Compliance with WHO's guidelines for multiple micronutrient powder fortification and Vietnam recommended dietary intakes to determine micronutrient levels of milk fortification and effec
Trang 1NATIONAL INSTITUTE OF NUTRITION
DETERMINING MICRONUTRIENT LEVELS
OF COMMON FOODS FORTIFICATION IN COMPLIANCE WITH WHO’S GUILDELINE FOR PRIMARY CHILDREN 7-10 YEARS AND
EFFECTIVENESS STYDY
Specialization: Nutrition
Mã số: 9720401
SUMARIZATION OF THE NUTRITION DISERTATION
HANOI - 2020
Trang 2THE DISSERTATION IS COMPLETED AT THE NATIONAL
INSTITUTE OF NUTRITION
Academic advisors:
1 Nguyen Xuan Hiep, PhD., Assoc Prof
2 Tran Thuy Nga, PhD., Assoc Prof
Reviewer 1:
Reviewer 2:
The dissertation will be defended at the Committee for the doctor of
philosophy degree at the National Institute of Nutrition at……….h,
date……… month…… year……
The dissertation is placed in:
- National Library
- Library of the National Institute of Nutrition
29
LISTS OF PUBLICATIONS RELATED TO THE DISSERTATION
1 Tran Khanh Van, Vu Thi Minh Thuc, Tran Thuy Nga, Nguyen Song Tu, Nguyen Tran Ngoc Tu (2018) Are there organoleptic differences
between micronutrients fortified pure natural milk and fortified reconstituted milk? Austin Journal of Nutrition and Food Sciences, 6(2);1103
2 Tran Khanh Van, Nguyen Xuan Hiep, Le Danh Tuyen, Tran Thuy Nga, Nguyen Song Tu, Nguyen Hong Truong and Nguyen Tran Ngoc Tu
(2020) Compliance with WHO's guidelines for multiple micronutrient powder fortification and Vietnam recommended dietary intakes to determine micronutrient levels of milk fortification and effectiveness study on school children aged 7-10 years Journal of Clinical Nutrition and Food Science 3(1); 10-20
3 Trần Khánh Vân, Trần Thúy Nga, Nguyễn Song Tú, Nguyễn Trần Ngọc
Tú (2020) Hiệu quả của sữa tăng cường vi chất dinh dưỡng đối với tình trạng hemoglobin và ferritin huyết thanh ở học sinh tiểu học sau 6 tháng can thiệp Tạp chí Y dược học Quân sự 45(6); 23-30
4 Trần Khánh Vân , Trần Thúy Nga , Nguyễn Song Tú (2020) Đặc
điểm khẩu phần ăn của học sinh tiểu học tại 5 xã huyện Phú Bình, tỉnh Thái Nguyên. Tạp chí Y học Việt Nam 1-2(492); 105-110
5 Tran Khanh Van , Nguyen Xuan Hiep , Tran Thuy Nga , Nguyen Song
Tu , Nguyen Tran Ngoc Tu (2020). Evaluation of micronutrients dietary intake and effectiveness of micronutrients fortified milk on serum zinc status of elementary children in 5 communes, Phu Binh, Thai Nguyen. Journal of Preventive Medicine. 30(4); 67-73
Trang 3- After 6 months: The serum vitamin A concentration in the two
intervention groups improved significantly compared to the control group
(p <0.05); The prevalence of sub-clinical VAD and the marginal VAD of
the 2 groups significantly decreased (p<0.01) compared to the control group
(group 1 decreased by 24.7%, group 3 decreased by 18.2% and control
group 12.3% reduction). The serum Hb concentration of the two
intervention groups improved significantly compared with the initial period
(p <0.01); Hb concentration after 6 months and difference of Hb after 6
months compared with before the intervention improved significantly
compared to the control group (p<0.01). Difference in median serum ferritin
concentration after 6 months compared with before intervention in the
MN-fortified fresh milk group (19.6µg/L) and the MN-fortified pasteurized milk
group (15.2 µg/L) significant improvement compared to the control group
(p<0.01). Difference in serum zinc concentration after 6 months compared
with before intervention in the group using fresh milk (0.65µmol/L) and the
group using pasteurized milk (0.75µmol/L) improved significant compared
to the control group (p<0.01).
RECOMMENDATIONS
1 Compositions and levels of micronutrients fortified in food (applied for
effectiveness study in milk) received good organoleptic characteristics,
effectively improves anthropometric, micronutrients and safety indicators
for elementary school students, so it should be widely applied throughout
the country.
