MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH NATIONAL INSTITUTE OF NUTRITION LUU KIM LE HANG EFFICACY OF MULTI MICRONUTRIENT SUPPLEMENTATION ON NUTRITIONAL STATUS, VISUAL ACUITY AND PHYSICAL[.]
MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH NATIONAL INSTITUTE OF NUTRITION LUU KIM LE HANG EFFICACY OF MULTI-MICRONUTRIENT SUPPLEMENTATION ON NUTRITIONAL STATUS, VISUAL ACUITY AND PHYSICAL FITNESS OF ADOLESCENT GIRLS AGED 1517 YEARS OLD IN MOUNTAINOUS AREAS OF THANH HOA PROVINCE Specialization: Nutrition Code: 9720401 SUMMARY OF DOCTORAL THESIS IN NUTRITION HA NOI, 2022 i THE WORK WAS COMPLETED AT THE NATIONAL INSTITUTE OF NUTRITION Science instructor: Asoc Prof PhD Nguyen Xuan Hiep Asoc Prof PhD Tran Thuy Nga Reviewer 1: Reviewer 2: Reviewer 3: The thesis will be defended at the Judging Committee of Institute-level doctoral thesis at the National Institute of Nutrition At ………….hour, date……month……year …… The thesis can be reviewed at: - National Library - Library of the National Institute of Nutrition INTRODUCTION Adolescence is a critical period of nutritional vulnerability due to an increased need to meet growth and development of the body Anemia and multimicronutrient deficiencies are still common worldwide and often occur from infancy to adulthood If not intervened, it will negatively affect the overall physical and cognitive development Therefore, the research of micronutrient status during adolescence has become an important area of interest Many domestic and foreign researches have shown that the efficacy of micronutrient supplementation not only improves nutritional status and micronutrient deficiency, but also improves cognitive and physical development in adolescents However, there have not been many multi-micronutrient intervention researches on adolescents aged 15-17 to evaluate the efficacy on nutritional status or physical fitness Therefore, the research team conducted the topic: "Efficacy of multi-micronutrient supplementation on nutritional status, visual acuity and physical fitness of adolescent girls aged 15-17 years old in mountainous areas of Thanh Hoa Province" to evaluate the efficacy of multi-micronutrient supplementation interventions on adolescent girls and make recommendations for multi-micronutrient supplementation interventions to prevent and control anemia and micronutrient deficiency THE OBJECTIVES OF THE TOPIC To describe nutritional status, visual acuity and physical fitness of adolescent girls aged 15-17 years old in mountainous areas of Thanh Hoa To evaluate the efficacy of weekly multi-micronutrient supplementation on improving anthropometry, visual acuity and physical fitness of adolescent girls aged 15-17 years old in mountainous areas of Thanh Hoa after months of intervention To evaluate the efficacy of weekly multi-micronutrient supplementation on improving hemoglobin and micronutrient levels of adolescent girls aged 15-17 years old in mountainous areas of Thanh Hoa after months of intervention New contributions of the thesis: The research was conducted to intervene on adolescent girls aged 15 - 17 years, who are at risk of anemia and micronutrient deficiency The intervention model is based on schools, health workers and homeroom teachers who directly distribute multi-micronutrient tablet in class and ensure students take them in class The content of multi-micronutrient tablets includes 23 vitamins and minerals, however, focus on iron (60mg), folic acid (2.8mg) as recommended by WHO 2011 for subjects at risk of anemia, iron deficiency with supplemental dose of one tablet per week In addition to evaluating the effectiveness of improving the anthropometric, biochemical and hematological indicators, the research also evaluated the efficacy on improving on visual acuity and physical fitness The results of multimicronutrient supplementation significantly increased levels of hemoglobin, ferritin, serum zinc and serum vitamin A, gave effective prevention and improved anemia and iron deficiency in adolescent girls aged 15 - 17 years The physical fitness level of adolescent girls also increased significantly compared to the control group Thesis structure: The thesis consists of 121 pages (excluding references and appendices), pages of introduction and objectives of research, 33 pages of overview, 22 pages of research methods, 30 pages of research results, and 30 pages of discussion, pages of conclusion, page of recommendation The thesis has 36 tables, 10 pictures and 175 references (44 documents in Vietnamese, 131 documents in English) Chapter OVERVIEW 1.1 Some related concepts Adolescence is the period of life between childhood and adulthood, between the ages of 10 and 19 The World Health Organization (WHO), the United Nations Children's Fund (UNICEF) and the United Nations Population Fund (UNFPA) agreed (1998) to classify this age group as adolescents and this age group is classified into phases: Early adolescence: from 10-14 years old; Middle adolescent: 15 - 17 years old; Late adolescence: 18-19 years old This is a period of rapid physical, cognitive, and psychosocial development of people, an important time to lay the foundation for good health Visual acuity is an important part of visual function, it includes many components of which mainly the ability to distinguish light and the ability to distinguish space Vision examination is a fundamental and important part of ophthalmology Evaluation of visual acuity should always include distance vision, near vision, contrast and acuity Physical qualities of a person are the sum of the qualities of the body expressed in