Micronutrient status of the children
- Conditions
- Subjects may or may not be macronutrients or micronutrients deficient
- Registration Number
- CTRI/2018/05/013999
- Lead Sponsor
- Centre of Food Technology
- Brief Summary
**Introduction:**
Malnutritionis still a major public health problem of staggering dimensions in developingcountries including India. “Protein Energy Malnutrition†covers a wide spectrumof clinical stages ranging from the severe forms like kwashiorkor and Marasmusto the milder forms in which the main detectable manifestation is growthretardation. PEM is due to food gap between the intake and requirement (Bhatia,2007). This may lead to retardation inboth physical growth and intellectual development in later years. In India,iron, iodine and vitamin A deficiency disorders have been major nutritionalproblems. Iron deficiency anaemia is a problem of serious public health significance,and has impact on psychological and physical development, behavior and workperformance. In India the prevalence of anaemia in pregnant women(haemoglobin<11g%) of different parts of the country was in the range of 33to 89% (Awasthi, 2003). Vitamin A deficiency, especially among preschoolchildren is still a significant public health problem in certain pockets of thecountry (Arlappa,2011). Vitamin ‘A’ deficiency affects many tissues in the body;the most dramatic changes are seen in the eyes resulting in tragic consequencesof total loss of vision in early life. Iodine is an essential micronutrient fornormal growth and development in animals and humans. Its deficiency not onlycauses goiter but is also responsible for impaired brain development in the fetusand infant and retarded physical and psychomotor development in the child (WHO/UNICEF/ICCIDD,1995). The deficiency of iodine also impairs children’s learning ability.Iodine deficiency is the most common cause of preventable mental retardation inthe world today (Hess, 2009).
**Aim of the Study:**
Theproposed study is aimed to carry out in order to learn about the epidemiologyof Protein Energy Malnutrition (PEM) and micronutrient deficiencies especiallywith reference to Iodine deficiency disorders of the children of Allahabaddistrict. Detailed analysis of salt consumption amount, pattern and storagepractices would help to identify the main lacunae which are responsible for thelow iodine bioavailability in amongst the household. Urinary Iodine excretionwould give a detail picture of the individual’s iodine status which would beassociated to anthropometric and other biochemical and clinical indices. Itwould also help in gauging and forecasting the future possibilities ofdeveloping thyroid related disorders and hence we could promulgate soundguidelines and promotional approaches so that on the basis of proper saltconsumption and storage practices we could mitigate the problem of Iodinedeficiency disorders.
**OBJECTIVES**
· To assess the nutritional status of thechildren (4-12 years) and identify the prevalence of PEM.
· To assess the prevalence of anaemia.
· To find out the prevalence of clinicalsigns and symptoms of common micronutrient deficiencies.
· To assess the dietary adequacy ofmicronutrients and correlate it with biochemical indices.
**Methodology:**
· ***Selection of the Sample and Samplesize:***
Sample sizewould be n≥425, consisting children of age group 4 to 12 years of age ofAllahabad district. For a survey designbased on a simple random sample, the sample size required can be calculatedaccording to the following formula. **(FAO1990, UNICEF 1995)**
n = t2xp (1- p) ; N= n x D
m2
**n** = required sample size
**t =** confidence level at 95% (standardvalue of 1.96)
**p =** estimated prevalence of PEM in the project area (42.5% in thiscase as reported)
**m =** margin of error at 10% (10% of the Prevalence rate i.e 42.5% whichwould be = 4.25)
**D**= Design effect (taken as 1 in this case)
n=3.8416 x 42.5 x 57.5= 9388 =519
(4.25) 2 18.06
To,N 10% Contingency has to be added, 0.10x519=51.9
**Final Sample Size: N= 519+52 rounded off to 571**
As two-third of the district’s population resides in the rural areas (census,2011) thus the distribution ratio of the samples will also follow this trend.Thus, out of the total sample size two-third of the sample would be drawn fromthe rural and one fourth of the sample would be drawn from the urban sector.
Out of the twenty blocks(i.e [Phulpur](http://allahabad.nic.in/bpl/phulpur.pdf) [Bahadurpur](http://allahabad.nic.in/bpl/bahadurpur.pdf) [Pratappur](http://allahabad.nic.in/bpl/pratap%20pur.pdf) Saidabad,Handia, Shankargarh, Chaka, Karchhana,[Uruwa ,](http://allahabad.nic.in/bpl/uruwan.pdf)[Meja, Kaurihar, Holagarh,](http://allahabad.nic.in/bpl/meja.pdf) [Koraon,](http://allahabad.nic.in/bpl/koraon.pdf) Dhanupur, Kaundhiyara Manda), four blocks were selected randomly in order tocollect the samples from theses blocks.
**Methodology**
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I. **Dietsurvey** **(Swaminathan,2002)** will be conducted.
**Survey Schedule:**
· It would be used to collectthe general information, anthropometric status and dietary in take and detailsof the clinical and biochemical indices will also be recorded in it. The data on socio-demographic profile, educational status ofmothers (of Children), family type, standard of living, religion and caste ofthe children was collected through a pretested structured questionnaire. Thecriteria for classifying the families in to different socio economic groupswere based on the physical assets available in the household. The criterionutilized by National Family Health surveys conducted in the country was used.
- A **3 day dietary recall** would be taken and it would be averaged out for one day.