2 For primary school students, use MN multi-fortified milk (21 vitamins
and minerals) with a dose of 2 boxes of 180 ml / day (7 days/1 week) for at
least 6 months; Long-term implementation is needed to help improve the
nutritional status and lack of MN of school-age students, especially in areas
with high rates of malnutrition children.
3 Compositions and levels of micronutrients which were formulated
micronutrients fortification can be applied for micronutrient fortification in
different types of common children food products, so it should be
popularized and widely applied.
1
INTRODUCTION
The nessecity of the dissertation
Micronutrient deficiency causes a triple burden to the nutrition, deeply affecting the physical and cognitive development as well as increase the morbidity and mortality Micronutrient deficiency, especially vitamin A, iron, zinc and iodine deficiencies still remain a public health problem in Vietnam.
School age (especially from 7 to 10) is a crucial period in which genetic potentials related to physical and mental strength can be fully developed, and is the period that needs necessary nutrients for the next stages of growth Micronutrient deficiency in this age often leaves consequences for children in both the near future and in the long run.
In order to improve the micronutrient deficiency status, helping to raise the Vietnamese stature, using micronutrient-fortified products is an important and sustainable intervention method, leading to the need to develop micronutrient-fortifying levels for the food.
There is a fact that researches into common micronutrient-fortifying products (including milk) and suitable formulas are still limited in numbers, and do not provide updates on school children’s needs and evaluation of the effectiveness of the products Therefore, it is necessary to do research on this topic.
Research objectives
1. Develop micronutrient-fortifying levels into milk for 7-10-year-olds
according to the guides provided by the World Health Organization in
2016
1.1 Determine the micronutrients and their quantity 1.2 Sensory evaluation of acceptability of micronutrient-fortified milk products in 7-10-year-olds
2. Evaluate the effectiveness of two types of micronutrient-fortified milk to the change of body weight, height, body mass index of students aged 7-10 years after 3 months and 6 months of intervention.
3. Evaluate the effectiveness of two types of micronutrient-fortified milk in improving the vitamin A status, anemia, zinc deficiency, of students aged
7-10 years after 3 months and 6 months of intervention.
Novelty contributions of the dissertation: For the first time in Vietnam,
the research has completed the compositions and levels of 21 different
Trang 42 micronutrients formulated for fortifying in common foods (applied for
effectiveness study in milk), used for school-age children, updating the
guidelines of the World Health Organization, taking screenings of
regulations and instructions of developed countries and other international
organizations The study also provides scientific evidence to prove the
effectiveness of using micronutrient-fortified milk follwing the
compositions and levels that has been formulated for the nutritional status
and micronutrients of school-age students, which is the basis for the
program to improve student nutrition status, raising the stature of
Vietnamese people
Layout of the dissertation:
This thesis is composed of 120 pages (excluding references and table),
in which: Introduction: 2 pages Research objectives and hypothesis: 1
page Literature review: 32 pages Subject and method of research: 30
pages Research results: 32 pages Discussion: 27 pages Conclusion: 2
pages Recommendation: 1 page
. The thesis includes 37 tables, 3 drawings, maps, charts and a total of
215 references, in which 22 are in Vietnamese and 193 are in English.
Chapter I . LITERATURE REVIEW
1 . 1 MICRONUTRIENT
1 . 1 . 1 . History of micronutrients
Micronutrients are essential compounds but with a very small amount
that helps the body produce enzymes, hormones and other fundamental
compounds required for growth and development; its deficiencies would
cause serious consequences to one’s health.
Among all micronutrients, vitamin A, iron, zinc, iodine are most
important, in which the lacking of them can cause global public health
problems Vitamin A, iron, zinc deficiencies is a major threat to the health,
physical and mental growth and development of children.
1 . 1 . 2 . School age characteristics and the role of nutrition towards this
age group
School age or childhood is a period from 7-10 years-old, an important
turning point in the development of each individual, and is the period of
maximum development of genetic potentials related to stature and intellect
During this period, nutrition is important for growth and development,
helping children keep up with the growth momentum, preventing
27 Micronutrients fortified milk improved nutritional status on weight, height and BMI
- After 3 months of intervention, the anthropometric index of the MN fortified fresh milk group increased by 0.75kg, the height increased by
1.57cm, the BMI increased by 0.1kg/m2 and the pasteurized milk group and fortifyd MN increased by 0.78kg, 1.68cm, and 0.1 kg/m2
, respectively; higher than that of the control group (p <0.001). The Z-Score weight/age, height/age and BMI/age index of the two intervention groups improved significantly compared to the control group (p<0.001). The rate of stunting malnutrition decreased from 14.5% to 12.9% in the group using MN-fortified fresh milk and 16.9% to 14.2% in the group using MN-fortified pasteurized milk (p<0.05) significant compared to the previous intervention.
