grateful to Assistant Professor Woralap Sangvatanachai, who always supported and helped me with English writing skills, without your help, it would be very difficult for me to complete this thesis

Sincere thanks also to Thai friends for helping me during difficult times, cheering me up and for all supports they provided

Also great appreciation to my lecturers and my colleagues at the Faculty of Public Health, Thai Nguyen University of Medicine and Pharmacy for their suggestions and encouragement throughout my course of study

Lastly, my deepest love and special thanks to my wonderful family for their love, endless support, and encouragement during my candidature

TABLE OF CONTENTS

Page

2.5 Factors effecting nutritional status among university students 22

TABLE OF CONTENTS (Cont.)

Table 3 Summary of studies about prevalence and socio-economic

factors of nutritional status

25

Table 5 Eating habits among ethnic minority students 42 Table 6 Self-perceived weight status among ethnic minority students 44 Table 7 Doing exercise among ethnic minority students 45 Table 8 Anthropometric data of ethnic minority students according to

Table 11 Average nutrients intake and percentage of Vietnamese

Recommended Dietary Allowances among students by

Table 13 Multinomial logistic regression analysis of factors associated

with nutritional status

57

Figure 3 Percentage of underweight in ethnic minorities children

under five years old

15

Figure 4 Percentage of CED in Vietnamese adults by ethnicity 16 Figure 5 Percentage of overweight in Vietnamese adults by ethnicity 17

Figure 7 Distribution of macronutrient intake according to the total

energy intake

53

LIST OF ABBREVIATIONS

24 HRs 24 hours dietary recall

BMI Body mass index

CED Chronic energy deficient

CI Confident Interval

FAO Food and Agriculture Organization

FFQ Food frequent questionnaire

RDA Recommended dietary allowance

TUMP Thai Nguyen University of Medicine and Pharmacy

WHO World Health Organization

CHAPTER I INTRODUCTION

1.1 Background

Nutritional status is a principal determinant of health Assessment of nutritional status, dietary intake, and related factors are worldwide paid attention Although recent studies reported that nutritional status has improved remarkably in past decades, the rates of underweight and overweight remain high and affect human health, particularly in developing countries [1-4]

Vietnam is a low-to-middle-income country, with 54 ethnic groups of inhabitants, of which Kinh ethnic group accounts for the majority and fifty-three are ethnic minorities accounting for 14% of the nationwide population Most of the ethnic minorities reside in mountainous areas, covering three-fourths of the country’s territory Each ethnic group has its own cultural identity; and the cultural and consumption behaviors, health culture, and beliefs may positively or negatively affect the healthcare, health of mothers and children in particular [5-7]

Up to now, nutritional status is a major public health issue that deserves attention in Vietnam The proportion of underweight is still high while the percentage

of overweight and obesity demonstrates a sharply growing trend This makes Vietnam facing a double burden of malnutrition The situation leads to the changing of patterns

of morbidity and mortality [8-10]

Studies in a variety of groups about nutritional status in Vietnam have indicated that the high underweight rate abides Furthermore, malnutrition is distributed unevenly; northern and mountain areas have the higher level of malnutrition than the other regions Prevalence of malnutrition in rural communities is greater than urban areas, and malnutrition percentage of ethnic minorities is higher than ethnic majority group [10, 11] The National Nutrition Survey 2010 showed that malnutrition rate of children was highest in the mountains, i.e., 35.2% in central highlands, 33.7% in northern midland and mountain areas, 31.4% in the north central area and central coastal zone [11] A recent study conducted among adults in a northern mountain

likewise assumed that the high percentage of the chronic energy deficient (CED) was 31.7% [12] Another research study in the south of Vietnam also contributed a similar prevalence of 35% [13] Simultaneously, the proportion of overweight and obesity has dramatically increased in both children and adults The rate of overweight for children under 5-year-old and adolescents were 5.6% and 17.8%, respectively [11, 14] Between 2002 and 2015, the percentage of overweight and obesity increased among adults, ranging from 5.2 % to 15.6% [10, 11, 13, 15-17]

In general, overweight/obesity and underweight severely affect the health and quality of human life, increase the risk of developing infections, reduce the ability to work, prolong hospitalization, and augment the risk of illness and death Thus, creating an ideal body weight or the “should be” weight is something everyone should observe Nevertheless, changes in lifestyle (ex eating habits, sedentary lifestyle, physical inactivity, etc.) are keeping pace with economic growth and social [18] Besides, due to the growing emphasis on convenience, the consumption of ready-to-eat foods and fast foods tends to replace traditional meals and becomes increasingly popular, especially in young people [19]

Undergraduates, as adult people, are valuable intellectual human resources in the future, especially in a developing country When students start entering university doors, a lot of changes will occur in their life, including academic environment, relationships and eating habits [20, 21] From the family environment, students will switch to an independent living environment They depend on self-regulation when facing problems of expenditure and need to take care of themselves For the young generation, results of living arrangement undesirably alter their food consumption patterns in terms of variety, nutrient composition and timing of food intake Based on substantial evidence that look at the eating patterns in young population, especially university students, the food consumption patterns and nutrients intake appear to be undesirable, namely they tend to skip meals frequently [22-25], eat limited food variety [26, 27], habitually take unhealthy foods [26, 28] and adopt unhealthy eating practices [29, 30], etc If they fail to control these problems, the nutritional status, and their health will be significantly affected, together with diminished ability to acquire innovative ideas [31, 32]