specific conditions of life, work, research and sports activities Mobility is an external expression of physical qualities, and sport is a means (through exercises) to improve mobility, contributing to the improvement of human physicality Physical qualities include: strength, speed, endurance, flexibility, dexterity 1.2 The role of micronutrients Iron is an essential component of hemoglobin, myoglobin, enzymes, cytochrome and is necessary for oxygen transport and cellular respiration Iron deficiency anemia causes children to become less agile, slow in mental development with cognitive delay, memory loss, poor concentration and results in a decrease in cognitive function and learning ability and physical development Zinc plays an important role in growth, immunity, and reproduction Zinc is important during adolescence because of its role in growth and maturation in sexual function Vitamin A has many roles in the body including vision, cell differentiation, immune function, reproduction, the formation and development of organs and bones, and keeping the skin and mucous membranes healthy Vitamin A participates in increasing the concentration of Hb in the blood together with vitamins C, E, and B9, B12 Vitamin A deficiency is the cause of vision loss, dry eyes, is the main cause of blindness, while slowing down physical development, reducing the body's immunity and increasing the risk of death Vitamin D is involved in promoting the absorption of calcium, iron, magnesium, phosphate and zinc Vitamin D status significantly affects skeletal health during adolescent growth and plays an important role in female reproduction Vitamins, minerals, antioxidants and other key nutrients have been shown to be essential for a good vision, able to protect eyes from conditions and diseases that cause vision loss, prevent and delay the development of cataracts, macular degeneration 1.3 Nutritional status of adolescent girls Adolescence is a period of growth and development, characterized by transformation In adolescent girls, this is the transitional period between childhood and womanhood Adolescent malnutrition is a problem of public health significance in Southeast Asian and African countries It is estimated that in Africa 22% of school children are stunted and 36% emaciated; Southeast Asia has 29% stunting and 34% emaciation The percentage of stunting and emaciation among Indian adolescent girls is 39.4% and 33%, respectively; In Vietnam, results from a number of researches on adolescent girls have shown a worrying nutritional and health status, especially in rural and mountainous areas The status of stunting malnutrition in adolescents is still high due to the lack of varied and adequate daily meals, insufficient energy, because children are still skipping meals, due to lack of nutrition knowledge and practice, as well as the economic conditions of each family and each region, which affects the quality of meals and nutritional status 1.4 Anemia and micronutrient deficiencies in adolescent girls Today in the world, iron deficiency anemia is still a problem of public health significance During adolescence, iron requirements increase due to the peak of pubertal development, characterized by an increase in total blood volume, an increase in body mass, and the onset of menstruation in adolescent girls The highest rate of iron deficiency anemia is in developing countries such as Nepal 68.8%, Pakistan 65%, India 53%, Sri Lanka 52.3%, Indonesia 45%, China 37.9 %, Morocco 35%, Philippines 31.8% In Vietnam, the situation of anemia, iron deficiency anemia, zinc deficiency and deficiency of other micronutrients is still high Anemia in women of reproductive age by rural area is 26.3% and by mountainous area is 27.9%, zinc deficiency in women of reproductive age in rural areas is 60.3% and in mountainous areas is 73.4% In addition to iron deficiency anemia, adolescent girls also lack other common micronutrients such as zinc, calcium, magnesium, vitamin A, group B, vitamin D Thus, the percentage of common micronutrient deficiencies in adolescent girls is still high, the percentage and extent of deficiency are very different in different countries, regions, and age groups, which affects the nutritional status, physical and mental development of adolescent girls 1.5 Intervention researches evaluating the efficacy of multi-micronutrient supplementation on improving nutritional status, anemia, micronutrient deficiencies, visual acuity and physical fitness of adolescent girls Many researches evaluating the efficacy of interventions have shown the efficacy on improving iron-deficiency anemia when iron is supplemented alone or in combination with other micronutrients with daily or weekly doses, which increases hemoglobin levels in the blood or improve the biochemical indicators of micronutrients added in the serum The fortification of multi-micronutrients, especially iron, zinc helps the body to grow, improve anemia, increase physical development of children and adolescents When taken in a combination of vitamins A, C and E with zinc, selenium, it will prevent cataracts, reduces the risk and reduces the progression of macular degeneration In Vietnam, researches on iron deficiency anemia and micronutrient deficiencies focus a lot on children under years old, pregnant women, and women of reproductive age More researches are needed on adolescent girls aged 15 - 17 years on improving nutritional status or improving visual acuity and physical fitness, because this is the target group at a stage of strong physical development, with high body's demands and also