- After 6 months, the anthropometric indicators of the MN-fortified fresh milk group increased by 1.81 kg, the height increased by 3.29cm, the BMI increased by 0.34kg/m2 and the pasteurized milk group increase
1.76kg; 3.38cm, and 0.3kg/m2, respectively, were significant compared to the control group (p <0.001). Z-Scores of weight/age, height/age and BMI/age
of the two intervention groups improved significantly compared to the control group (p<0.001). The stunting malnutrition rate decreased from
14.5% down to 12.9% in the group using fresh milk and decreased from
16.9% to 14.2% in the group using pasteurized milk (p <0.05), significant compared to before intervention.
3 . Effect of intervention on micronutrient status
Micronutrients fortified milk improved serum concentrations of vitamin
A, haemoglobin, iron and zinc:
- After 3 months: The serum vitamin A concentration and the difference
in serum vitamin A concentration compared with the initial of the two intervention groups improved significantly compared to the control group (p<0.05); The prevalence of sub-clinical VAD and the marginal VAD of the
2 groups significantly decreased (p<0.01) compared to the control group (the group using MN-fortified fresh milk decreased by 21.2%; the group using MN-fortified pasteurized milk decreased by 19.8% and control group decreased by 9.6%). The Hb concentration of the two intervention groups improved significantly compared with the initial period (p<0.01). Difference
in serum zinc concentration after 3 months compared with before intervention in the group using fresh milk (0.28 µmol/L) and the group using pasteurized milk (0.36 µmol/L) The treatment was significantly improved compared to the control group (p<001)
Trang 526 noted that the use of MN supplements significantly improved anemia when
the prevalence of anemia at the starting point of the intervention was high.
The improvement in Hb content in 2 intervention groups compared to
the control group was significant after 6 months of intervention.
Multivariate linear analysis predicting related factors also results in fortifyd
use of MN to improve Hb content in children after controlling gender
factors of children, age group and maternal education, family economic
status, maternal occupation, vitamin A deficiency of students (linear
regression, p<0.05).
4 . 4 . 5 . Effectiveness for prevalence of zinc deficiency
The average diet of Thai Nguyen elementary students meets about 55%
of daily zinc requirements. The use of MN fortified milk provided with 4.3
mg of zinc (corresponding to 26-46% of RDA) improved serum zinc levels.
Compared in each group, zinc content increased in the two intervention
groups (p<0.05), while in the control group, the level did not increase
(p>0.05). The difference in serum zinc concentration was significantly
different between the intervention group and control group in T3 and T6 ,
(p<0.05).
MN fortified milk improves the effectiveness of zinc levels, so it also
improves the rate of zinc deficiency in children. The rate of zinc deficiency
decreased significantly after 3 and 6 months (p<0.05) only in group 3. The
control group showed no reduction (even increased).
CONCLUSIONS
1. Compositions and levels of micronutrient formulated for food
fortification (applied for effectiveness study in milk) meets the level for
prevention of depletion of MN reserves of 21 different vitamins and
minerals and is safe. Multi-MN fortified milks have good organoleptic
characteristics of color, smell, taste, and taste, and 99.5% of children prefer
fortified milk.
2. Efficiency of using fortified micronutrients and sterilized fortified
milk for anthropometric indicators
Before the intervention, the nutritional status of students in 6
elementary schools in Phu Binh district: the rate of underweight
malnutrition is high: 24.3% (the severity is 3.5%); the stunting rate is 17.5%
(the severity is 1.8%) and the wasting rate is also quite high at 8.1%; The
rate of overweight and obesity is 3.3%. There is no difference in the
prevalence of malnutrition between boys and girls
3 malnutrition, overweight, obesity, developing intellectually, emotionally and strengthening immunint to infection.
1 . 1 . 3 . The micronutrient deficiency situation in school age children
1 . 1 . 3 . 1 . Globally
Malnutrition and micronutrient (MN) deficiency in school schildren is a public health problem Lacking multiple vitamins and minerals often happen and affects simutanously throughout children’s growth and development, causing them to run risks, such as catching infetious diseases (cholera, fever, etc.), affecting their physical development, awareness and academic achievement
Vitamin A deficiency greatly affects the body's growth and development, can cause night blindness and the disease associated with vitamin A deficiency According to UNICEF, about 750 million children suffer from nutritional anemia due to iron deficiency In developing countries, the rate of anemia in children is still very high: 53% in India, 37.9% in China, 45% in Indonesia Zinc deficiency in children causes long-term effects, associated with poor growth (growth retardation, rickets, malnutrition, growth retardation), reduced immunity and increased incidence of infectious diseases Zinc deficiency is currently common in developing countries A number of studies have found selenium deficiency, folate deficiency, vitamin B12, vitamin B1, B2, and B6 deficiency in school age children.