However, to date, limited studies have determined nutritional status among university students in Vietnam, especially medical students who have to spend a lot of time to study in the amphitheater and practice long hours including nights and weekends in hospitals and communities; so their eating habit may not be sufficiently healthy

Thai Nguyen University of Medicine and Pharmacy (TUMP) is in the Northeast

of Vietnam and plays a key role in producing medical doctors for the mountainous provinces of Vietnam TUMP has approximate five thousand students, of which more than a third are ethnic minority students They come from different areas of the northeastern region where many studies showed that the rate of malnutrition is still high [33-35] Moreover, no study conducted about the nutritional status of medical students as well as separate groups of an ethnic minority in Vietnam Hence, the better understanding of nutritional status among ethnic minority students and identifying the association between food consumption patterns and nutritional status are required This study is believed to be the first survey in nutritional status of ethnic minority students in the northern mountainous area in Vietnam The results would provide basic knowledge of nutritional status among this group as well as young adults This evidence would contribute to the development of the strategy to prevent nutrition problems

 To describe the eating habit among ethnic minority students at Thai Nguyen University of Medicine and Pharmacy, Vietnam

 To investigate factors associated with nutritional status among ethnic minority students at Thai Nguyen University of Medicine and Pharmacy, Vietnam

1.6 Definition of terms

Malnutrition Malnutrition is a general term indicating an excess, deficit, or

imbalance in one or more of the essential nutrients Malnutrition

is frequently classified as either underweight or overweight individual, indicating either inadequate or excessive caloric intake [36]

Eating habits Eating habits are defined as what and how people eat, their

selection of food

Nutritional status Nutritional status of each individual is the result of supply,

absorption of nutrients fromdiet and nutrients used in the body Nutritional status is classified as either underweight, normal weight, overweight or obesity based on the body mass index

Health status The level of health (good or poor) of the individual, group, or

population as subjectively assessed by the individual or by more objective measures

CHAPTER II LITERATURE REVIEW

This study aims to investigate nutritional status among ethnic minority students

at Thai Nguyen University of Medicine and Pharmacy, Vietnam Literature related to these subjects was reviewed This chapter is separated into six parts to review: 1) overview of nutritional status in the world, 2) overview of nutritional status in Vietnam, 3) overview of ethnic groups in Vietnam, 4) nutritional status assessment tools, 5) factors affecting nutritional status, and 6) conceptual framework

2.1 Overview of nutritional status in the world

Nutritional status of each individual is the result of supply, absorption of nutrients from diet and nutrients used in the body Quantity and type of foods needed

to meet nutrient requirements vary for each person, depending on age, sex, physiological status, level of physical activities and mental health A good nutritional status reflects the balance of energy and nutrients from the dietary intake and energy expenditure to the need to use the body’s nutrients Energy balance results when the number of kilocalories (kcals) consumed equals the number used for energy The body weight is an index of this relationship of intake to output Thus, an imbalance (deficiency or redundancy) between energy intake and energy expenditure will lead to underweight (or CED) or overweight and obesity [36]

In the last decade, as a result of economic growth, urbanization and globalization, the change of global nutrition landscape have, without doubt, impacted

on the eating habits and the health of many societies around the world

According to the WHO, today a variety of countries face a double burden of malnutrition, especially in developing countries There were nearly a half million adults people all over the world considered to be underweight, at the same time, more than 1.9 billion people were overweight, and approximately 600 million were obesity

in 2015 Both underweight and overweight has significant threats to human health [37]

Health is factor that directly affects learning ability, creativity, evolution and future of people life, in particular the young population Undergraduate students, ages are in the third decade of life It is considered as future generations, not only contributes to the development of economy, society of nations but also the most crucial role for education about positive healthy lifestyles and health guarantee

Malnutrition in young people may increase the health risk in adulthood This is a real

potential threat in the future

Around the world, there is substantial evidence of problems about the nutritional status of university students, and some examples are presented in Table 1

As is illustrated by the Table 1, studies reveal nearly a quarter of underweight students or overweight students of the whole university students Generally, the rate

of being underweight in Asian students tends to be higher when compared with students in other European and American countries Supa Pengpid (2015) assessed the nutritional status of 860 Thai students in the age range of 18 to 25, the results of which indicated that there was a high rate of chronic energy deficiency (21.5%), overweight and obese (20.8%) [38] In particular, the rate of chronic energy deficiency of students from Pakistan was 41.4%, which was significantly higher than the group of students from Malaysia (27%) and China (27.5%) [39-41]

A cross-sectional study of 557 Canadian undergraduate students reported that only 8% of samples were underweight, and nearly 27% of the participants were overweight and 8% were obese Most of the samples had unhealthy eating patterns The majority of overweight students were reported to eat more pork, lamb, veal, fish and all meats (p < 0.05) Of the remaining students, the percentages of samples consuming fewer fruits, or vegetables were 33% and 9%, respectively Just as important, 14.9% of the respondents reported being on a diet Almost a quarter of students reported smoking, and more than one-third of samples reported drinking alcohol [26]