the pre-reproductive age, thereby we will have more scientific evidence to help prevent malnutrition, obesity as well as micronutrient deficiencies in adolescent girls CHAPTER RESEARCH SUBJECT AND METHOD 2.1 Research subject The research was conducted on female students from two high schools: Ngoc Lac High School - Ngoc Lac District and Lang Chanh High School - Lang Chanh District - Thanh Hoa province Inclusion criteria: Female students of the two schools are from 15 to 17 years old Students and families agree to participate in the research Have a commitment to participate in the research and consent to so as required by the intervention research 2.2 Research design A community intervention trial research, randomized and double-blind, with a control group, pre-intervention and post-intervention evaluation Phase 1: evaluating the nutritional status, anemia, micronutrient deficiencies, dietary intake, visual acuity and physical fitness of students Phase 2: controlled weekly multimicronutrient supplementation intervention trial and post-intervention evaluation of efficacy Research design diagram Evaluating the nutritional status - Anthropometric survey, general information interview, optometry (n=740) - Investigation of 24h rations, blood tests and evaluation of physical fitness (n=300) Intervention group (n=370) Deworming before intervention Take multi-nutrients once a week Drop-out (n=20) Endpoint survey of intervention - Anthropometric survey, Phase 1: Evaluating the nutritional status Control group (n=370) Deworming before intervention Take a placebo once a week T0 Drop-out (n=15) Endpoint survey - Anthropometric survey, optometry (355) T9 Phase 2: multimicron utrient interve ntion for months - Investigation of 24h dietary recall, blood tests and evaluation of physical fitness (n=150) dietaryrecall, blood tests and evaluation of physical fitness (n=150) 2.3 Time and study sites The research period was from June 2019 to December 2020 (in which the multi-micronutrient intervention period is months) Selected purposefully mountainous and densely populated districts of Thanh Hoa province: Ngoc Lac district and Lang Chanh district Selected one high school in each district, Ngoc Lac High School - Ngoc Lac District, Lang Chanh High School - Lang Chanh District to ensure a sufficient number of female students of the sample size to participate in the research 2.4 Sample size Applying the formula to calculate the sample size for community intervention, to prevent the number of students giving up, the sample size according to the indexes in the research was calculated as follows: sample size for each group to evaluate anthropometric status, visual acuity was 350 subjects, evaluation of hemoglobin and micronutrients was 150 subjects, evaluation of physical fitness was 120 subjects 2.5 Methods of data collection and evaluation At the times: T0 and T9, students in two groups were interviewed for general information, the last 24 hour diet recall The indexes regarding anthropometric aspects, optometry and physical fitness, taking venous blood for testing were evaluated a) General demographic information group b) Anthropometric index group: age, weight, height, nutritional status of students: Based on WHO 2007 reference population c) Hematological and biochemical indexes: hemoglobin, ferritin, serum zinc, serum vitamin A Normal and pathological values were according to WHO guidelines and the International Zinc Association d) Group of visual acuity index: distance visual acuity, near visual acuity, contrast visual acuity and acuity with Helen Keller International's Snellen chart e) Group of physical fitness index: squeeze force of the dominant hand, lying on your back with stomach bent, turning on far in place, 5-minute running according to own strength Evaluated physical fitness level for students according to Decision No 53/2008-QD of the Ministry of Education and Training 2.6 Methods for data processing and statistical analyses Used the questionnaire to collect data in the field All questionnaires were transferred at the end of each survey to collect data to the National Institute of Nutrition to be entered and saved on the computer Biochemical test data, including standard sample and marked sample of the laboratory, are also stored in the database file on the computer Data were entered using Epidata 3.1 software Anthropometric data were processed by WHO AnthroPlus software, 2006 Dietary data were processed by ACCESS 2010 software Data were analyzed by SPSS 20.0 software All data are cross-checked and cleaned before analysis 2.7 Ethics of research The research outline was approved by the National Institute of Nutrition's Biomedical Research Ethics Committee under Approval Certificate No 251/VDDQLKH dated June 12, 2018 prior to implementation Chapter RESEARCH RESULTS 3.1 Status of nutritional status, visual acuity and physical fitness of adolescent girls aged 15-17 years old in mountainous areas of Thanh Hoa province 3.1.1 General information of students and their families 15 (pb) Paired samples t-test, comparing the means of the same group before and after the intervention After months of intervention, the intervention group had the squeeze force of the dominant hand, the number of times of lying on your back with stomach bent, the number of centimeters of turning on far in place, the number of meters of 5minute running according to own strength on average all increased compared to the time of T0 and higher than that of the control group, the difference between the two groups after intervention was statistically significant (p