1 . 1 . 3 . 2 . In Vietnam
SEANUTS survey (2011) in 6 provinces have shown: at elementary-school children, the prevalence of sub-clinical vitamin A deficiency, marginal vitamin A deficiency, anemia, and depleted iron reserves in children are 7.7%, 48,9%, 11.8%, and 6% respectively Rate of children with low iron reserves is 28.8% There are few researches into the zinc deficiency situation in school children.
1 . 1 . 4 . Risk factors of the micronutrients deficiency in school children
- Inappropriate nutritional diet: is one of the main factors causing
nutritional disorders The diet of school children is imbalanced and does not meet RDA In low and middle-income countries, school meals are often poor in fruits, vegetables and animal foods, resulting in insufficient protein and micronutrients School-age diets often lack vitamins like vitamins A, B1, B2, B3, B12, folate, và β-caroten.
- Eating behavior and habits changes unreasonably: skipping meals,
replacing with light meals, fast food often has high content of iron, calcium, vitamin B12, vitamin A, very low fiber, eat less vegetables and fruits
Trang 6In Vietnam, school-age children's meals depend on family meals, lack
of nutrients and imbalance The mainfood is still rice, the amount of milk
consumed is limited, the amount of vegetables varies with the seasons; Ripe
fruits consumed daily for small meals The family meal only reaches about
84% of the energy needs; The source of animal protein at meals is low,
especially the fat in the countryside is very low SEANUTS survey data in
2011 showed that the diet of children from 6 to 11 years old reached about
76% of the recommended energy needs, MN has not reached the demand
1 . 2 . MICRONUTRIENTS FOOD FORTIFICATION
1 . 2 . 1 . History of food fortification
In 1990, the Child Summit identified food fortification as one of three
approaches to preventing micronutrient deficiency, with the aim of
preventing one or more micronutrient deficiency in the community or for a
group of special objects
1 . 2 . 3 . Effectiveness of fortified foods to micronutrient status
MN interact with each other in the body When the diet is poor and
monotonous, the body often lacks many types of MNs School-age children
are at greater risk of missing many types of MNs Multiple micronutrient
interventions of this age group benefit the status of micronutrients, health,
growth and development, more effectively than a single micronutrients.
1 . 2 . 5 . Method of micronutrient milk fortification
Milk is a widely used food that contains many nutrients that are easily
digested and absorbed by children However, the disadvantage is that the
milk content of VCDD is not high Increasing VCDD in milk helps
overcome this problem and can meet the nutritional needs of children,
especially school-age children There are two types of canned milk
currently used for school age children: fresh milk and reconstituted milk
This study aims to enhance VCDD in two types of milk to make
recommendations for school milk programs and for consumers.
* Limitations of studies of micronutrients fortified milk: focuses on
children under 5 years old, not much research for school children Most
studies only enhance one or several types of micronutrients, not diverse
types of micronutrients
A number of school-age studies do not disclose the compositions of
MNs, the foudation for developing micronutrients’ fortification formulas, or
have not updated WHO guidelines There have been no studies evaluating
the effectiveness of MN fortification for both fresh and reconstituted milk
25 Using MN fortified milk has therefore improved Hb concentration. Comparison in each group: the control group increased after 6-months, while the 2 intervention groups increased gradually from the times of 3- and 6-months (p<0.01). Comparing the Hb concentrations among the groups: At
T0 and T3 , there was no significant difference between the 3 groups (p>0.05) (probably because the intervention time was not enough to make change). After 6 months, the Hb concentration of intervention group was significantly higher than that of the control group (p <0.001). The difference
in T3 had a significant difference between group 1 (1.6 g/L) and control group (0.2 g/L) (t test, p = 0.048). The difference in T6 between group 1 (4.7 g/L) and group 3 (4.2 g/L) compared to the control group (1.7 g/L) was significantly different (p = 0.001). Other studies have also reported that the use of MN fortified milk (with vitamin A and iron) has increased Hb levels.
4 . 4 . 3 . Effectiveness for serum iron status
Comparing the median serum ferritin content between 3 groups: at the time of T0 and T6, there was no significant difference (p> 0.05). At T3 ; the median serum ferritin content in 3 different groups was significant (p
<0.05), but did not show an improvement in ferritin content. The difference between T6-T0 median serum ferritin content in group 1 (19.6 µg/L), control group (9.3 µg/L) and group 3 (15.2 µg/L) was significantly different (p<0.01).