Another cross-sectional study in Greece also contributed a similar prevalence of overweight and obesity in undergraduate students Of the male sample’s population, there was 32.1% overweight, 5.9% obese and only 0.5% underweight For female participants, there was 8.4% overweight, 1.5% obese and more than five percent underweight The results of this study indicated that students had the habit of

unhealthy nutrition such as not regularly consuming vegetable, eating more fast foods and fried foods, plus less physical activity Less than half of males and females consumed fried foods More than one-third of male students and almost a quarter of female students reported eating fast foods more than three times per week [42]

A study was conducted among 200 Malaysian students which showed that 20.9% and 10% of female participants were underweight and overweight, respectively, while 16.7% and 17.8% of male counterparts were underweight and overweight, respectively More than half of total students skipped breakfast Compared with recommended demand, the majority of the samples did not meet the requirement for energy as well as calcium and iron (female only) intake The consumption of fruit and vegetable was low, only 18% and 42% of students ate fruit and vegetable daily 33.3% of male students and 29.1% of female students reported eating fast foods one to four times per week [25]

(year, country) Study design Sample size Results Ref

SuPa Pengpid et al

(2015, Thailand) A cross-sectional survey 860 university students

- 21.5% of participants were underweight

- 20.8% of participants were overweight and 13% obese [38]

Xiaohua Ren et al

(2015, China) A cross-sectional survey 2617 university students

- For male participants: 14.2% underweight, 11.5% overweight, and 2.5 obesity

- For female participants: 27.5% underweight, 2.4% overweight, 0.3% obesity

[39]

Akhtar Amin Memon

et al (2012, Pakistan) A cross-sectional survey 435 medical students

- 9% of samples were severely underweight

- 41.4% of samples were underweight

- 7.6% of samples were overweight

[40]

Nurul Huda and et al

(2010, Malaysia) A cross-sectional survey 624 university students

- 27% of all the samples were underweight

- 12% of all the samples were overweight or more [41] Ardith Brunt and et al

(2008, Canada) A cross-sectional survey 557 university students

- 8% of the participants were underweight

- Approximately 27% of the participants were overweight and 8% was obese

[26]

Michael Chourdakis

and et al

(2010, Greece)

A cross-sectional survey 408 medical students

- 32.1%, 5.9%, and 0.5% of male participants were overweight, obese, and underweight, respectively

- 8.4%, 1.5% and 5.4% of female participants were overweight, obese, and underweight, respectively

[42]

The high rate of underweight and overweight leads to the severe consequences

Underweight Underweight affects the health of each individual and the whole

social community Especially, for working-age adults, improvement of their

nutritional status will contribute to the reduction of health care cost and increases in labor productivity and thus contribute to social and economic development

Underweight will leave in the short - and long-term consequences on health, namely:

The link between underweight and ill health are well established Underweight

is considered one of the leading global reasons for the burden of disease in the world [3] As a result of underweight, many children may suffer from health problems, for instance, increased rate or severity of infectious diseases (measles, malaria, pneumonia), diarrhea, anemia, especially in early childhood [43-45] Among women

of reproductive age, nutritional status essential implications for not only women’s health, including osteoporosis, chronic fatigue, and fertility impairment, but also negatively influence pregnancy and infant outcomes, including increased risk of developmental disabilities in infants, low birth weight, and complicated delivery [46]

Overweight/ obesity As the economy is growing, the more people's lives are

attention, the higher amount of food is supplied It helps to increase overweight and obesity rate in children as well as adults

Overweight and obesity are associated with some diet-related severe chronic disease such as coronary heart diseases, hypertension, diabetes, gallstones, stroke and some kinds of cancer [46-49] Overweight/obesity in childhood may also cause detrimental effects on adults at the onset of the non-communicable diseases [3] Weight gain and loss are associated with blood pressure The study results showed that every one-kilogram decrease would reduce 1.0-1.2 mmHg in systolic blood pressure and 0.8 to 1.0 mmHg in diastolic blood pressure [50-52] Conversely, hypertension prevalence increased linearly with each unit of BMI increase [53] Outcomes of the study done by P Chhabra et al to determine the association between nutritional status and blood pressure of medical students in Dehli showed that 13.4%

of samples were underweight and 11.7% of samples were overweight This study also found that the prevalence of grade I hypertension in participants was 7.16%, and the overweight students were more likely to have hypertension than normal weight students (p < 0.05) [54]

Underweight or overweight/ obesity is causing the impact on economics and society Direct consequences are the costs for the treatment of diseases and related diseases Indirect consequence is the reduction in production capacity due to diseased original from obesity, underweight such as anemia, hypertension, diabetes Therefore, the prevention of underweight, overweight/ obesity, and maintaining the ideal body weight is essential at any age to keep a healthy health

2.2 Overview of nutritional status in Vietnam

Vietnam is going into the second decade of the twenty-first century with many changes and variations The rapid industrial development, as well as economic growth

in Vietnam, has improved the living standard and life expectancy The shift from a traditional agrarian economy to an industrial one brings about changes in lifestyle and improves the health status along with the nutrition of the people significantly In recent years, numerous studies of the nutritional status and feeding habits of infants, children, adolescents and elderly in Vietnam have highlighted those mentioned above Among children under five years old, the prevalence of underweight has been generally and remarkably improved Vietnam has achieved the reduction of underweight prevalence as compared to the Millennium Development Goals (MDG), with a national average of 1.5% per year, from 30.1% in 2000 to 22.9% in 2005 and 17.5% in 2010 [11] Figure 1 presents underweight percentages among children under five-year-old by years

Figure 1 Underweight percentage among children under five-year-old by years

Source: National Institute of Nutrition, Ministry of Health (2012) Summary

Report General Nutrition Survey 2009-2010 Hanoi:NIN [11]

However, the percentage of underweight still prevails more than overweight The result of Vietnamese National Nutrition Survey from 2001 to 2010 exhibited three times as high the percentage of underweight people as that of overweight children (with 17.5% and 5.6%, respectively) The rate of child malnutrition remains

at a high level, with regional disparity Notably, there were twelve in sixty-four provinces with more than one-third of stunting percentage, mostly in three regions: Central Highlands, Central Coastal, and Northern Midland and Mountain areas [11] The prevalence of stunting by eco-regions is shown in Figure 2

Figure 2 Stunting prevalence among children under five-year-old by

In contrast, the overweight and obesity prevalence has been dramatically increased, more than double in the period from 1992 to 2010 (from 2.0% to 5.6%) [11, 55] Substantial increases were found in urban and rural areas The highest prevalence of overweight and obesity was people with age range from 55 to 59 years old (for male was 7.8% and for female 10.9%, respectively) [11] People in urban areas tend to be overweight or obese as compared to those in rural communes The findings of a study of 1713 participants age ≥ 35 years in the south of Vietnam indicated that urban residents have a higher percentage of overweight than their urban counterparts (69% for urban versus 15.5% in rural communes, p<0.05) [16]

A recent survey on the nutritional status of 244 female university students in capital Vietnam stated that the overall percentage of underweight was extremely high,

or 45.3% On the other hand, the percentage of overweight was quite low, 1.5% [56]

No study observed nutritional status among separate groups of ethnic minority people

2.3 Overview of ethnic groups in Vietnam

Vietnam is a multi-ethnic country with fifty-four distinct groups, of which Kinh ethnic group accounts for the majority and fifty-three are ethnic minorities, each with its own language, lifestyle, and cultural heritage The largest ethnic groups consist of 85.7% Kinh (Viet), 1.9% Tay, 1.8% Thai, 1.5% Muong, 1.5% Khmer, 1.2% Hmong, 1.1% Nung, 1.0% Hoa, 0.9% Dao, 3.4% others (2009 census) [7] Moreover, 53 different ethnic minority groups inhabiting in Vietnam can divide into eight different groups according to the Vietnamese language as follows: Muong group with four ethnicities, Tay-Thai group with 8 ethnicities, Mon-Khmer group with 21 ethnicities, Mong-Dao group with 3 ethnicities, Kadai group with 4 ethnicities, Malayo - Polynesian group with 5 ethnicities, Han group with 3 ethnicities, and Tibeto - Burman group with 6 ethnicities [57] The Kinh people mainly concentrate in the Red River delta, the central coastal delta, the Mekong delta and major cities Most of ethnic minorities reside in the high mountains or extremely remote areas, with difficult terrain, where public services and basic infrastructure lag behind [7, 58] Nutritional customs are lifestyle habits in a social life, in production and daily activities recognized and followed by everyone Each ethnic group living in different natural conditions has formed differences in terms of the way to make a living, their

eating styles and food processing method and meal preparation Each region of Vietnam has different food dishes that have distinct methods that are identities of each ethnic group Cooking custom and eating habits of each ethnic group also certainly affect the quality of meals, health of family members, especially children There are customs beneficial for health and nutrition for women and children as babies with early breastfeeding extended the nursing period and breastfeeding by mothers However, in some ethnic groups, there are habits to feed supplement for infants and to stop early breastfeeding [34, 59] Furthermore, the feature of abstinence in the daily diets of ethnic groups in mountainous areas is still quite popular to occur with focus

on nutrient-rich foods

As an example, the largest ethnic minority is Tay ethnic people [7] People inhabit the area mainly in the north-eastern part of northern Vietnam Main agricultural product of Tay group is the ordinary rice Thus, the ordinary rice is a major component of their daily meals, in addition to the food derived from animals such as fish, meat with a certain rate Their usual meals structure per day includes two main meals and two or three sub-meals Food types for their daily meals are mainly bamboo shoot, vegetables, and beans The fresh foods rich in protein such as fish, meat, eggs, crabs, snails, etc account for a low rate and are used irregularly The origins of foods Dao, Nung, and Hmong ethnic groups are mainly corn, rice and some other animal source foods with very the modest rate Corn is ground into flour to make a thick soup Foods are fried, stir-fried, or well-cooked, but seldom boiled Many Nung people don’t eat water buffalo or beef The Hmongs usually eat two meals per day, but during harvesting time, they increase to three meals per day There are traditional dishes in a daily meal, like steam corn flour or rice, fried vegetables, and soups A more common feature of the ethnic minorities is often excessive drinking In the happy days, sad days, festivals and also normal days, they often drink [60, 61] Due to drinking a lot of alcohol, many families have to use up to one-third of grain crops for cooking wine or buying alcohol; this is also a feature contributing to impact directly or indirectly to the loss of food security of their families Generally, for the patterns of food consumption, the ethnic minority groups do not only consume less energy-rich food but also eat less food rich in starch [62]