Closely related to serum iron content is low iron reserve ratio. Compared among each group, the rate of iron reserves was low among 3 groups after 3 months and 6 months of significant improvement (p <0.001). However, the difference in median ferritin content between the 3 groups was not enough to improve the percentage of children with low iron reserves (SF <30µg/L) that was significant between the 3 groups (p> 0.05)
at T3 and T6 This may be due to an increase in iron mobilization from reserves.
4 . 4 . 4 . Effectiveness for anemia prevalence
There were differences in the trend of improving anemia among the three groups. The anemia rate in groups 1 and 3 decreased after the intervention. Meanwhile, the control group had the opposite trend: the rate
of anemia did not decrease but increased from 22.9% before intervention to
23.5% after 6 months. However, the difference is not statistically significant (p>0.05). Comparison at T3 among 3 groups also showed no difference, p>0.05. The reason may be due to the anemia rate in Phu Binh primary school students at an average is a public health problem. Nguyen Thanh Ha
Trang 724 The effect of MN fortified milk showed that the vitamin A
concentrations in 2 intervened groups were significantly increased
compared to that of control group (p<0.05). The difference in vitamin A
concentration at T3 in the two intervention groups compared to the control
group (1.20 μmol/L) was also significantly different (p<0.05). After 6
months, the results were similar, but the difference was not significant in
group 1; In group 3, the difference in vitamin A level was significantly
different (0.12 µmol/L) compared to the control group (0.06 µmol/L),
p=0.038. This result is consistent with the publication of Manorama.
Multi-MN fortified milk has improved (increases) the vitamin A
content, thus also improving sub-clinical vitamin A deficiency and marginal
vitamin A deficiency. Compared among each group, the percentage of
students lacking sub-clinical VAD and marginal VAD both decreased
(Table 3.21), p<0.001 with two intervention groups and p<0.01 with the
control group. The effects of MN multiple micronutrients fortified milk
improved sub-clinical VAD and marginal VAD was evident when
compared among the three groups. The rates of sub-clinical VAD and
marginal VAD reduction of the intervention groups compared with the
control group at T3 and T6 were significantly different (p <0.01). The results
are consistent with the study in Ha Nam in 2016.
Logistic regression analysis and multivariate linear regression after 3
and 6 months both showed that the intervention using MN fortified fresh
milk improved serum retinol content (linear regression, p<0.05) and the rate
of sub-clinical VAD and marginal (multivariable regression, p<0.01). At the
same time, logistic regression and multivariate linear regressions showed
that intervention results using MN-fortified pasteurized milk improved
serum retinol concentration (linear regression, p<0.01) at 6 months
post-intervention and improve of sub-clinical VAD rate and of marginal VAD
(multivariable regression, p<0.01) in subjects after 3 months of intervention
after controlling gender factors of children, age groups and mother's
education, household economic situation, maternal occupation, anemia of
students.
4 . 4 . 2 . Effectiveness for serum Hb status
The diet of Thai Nguyen primary school students does not meet the
needs of MN for hematopoiesis, e.g. approximately 64% of the daily Fe
requirement. MN-fortified milk supplemented MN that play an important
role in hematopoiesis such as iron 5.4 mg/day (60-75% RDA), folic acid
108 µg/day (54% RDA), vitamins B12 0.6 µg/day (20-30% RDA).
5
2 . 1 . Subjects, materials and research place
2 . 1 . 1 . Research subjects
2 . 1 . 1 . 1 . Subjects for effectiveness to anthropometrical status
All students of 7-10 years old attend 6 primary schools
Selection criteria: Children aged 7-10 years at the time of baseline
survey (T0), did not take vitamin and mineral supplements for the past 3 months The child has not puberty yet Currently residing permanently in 5 communes in the study area (over 1 year) Families voluntarily agree to allow the children to participate in the study
Exclusion criteria: Lactose intolerance; Severe malnutrition (CN / CC
≤ -3SD), stunting HAZ ≤ - 3SD, underweight WAZ ≤ -3 SD; Having birth defects (cleft palate, cleft palate, congenital heart), infectious diseases, severe chronic diseases, metabolic disorders; Expected to leave the study area in the next 12 months; The family did not agree to the study.
2 . 1 . 1 . 2 . Subjects for effectiveness to micronutrients status
Students aged 7-10 have -3.0 SD <HAZ <-1.0 SD of 6 elementary
schools (5 communes) in Phu Binh district, Thai Nguyen province Selection criteria: Students aged 7-10 years old at T0, took part in the
initial screening survey; There is a risk of stunting or stunting (-3,0 SD
<HAZ-score < -1,0); Families voluntarily allow their children to participate Exclusion criteria: lactose intolerant; badly malnourished; Anemia with
Hb<80g/L or severe VAD (retinol serum <0,35μmol/L); Having chronic illness or having a serious infection; Having birth defects; expected to move out of the research area.