It is particularly worth to concern about nutritional habits There are habits

causing the adverse effect on the nutritional status of people in general, for mothers and children of ethnic minorities in particular They have become a lifestyle of social life in mountainous areas Indicators of morbidity, mortality, and malnutrition in the ethnic minorities communities are still higher than the national indexes [7, 11, 63-65]

As high as 20% of children under five years of age, some ethnic communities are underweight, as compared with the national average of 17.5% The highest underweight frequency was found amongst Hmong (33.9%) [11] Figure 3 gives information about a large variation in the underweight rate by ethnic groups in Vietnam

Figure 3 Percentage of underweight in ethnic minorities children under five years old

Source: National Institute of Nutrition, Ministry of Health (2012) Summary Report

General Nutrition Survey 2009-2010 Hanoi:NIN [11]

For adult population, the CED prevalence among ethnic groups is presented in Figure 4 The frequency of CED among Kinh people is slightly higher than that in Nung and Kho-me population, at 17.6% and 17.1%, respectively The smallest CED rate is Hmong adults [11]

Figure 4 Percentage of CED in Vietnamese adults by ethnicity

Source: National Institute of Nutrition, Ministry of Health (2012) Summary Report

General Nutrition Survey 2009-2010 Hanoi: NIN [11]

There was a small variation in the percentage of overweight in adults over 19 years old by ethnic groups The lowest rate was amongst the Muong (1.2%), then Thai (1.4%), Dao (2.2%), Tay (3%), Nung (5.3%), Hmong (5.4%), Kho-me (5.6%) The overweight prevalence of Kinh, the ethnic majority, is higher than the ethnic minority groups with the overweight rate among adults of 5.9% [11] Figure 5 reveals the overweight rate among adults by ethnicity

Figure 5 Percentage of overweight in Vietnamese adults by ethnicity

Source: National Institute of Nutrition, Ministry of Health (2012) Summary Report

General Nutrition Survey 2009-2010 Hanoi: NIN [11]

Many risk factors for diseases are also mentioned by multiple authors such as economic, cultural and social factors, and a number of other factors [11] However, a few studies are mentioning about nutritional habits of ethnic minority people, and it is necessary to have in-depth studies on this issue

2.4 Nutritional status assessment tools

Nutritional status assessment is the process of gathering and analysis of data information about the nutritional status, uses a number of quantitative methods in evaluating nutritional status, such as anthropometry, survey rations, food consumption pattern, physical examination/clinical signs and biochemical assessment/ laboratory

tests Indexes on weight, height, waist-to-hip ratio and skinfold thickness are usually

applied in the assessment So anthropometric methods are commonly used in most basic surveys

2.4.1 Anthropometry

Anthropometry is the most useful method to assess the nutritional status of

individuals at the population level The aim of nutritional anthropometry is to measure changes in body sizes and structure under age and nutritional status Anthropometry is also the most widely used tool and it has more advantages compared to other indicators Advantages of the anthropometric method are simple and safe, can survey large samples with equipment inexpensive, easy to transport, and can exploit and evaluate signs of nutritional status in the past and determine malnourished level [66, 67]

Anthropometry commonly used to assess the nutritional status of adults by acting as a screening device to identify individuals at risk of obesity and undernutrition For this purpose, a body mass index is used together with other measurements to describe overall body composition and fat distribution The most common used anthropometric measurements are discussed in the following

2.4.1.1 Body Mass Index (BMI)

BMI is recommended by the World Health Organization (WHO) and Food and Agriculture Organization of the United Nations (FAO) to assess the nutritional status

in adults According to the definition, BMI is calculated by dividing weight in kilograms (kg) by height in meters (m2) squared

BMI indicates the nutritional status balance between weight and height, the weight-adjusted index, and the body shape and reflects the state of fat storage in the body High BMI means high fat reserves and low BMI means less fat reserves Therefore, BMI is an index to assess obesity and malnutrition caused by chronic energy deficiency [68] The primary classification of underweight (or CED), overweight and obesity is based on the particular BMI values, shown in Table 2 Underweight or CED is defined as BMI under 18.5 kg per m2 This indicates that person who has BMI < 18.5 kg/m2 is suffering from malnutrition or other health problems Adult overweight is defined as BMI at or above 25 kg/m2 and obesity is defined as BMI equal or more than 30 kg/m2 [69]

Table 2 Classification of nutritional status in adults according to BMI kg/m2

as a suitable indicator of additional risk within a given range of BMI As a general rule, risk of central obesity-related health problems increases for women with a waist circumference greater than 88 centimeters and for men greater than 102 centimeters

To modify health risks for Asians, the cut-off points should be modified to 80 centimeters in Asian women and 90 centimeters in Asian men [72] Smoking, high alcohol intake, and menopause tend to increase abdominal fat, and exercise tends to decrease it

2.4.2 Dietary assessments

Dietary measurement methods are used indirectly to determine the nutritional status A detailed record of current food consumption and a history of changes in eating habits over time are needed to assess diet adequacy The evaluation should detect persons who avoid certain food groups, adhere to unusual dietary practices, or consume excessive or insufficient amounts of essential nutrients The adequacy of fluid intake should be assessed as well Dietary measurement techniques can be

categorized as daily food consumption methods (24-hour recall) or average food consumption methods (food frequency questionnaire) [73]

2.4.2.1 Twenty-four hours dietary recall

The 24-hour recall method is one of the most widely used diet assessment methods In this method, subjects are asked by a trained interviewer to remember (to recall) all the foods and drinks they consumed in the past twenty-four hours or the previous day In most instances, the time period is the previous 24 hours, however, in some special cases, the time period is the previous 48 hours, the past 7 days, or in rare instances, even the preceding month [74, 75] Nevertheless, memories of intake may fade rather quickly beyond the most recent day or two, so that loss in accuracy may exceed gain in representativeness [76]

In addition to recording responses, the interviewer helps the respondent remember all that was consumed during the period in question and assists the respondent in estimating portion sizes of food consumed A common technique of the 24-hour recall is to begin by asking what respondent first ate or drank on the last awakening The recall proceeds from the morning of the present day to the current moment The interviewer then begins at the point exactly 24 hours in the past and works forwards to the time of awakening Some researchers asked respondents to recall their diet from midnight to midnight of the previous day Asking the respondent about his or her activities during the day and inquiring how they might have been associated with eating or drinking can help in recalling food intake An inquiry into the previous evening’s activities, for instance, will stimulate the respondent’s memory and may help him or her recall the snack eaten while watching a favorite television program [73]

After the interview, the recall is checked for omissions or mistakes A respondent may have to be contacted later by telephone or mail to clarify an entry or

to obtain information such as brand names, preparation methods, and serving sizes The recall can then be analyzed using a computerized diet analysis program Most programs allow research staff to enter the name of the food into the computer and then select the appropriate method of preparation, serving size, and number of servings from a list of choices displayed on the computer screen In some instances, however, each food may have to be coded using a unique number or food code that

identifies each food [73]

2.4.2.2 Food frequency questionnaire

The purpose of the food frequency questionnaire to assess the frequency with which food items or food groups are consumed during a specified time period, from day to day or from season to season It was originally designed to provide descriptive qualitative information about usual food consumption patterns [77] With the addition

of portion-size estimates and the introduction of improved computerized administered questionnaires, the method has become semi-quantitative, allowing the derivation of energy and selected nutrient intakes [78, 79]

self-The number of food items on the questionnaire depends on the purpose of the study In general, it varies between 75 and 150 food items Respondents indicate how many times a day, week, month, or year that they usually consume the foods [73] The advantage of a food frequency questionnaire includes a high response rate and low subjects’ burden This method is also speedy, relatively It can be administered by non-professionals or can be self-administered and generated standardized results It is useful in examining possible associations of the use of a particular food and certain disease, as it also allows investigators to rank people according to their intake of a particular food However, estimating intake of staple foods or foods that are consumed in large quantities is easier than estimating food that

is eaten infrequently or in small quantities This method is appropriate when the term diet is assessed but is inappropriate when a precise measurement of short-term food consumption is required [73]

long-Generally, dietary data survey showed that most noteworthy food consumption situation tends to change in many countries around the world including both quantitative and qualitative data In developed countries, consumption of cereal and vegetable is reducing gradually; however, the amount of meat, fat (mostly from animal sources), and fast foods is increasing General features of diets in poor countries consist of deficiency of energy, monotonous foods, mostly based on the type

of food crop products When economic development and increased income, the general trend is the rapid increase of animal-derived food, especially meat, fat, refined glucose sources (sugar, pastries) and reduction of the use of food crop products, potato, tubers and high-fiber foods [80]

In Vietnam, the National Nutrition Survey 2010 using the dietary intake interview showed that average consumption of total energy and dietary composition has changed Consumption of rice and other staple foods has decreased, with mean rice consumption reduced from 397.3 gram per capita per day in 2000 to 373.2 gram/capita/day in 2010 Over the ten years, the average consumption of protein steeply increased from 62 gram/capita/day to 74.3 gram/capital/day in 2010 Average consumption of lipid increased markedly from 1.6 gram per day in 1990 to 8 gram per day in 2010 However, the amount of vegetable consumption decreased from 214 gram per day to 190 gram per day in 2010 The ratio of energy from protein: lipid: glucose in 1985 was 11.2: 6.2: 82.6, while this ratio in 2010 was 15.9: 17.8: 66.3 [11] This proportion showed that dietary consumption in Vietnam has improved remarkably

2.5 Factors effecting nutritional status among university students

The process of growing up with the development of body sizes of anthropometry in a certain population has proved to be inconstant, change from time

to time, be influenced by several factors Some researchers discussed this issue at the beginning of the 19th century, and so far, most authors have agreed that the growth of the body is influenced by genetic and external environmental factors, especially nutrient and disease factors [81, 82] In addition, other factors have the indirect influence due to their impact on the nutritional status and health Those factors include:

2.5.1 Socio-demographic status

Nutritional status is considered as a mirror image of the living conditions Malnutrition is a sign of poverty, nutrient deficiency; when living conditions are better, nutritional status is improved Many social and economic factors that affect nutritional status have been known as the income of people, social class, geographic areas of residence Table 3 shows more detail about summary of studies about prevalence and socio-economic factors of nutritional status