2 . 1 . 1 . 3 . Subjects for sensory evaluation of the fortified milk
Children 7-10 years old from two groups using MNs-fortified milk.
2 . 1 . 2 . Places and time of research
The study was conducted at 6 elementary schools in 5 communes of Phu Binh district, Thai Nguyen province
Time: from February to September 2017
2 . 1 . 3 . Research materials
2 . 1 . 3 . 1 . Milk for the study
Pasteurized sweetened fresh milk and reconstituted sweetened milk with micronutrient enhancement; allowed to use in Vietnam according to the certification of compliance with food safety regulations of the Department of Food Safety, Ministry of Health.
2 . 1 . 3 . 2 . Research equipments
TANITA SC330 electronic scale (Japan); wooden ruler to measure height
Trang 86 High-pressure liquid chromatograph (USA); Atomic absorption
spectrometer (Germany); ELISA kit and determination machine (USA).
2 . 2 . Research method
2 . 2 . 1 . Develop a set of micronutrient levels for milk fortification
- Scientific bases for development of MN level in milk fortification:
Pursuant to the circulars provided by the Ministry of Health;
Vietnamese studies, relevant international guidelines (WHO, UNICEF ).
- Steps to set up micronutrient composition and levels: Select the
type and content of MN for fortification; Choice of milk as food vehicle;
Sensory evaluation; Conducting the effectiveness study of MNs fortified
milk
2 . 2 . 2 . Effectiveness study of micronutrient fortified milk
2 . 2 . 2 . 1 . Research method
Anthropometrical status evaluation: Cross sectional study
Effectiveness study for intervention: A randomized community
intervention trial with control group, pre- and post-intervention evaluation.
2 . 2 . 2 . 2 . Sample sizes
- Sample size for evaluation of nutritional status of children aged
7-10: conducted on all primary children in grades 2-4 at 6 schools in 5
communes Calculate the sample size according to the formula In fact, the
study carried out a survey of all children from grades 2 to 4 of 6 primary
schools, which are 2,094 students (larger than the minimum sample size
required).
- Sample size for the effectiveness study on the status of MN
Calculate the sample size according to the formula The minimum sample
size requires 196 children/group, preventing 20% of children giving up In
fact, 251 children/group were selected; 2 intervention groups = 502 children
and 250 children/control group Thus, a total of 752 children were selected
to evaluate the effectiveness of interventions to the nutrition
anthropological status and MN
- Sample size of the dietary intake survey: calculate the sample size
according to the formula, calculate the sample size of 50 children/group
- Sample size for sensory evaluation of MN fortified milk: Each
group (700 children) randomly selected 25% of children to drink milk in
each group of 175 In fact, 188 children in the group who drank fresh milk
with MNs and 172 were selected children drinking MN fortified milk
2.2.3 Sampling method
Research subjects selection:
Step 1: Make a list of all students in grades 2-4 of 5 communes
Investigate nutritional status, identify stunted children and risk of stunting
23 The effect of MN fortified milk was also manifested in stages T3 and T6 , Z-Score BMI/age was different between the two groups compared to the control group (p <0.001 in T3 , p <0.05. at T6). Difference in T3-T0 and T6-T0 , Z-score BMI/age of the intervention group improved (p <0.05) compared to the control group.
There was no difference in Z-Score weight/age, Z-Score height/age, Z-Score BMI/age between the 2 intervention groups at different time points (p>0.05). Thus, the effects of the two types of MN fortified milk are similar.
- Effectiveness to malnutrition status of children: Comparing the
prevalence of underweight among students of the 3 groups at different time points was not significantly different, p> 0.05. When comparing this rate in each group: intervention group 1 and 3 tended to decrease after 6 months (not statistically significant, p>0.05). While the control group tends to increase this ratio after 3 months. This may be because the weight gain of children over 3 months is not enough to change malnutrition status.
MN fortified milk has significantly improved stunting status. Tracking
in each group noted a difference. The stunting rate decreased significantly (group 1 decreased by 1.6% with p<0.05; group 3 decreased by 2.7% with p<0.001) after the intervention at T3 and T6 The result is similar to the study of using milk on elementary students in Nghia Dan district.
Two types of MN fortified milk have significantly improved the status
of wasting. In the two intervention groups, the wasting prevalence during the study did not increase (p> 0.05). Students in groups 1 and 3 were provided with 2 boxes of milk/day supplemented to meet 100% of energy RDA, so the malnutrition rate was unchanged. The prevalence in the control group was different: increasing gradually, corresponding to the 3 points of time: 5.7%; 10.8% and 8.9% (p<0.001).
At the time of T3 , the prevalence of wasting malnutrition in the two intervention groups was lower than that of the control group (p <0.05), related to the infant's dietary response compared to RDA in terms of energy intake. In the period from April to June after the intervention, the diet of children in the 3 months of summer may change, so in the control group, the prevalence of wasting compared to the time of T3 decreased, but if compared with T0 , this still increases significantly (p<0.001).
4 . 4 . The effectiveness of MN fortified milk for MN status
4 . 4 . 1 . Effectiveness for vitamin A status
Over time, the vitamin A levels increased in each group (in T3 , p <0.001 for groups 1 and 3, p<0.05 for the control group).
Trang 9- Effectiveness on children’s height: After 3 and 6 months, the height
of each group of students increases significantly, suitable for the age of
developing children. This result is similar to the study in Indonesia in 2009.
However, the comparison between groups recorded that MN-fortified milk
improved the height of children compared to the control group, p<0.001.
The height difference in the two intervention groups is significantly higher
than the control group (p <0.001). The results are similar to those of Bui Thi
Nhung's studies on MN-fortified milk on primary school children
- Effectiveness to children’s BMI: Comparison among group recorded
an improved BMI. Comparisons between the MN-fortified formula groups
improve the child's BMI: 2 intervention groups had a higher BMI (p
<0.001) compared to the control group at T3 and T6 Differences in T3-T0
and T6-T0 in the two intervention groups improved significantly (p <0.001)
compared to the control group.
- Effectiveness on Z-Score weight/age: MN fortified milk significantly
improved Z-score weight/age in school age children. In the two intervention
groups, this indicator increases gradually compared to the initial survey (p
<0.001). In the control group, there was no improvement in Z-score.
Comparing the indicators between groups at T3 and T6 as well as the
difference of Z-score weight/age between T3-T0 and T6-T0 showed, the two
intervention groups have significant differences compared to the control
group (p<0.001 and p<0.05 respectively).
- Effectiveness to Score height/age: MN fortified milk improves
Z-Score height/age. Monitoring in each group noted that this indicator
increased (p <0.01), consistent with age characteristics (children continue to
develop height). However, the comparison among the 3 groups showed that
the Z-Score indicator in the intervention group was much higher than that
of the control group at T3 and T6 (p <0.001) as well as the difference of
Z-Score height/age indicator between T3-T0 and T6-T0 are significantly
different from the control group (p <0.05). This improvement is equivalent
to the research using MN fortified fresh milk in Nghe An
- Effectiveness to Z-Score BMI/age: After 3 months, there was no
improvement in Z-Score BMI/age in the two intervention groups (p> 0.05).
Meanwhile, the control group had Z-Score BMI/age decreased (p<0.001)
(possibly due to insufficient diet). The intervention group had the support of
2 servings of milk per day so the Z-Score BMI/age indicator maintained as
the initial stage. After 6 months, the Z-Score BMI/age improved
significantly in the intervention group (p <0.01), while in the control group,
there was no difference (p> 0.05).
7 The number of children participating in the screening and evaluation of nutritional status was 2,094 students
Step 2: Grouping to assess the effectiveness of intervention on
nutritional status From the number of children selected above, based on the HAZ Score anthropometric index, stunting malnutrition indicator (-3.0
<HAZ<-1.0) and selection criteria to assess MN status, randomly selected single of 752 children After that, the children were randomly arranged into
3 groups so that each group of 250 children was based on the units of school and class, ensuring similarity of nutritional status and avoiding cross-use of milk in the same class Selecting 175 infants in each group to drink milk assessed the sensory preference for MNs fortified milk and 50
children assessed the ration Specifically: Group 1: Group using MNs fortified fresh milk (n = 701): Every day the child was given 2 servings (2 bottles of 180ml milk) of milk for 6 months Group 2: Control group (n =
700): After 6 months of intervention in groups 1 and 3, children in the control group received 2 servings of milk every day for the next 6 months
Group 3: The group using MNs fortified reconstituted milk (n = 693):
Every day the child is given 2 servings of milk for 6 months
All 3 groups ate the normal diet In the first 6 months, the amount of milk of each intervention group (groups 1 and 3): 2 boxes / day (each box
of 180 ml / time) x 7 days a week x 6 months (about 24 weeks) For the next 6 months, the control group received milk in the same amount as
above
2 2 7 Method for data collection and evaluation
Trang 10At the times: T0, T3 and T6, all children in the 3 groups were assessed
anthropometric indicators, taken intravenous blood (8h to 9h30) for testing
Interview diets last 24 hours (at T0).