Age Several studies have reported on change BMI among different age BMI

score was substantially higher among older adult than younger ones [29, 83, 84] Tahereh Mokhtari et al (2015) mentioned that some socio-demographic factors have

a positive correlation with nutritional status among university students Their study surveyed among 311 university students in Malaysia The data showed that BMI has been strongly associated with age BMI values in older students group were higher than that in younger students (r = 0.19, p = 0.001) [29]

The evaluation of 3962 respondents at New Mexico State University also supported that the percentage of overweight considerably rose with age (more than 3kg/m2,p < 0.001) The odds of increased BMI were 2.63 times (95%CI: 2.47-3.66) higher among the age group over 35 when compared with age group under 35 [83]

Gender Many studies found that gender has an identified relation with

nutritional status [29, 83-86] For example, the examination of medical students in Romania showed that statistically significant differences between male and female regarding the BMI, with 24.41 ± 4.28 for male versus 19.61 ± 2.21 for female, p < 0.0001 [85] In 2014, Pablo Vera-Villarroel et al published a paper, in which they also described the relationship between gender and nutritional status Among 3311 Chilean university students with an age range of 17-24 years, the frequency of underweight, overweight, and obesity in samples was 3.3%, 16.7%, and 2.1%, respectively The data of this study emphasized that the overweight male rate was twice times higher than that in female (24.5% versus 11.6%) Similarly, the underweight prevalence among female was higher than male (p = 0.001) [84]

Income El Rhazi studied in Morcco (2011) indicated that BMI of people with

income above 45 € per month was 2.62 times higher than that of those with income below 180 € per month [87, 88] Similar finding was seen in previous studies as well

A study on Bangladesh students also showed that positive monthly expenditure is a risk factor for being overweight The students with average monthly household income more than 60000 takas (approximately 750$) were more likely to be overweight (χ2 = 4.32, p = 0.038) [88] Using Asian reference, from BMI data, Vietnamese women in the wealthiest group are also more substantially overweight and lower underweight [11]

Furthermore, economic situation of students also affects the consumption of foods and skipping meals Living with family, students do not need to care about buying food for meals, however, when starting independent life, low-income students could be affected to buy food A quarter of students reported that they inadequate

resources to buy foods, their income per month did not allow them to eat what they wanted [89, 90] Generally, the economic situation of households and pocket money

per month of students can affect the students’ nutritional status

Residence The increase of BMI and height is likewise related to living

geography A study was conducted among 31,324 youths in the south central area of China which showed that both genders aged 15-18 years from urban areas had significantly greater BMI and taller than youths from rural areas (p<0.001) [91] The survey results through Vietnam also showed that the mean height values of adults in the urban areas were generally higher than those in rural areas, as well as those from households with higher living conditions Moreover, the rate of CED in rural areas was higher than that in cities and at the same time, overweight and obesity was lower rate (p<0.05) [11, 12]

Student’s accommodation A variety of evidence indicated that student’s

accommodation during their university periods associated with forming new harmful eating habits after switching from habitat with their family to live independently Undergraduate students not living with parents regularly consume unhealthy foods such as fast foods, oily foods, sweet and salty foods, and eating small amounts of vegetables and fruits [28, 31] Skipping meals also tend to occur more frequently in students living away from home [92]

Students living without their family or living alone tend to consumed alcohol less than students living with roommates or somewhere with a high density of students [93]

Because of the differences mentioned above that the percentage of students with CED, overweight, obesity of the group of students living in dormitories and students living with family is not the same Even some researchers showed that undergraduate students who live in dormitories have higher overweight/ obesity rate than students live with their family [26, 94]

(year, country) Study design Sample size Results Ref

Tehereh Mokhtari et al

(2015, Malaysia) A cross-sectional survey

311 undergraduate students

- The frequency of underweight, overweight, obesity was 8%, 25.1%, 3.9%, respectively

- Factors associated with nutritional status included:

Age, gender, income level of the respondents

[29]

Wilson S L., et al

(2012, Mexico) A cross-sectional survey 3962 participants

- The mean BMI of participants was 26.3 ± 6.18 kg/m2 The rate of overweight and obese in the sample was 47.2%

- Age, gender, ethnicity, residence are associated with BMI and BMI categories

[83]

Pablo Vera-Villarroel et al

(2014, Chile) A cross-sectional survey

3311 Chilean university students

- The overweight/obesity rate in male was higher than those in female

- Older students’ BMI scores were significantly higher than those who were at normal weight (p=0.001)

[84]

Alexandrina L

Dumitrescu and et al

(2011, Romania) A cross-sectional survey

150 first year medical students

- 21.3% and 11.3% participants were underweight and overweight, respectively

- Associated risk factors: Gender (with average BMI

in male was higher than that in female, p <0.0001)

[85]

between physical activity and nutritional status [29, 95, 96] Nowadays, the situation of energy redundancy of young people is not only due to excessive dietary rations, but also their lack of participation in physical activities, only enjoying recreational activities These causes lead to the elevated risk for overweight and obesity in this age group [97] To lose weight, physical activities should combine simultaneously with control of the daily diet