a) General demographic information group
b) Group of indicators on energy and dietary intake: Dietary intake and
and food frequency;
c) Anthropometrical indicators: Age; weight; height; Nutritional status
of children: Based on the reference population of WHO 2007
d) Hematological and biochemical indicators: Serum vitamin A index,
Hb, ferritin, serum zinc Normal and pathological values according to WHO
and international zinc advisory organization
e) Disease indicators: Track disease signs (cough, fever, diarrhea,
vomiting, bloating, etc.) daily, for 6 months of intervention
g) Acceptability and organoleptic characteristics of the product:
Sensory evaluation of the product: using a Hedonic scale of 9 points of
likelihood (Degree of like - DOL), done at the time of T3
2.2.8 Data analysis
Data were entered using Epidata software 3.1 Processing
anthropometric data using WHO AnthroPlus software, 2006, diet data using
ACCESS software, general data using SPSS 18.0 software P value <0.05 is
considered to be statistically significant
Chapter III . RESEARCH RESULTS
3 . 1 . Characteristics of students in the research
Table 3 . 2 . Dietary intake of 3 groups at T0
Indicators
Group 1 (n-57)
Control group (n=60)
Group 3 (n=64)
Total (n=181)
p*
Median
(p25;p75)
Median
(p25;p75)
Median
(p25;p75)
Median
(p25;p75)
Energy (Kcal) 1501 (1270;1646) 1428
(1273;1642)
1600 (1351;1719)
1516 (1300;1683) 0,085
Protein:
Total (g) 56,9 (46.7;63.2) 50,1 (44.3;61.6) 59,1 (49,8;69) 55,8 (45.1;64.2) 0,047
Animal (g) 25 5 (18 1;33,7) 25,5 (17;33) 27.5 (18.1;42,1) 26 3 (18;35,3) 0,373
Ratio Protein
Lipid:
Total (g) 27,6 (21,1;39,3) 28 (23;38,3) 35,3 (26,8;44,3) 30,9 (23,5;39,8) 0,025
Plant (g) 8,4 (3 4;15,8) 9,4 (3,9;14,9) 10 8 (4,9;18,3) 9,8 (4,2;16,6) 0,232
21 (from 0 to 1.7%). This result is equivalent to studies on MN fortified milk (Osman, Gaur ). However, the sensory evaluation of the tastes of school children for fortified milk with 21 types of MN has not been published by any author.
4 . 1 . 5 . Safety concerns about increasing doses of MN in milk
The formula to fortify MN with a response within the limit of RDA should be safe. MN fortified milk only adds nutritional value to meals (no meal replacement), children still have to eat more diverse foods to ensure the needs.
4 . 1 . 6 . Energy and milk consumption issues
In the study, children who drank 2 cartons of MN fortified milk (180 ml/box) in 1 day add 285 kcal. The infant's diet has been raised to 1801 kcal, meeting 100% of the RDA of energy. In practice: in the 6 months of the intervention group and 6 months after that of the control group, with a total of 2,094 infants drinking milk in the amount of 2 boxes / day, 7 days / week, no records of abnormalities resulted from the use of milk.4.2. Some dietary characteristics and nutritional status before intervention- Dietary characteristics: before intervention, in all 3 groups of children the diet only reached 72% (control group) to 82% (group 3) and 87% (group 1) RDA. No type of MN meets RDA.
- Nutrition status: underweight malnutrition is 24.3% (equivalent to SEANUT results in 2009); stunting is 17.5% (higher than in SEANUT 2011); wasting is 8.1%. Deficiency of MN, malnutrition status of students is
a problem of public health significance.
4 . 3 . Effectiveness of using MN fortified milk to change the anthropometric indicator
Before the intervention, 3 groups of students guaranteed similarity, showing no statistically significant differences in age, weight, height, weight-to-age Z-score, height-to-age Z-Score, BMI-to-age Z-Score (p>
0.05)
- Effectiveness on children's weight: The weight of 3 groups of
children all significantly improved after the study, consistent with the age of developing children; is equivalent to the 2009 Saptawati study.
When comparing among 3 groups, MN-fortified milk significantly improved the children's weight, indicating that the intervention group had a higher weight gain than that of the control group after 3 and 6 months (p
<0.001). The difference in weight of T3-T0 and T6-T0 of the two intervention groups was significantly different from the control group (p<0.001). This result is similar to the research of Nguyen Xuan Ninh in children aged 7-8, and Shartrugna in children aged 6-16 in India