A cross-sectional study in India reported that before and after adjusting for other variables such as age, gender, the result showed that there was associated with each hour of moderate physical activity with a 0.095 kg/m2 and 0.085 kg/m2 decrease in BMI, respectively [98] Previous studies also demonstrated that more physical activity showed a tendency towards being significant factors for a low BMI and waist circumference [95, 96] According to the Physical Activity Guidelines for adults, to stay healthy, people should try to be active daily and should do

at least two hours and thirty minutes of moderate-intensity aerobic physical activity per week, or

at least 75 minutes of vigorous intensity activity per week or do combination of moderate and vigorous activity throughout the whole week [99] However, the percentage of inactive physical conditions among undergraduate students was relatively high, ranging from 27.2% to 62% who did not practice any kinds of sports [100, 101]

Many studies also found that the rate of overweight and obesity in people who regularly participate in sport and physical activity is low Moreover, women tend to be less physically active than men [102] A study focusing on undergraduate students in Malaysia gave the data of the difference in males’ and females’ activity levels The findings revealed that females take part

in less active than males On the other hand, male students do more vigorous physical activities than female counterparts (36% and 29.9%, respectively) In this study, the result showed negative association between physical activity and BMI [29]

Other scientific evidence has proved benefits of active lifestyles and enhancement of physical activities in the obese prevention Activities reduce weight gain of middle age Physical exercise impacts at average weight loss for overweight and obesity and weight loss of supplements with people with reduced energy diet Physical activities effectively reduce the belly fat and visceral fat A cross-sectional study in nine European countries, 405,819 individuals were recruited to discover the association between physical activity and BMI, waist circumference The results indicated that if moving from the lower physical activity level to

individuals who depend on the control diet alone

2.5.3 Perceived weight status

Self-perception of one’s own health status is an important predictor of life satisfaction among adult people, as well as undergraduate students Perception of weight is a real factor that reflects in weight control practices and determinant of health behavior of individual Significant discrepancy between self-perception weight status and medical classification of weight status among undergraduate students has been found Most students tend to overestimate their weight rather than underestimate [103, 104] A cross-sectional study in 368 Ghana students reported that only 4.9 percent of the entire samples were underweight, and 13 percent of the participants were overweight/ obesity However, there was a high proportion of participants misclassified their weight status Base on the BMI classification, nearly three-fifths of overweight students underestimated their weight status, 10.6 percent correctly identified their weight category 66.7 percent of underweight students overestimated their weight status and only 1.3 percent classified themselves correctly [103]

Iwona Wronka and colleagues published a paper, in which they also described the difference between self-evaluation and actual weight status among 1129 university students in Poland The results of this study indicated that participants had BMI less than 18.5 tended to consider their weight incorrectly more often than other groups 56.8% of underweight participants assessed their body weight incorrectly Among normal weight group and overweight group, only 24.7% and 22.8% of the eligible respondents incorrectly estimated These differences were statistically significant (p < 0.001) Across the entire sample, 71.9%, 24.2%, and 3.9% participant classified body mass accurately, overestimated and underestimated, respectively [104] If body weight is identified accurately, it will prevent a number of adverse health outcomes, such as depression symptoms, weight gain and so on

2.5.4 Food consumption patterns and eating habits

The rapid change of diet and lifestyle occurring with industrialization, urbanization, economic development and globalization of markets has increased in the past decade This has a significant impact on nutritional matters and health of the residential population, especially in developing countries and countries in the transitional period With improved living standards, available and diverse food and increasing access to services, there appeared the significantly

impact of various aspects of the food

Many studies on nutrition for undergraduate students were conducted and showed that the diets of students are often negative There are many factors responsible for these changes that may be due to stress, a sedentary lifestyle, or changes in food intake, eating patterns, and so on [105, 106] Investigation on diets as well as eating habits is essential parts of the research on nutrition survey Through the collection of data on food consumption and eating habits, conclusions can be drawn about the association between diets and health conditions

Findings from previous studies indicated that there was a statistically significant relationship between eating habits and nutritional status among university students The majority

of students reported only eating from one to two meals per day [100, 107] There were more than half of students skipping breakfast (ranging from 31.7% to 62%) [100, 108], about one-third of students consuming fast food at least once a week [100], more than a quarter of university students smoking daily [29, 107], and one in ten students drinking alcohol more one time per week [86, 107] The rate of CED of students eating fast food was lower than that of students not having it Nevertheless, the overweight and obesity rate of students skipping meal was nearly two times higher than that of students consuming meal regularly [109, 110] Additionally, there was a significant gender difference in eating habits Many studies conducted to discover the eating habits and nutritional status of undergraduate students showed that skipping meal tend to occur more frequently in males than females, especially skipping breakfast consumption In

2013, Juan Sun et al highlighted the rate of skipping breakfast among male medical students was sharply higher than in female counterparts, with 41.7% of male students and 23.5% of female students not eating breakfast, respectively [24] A cross-sectional study was undertaken in four Malaysian universities (2012) also showed that there was a higher rate in both genders who did not consume breakfast daily, 65.6% males skipped meal more than 52.8% in females [25] Several different eating habits were found in undergraduate students, and these habits can

be considered harmful to health and educational consequences, such as drinking alcohol and smoking tobacco Indeed, Matthias Wicki and colleagues reviewed sixty-five studies investigating the characteristics of alcohol-consuming in European university population [93] They concluded that alcohol consumption was popular among university students, with male students having greater tendency to consume alcohol when compared to female students More