· **FoodFrequency Questionnaire (FFQ**) will be utilized tofind out the consumption of food items of various food groups. This method obtains retrospective information on thepattern of food consumption of a defined period in past on usual intakes of thefood items categorized in major food groups, like cereals/grains (wheat andrice), pulses and legumes, green leafy vegetables, roots and tubers, othervegetables, fruits, milk, milk products, eggs, flesh foods, nuts and oil seeds,Fats and oils, Sugar/jaggery. The common food items consumed by a child werelisted to mother to facilitate her to comprehend and recall the food itemsconsumed by her child. The mother of the study subject was inquired about thefrequency of food items of the specific food group consumed. The frequency ofconsumption was assessed under four categories (i) Number of days per week (1to7 days) (ii) Once per 15 days, (iii) Once per month, and (iv) Never.
· The dietary intake of micronutrientswould be calculated using the Food Composition Tables **(Gopalan, 2002)** to finally compute the intakes of macro and micronutrients. The calculated values ofMacronutrients (Energy, Protein, Fat and Water) and Micronutrients (Vitaminsand Minerals – Iron and Zinc) would be compared to the RDA.
· Type of Salt consumed; Salt Consumptionamount per head and the details of salt storage And usage practices will alsobe recorded.
**II.****Anthropometric measurements** will be taken for theassessment of nutritional status by the health indicators for which referencewould be used is **(WHO child GrowthStandards, 2006/ NCHS 2006)** :-
· **Body weight (kg):** Weight of the child will be taken with minimal clothing using alever balance. Measurement will be taken to the nearest 100 g value.
· **Height(cms):** Standingheight of a child will be measured with anthropometry rod taken to nearestmillimeter (mm). The child will be made to stand erect with heels touchingtogether without any foot wear.
· **Mid-armcircumference for age (cm.):** It will be measuredwith a fiber non stretchable tape at the mid point of the acromian andolecranon on one side to the nearest mm.
**TableNo. 1****: SD classification ofmalnutrition by WHO**
| | | |
| --- | --- | --- |
|**NUTRITION**
**STATUS CLASSIFICATION**
**Z- score**
|**Weight-for-age**
**(Underweight)**
Normal
-1 SD ≤
|Mild
-2 SD ≤ Z < -1 SD
|Moderate
-3 SD ≤ Z < -2 SD
|Severe
<-3 SD
|**Weight-for-height**
**(Wasting)**
Normal
-1 SD ≤
|Mild
-2 SD ≤ Z < -1 SD
|Moderate
-3 SD ≤ Z < -2 SD
|Severe
<-3 SD
|**Height-for-age**
**(Stunting)**
Normal
-1 SD ≤
|Mild
-2 SD ≤ Z < -1 SD
|Moderate
-3 SD ≤ Z < -2 SD
|Severe
<-3 SD
The nutritional status of children will be calculatedaccording to above mentioned threemeasures is compared with the nutritional status of an international referencepopulation recommended by the World Health Organization **(WHO child Growth Standards, 2006/NCHS 2006/** **Dibley etal, 1987**). The use of this reference populationis based on the empirical finding that well-nourished children in allpopulation groups for which data exist follow very similar growth patterns. Ascientific report from the Nutrition
Foundation of India **(Agarwalet al., 1991)** has concluded that the WHO standard is generally applicableto Indian children.
**Analytical and Biochemical Tests:**
1. **Quantitative estimation of Salt’s iodine content: (ICCIDD, 1995)**
**Reagent preparation**:The preferred water for this method should be boiled distilled water, whichrequires provision of a distillation unit. As a simpler alternative, regulartap water treated with a mixed bed deionizing resin can be used, thus avoidingthe need for an expensive distillation unit. 0.005 M Sodium thiosulfate (Na2 S203 ): Dissolve 1.24 g Na2 S2 03 5H2 0 in 1000 ml water. Store in a cool, darkplace. This volume is sufficient for 100-200 samples, depending on their iodinecontent. The solution is stable for at least one month, if stored properly. 2 NSulfuric acid (H2 S04): Slowly add 6 ml concentrated H2S04 to 90 ml water. Make to 100 ml with water. This volume is sufficient for100 samples. The solution is stable indefinitely. Always add acid to water, notwater to acid, to avoid excess heat formation and spitting of acid. Stirsolution while adding acid. 10% Potassium iodide (KI): Dissolve 100 g KI in1000 ml water. Store in a cool, dark place. This volume is sufficient for 200samples. Properly stored the solution is stable for six months, provided nochange occurs in the colour of the solution. Starch indicator solution:Dissolve reagent-grade sodium chloride (NaCl) in 100 ml double-distilled water.While stirring, add NaCl until no more dissolves. Heat the contents of thebeaker until excess salt dissolves. While cooling, the NaCl crystals will formon the sides of the beaker. When it is completely cooled, decant thesupernatant into a clean bottle. This solution is stable for six to twelvemonths. Dissolve 1 g chemical starch in 10 ml double-distilled water. Continueto boil until it completely dissolves. Add the saturated NaCl solution to make100 ml starch solution. This volume is sufficient for testing 20 to 45 samples.Prepare fresh starch solution every day, since starch solution cannot bestored.
2. **Quantitative estimation of hemoglobin:**
**Cyanmethemoglobinmethod. (Bhaskaran, 2003)**
The(filter paper) method of choice for hemoglobin determination is thecyanmethemoglobin method (This is a type of colorimetric method). The principle of this method is that whenblood is mixed with a solution containing potassium ferricyanide and potassiumcyanide, the potassium ferricyanide oxidizes iron to form methemoglobin. The potassium cyanide then combines withmethemoglobin to form cyanmethemoglobin, which is a stable color pigment readphotometrically at a wave length of 540nm.5 ml of Cyanmethemoglobinreagent will be pipetted into each tube. 20 mlof the appropriate sample would be added into each tube. Tubes then have to beallowed to stand for 10 minutes. Absorbance (A) has to be noted in thespectrophotometer at 540 nm, zeroing the spectrophotometer with the BLANKsolution. A graph will be plotted Absorbance vs. Hemoglobin concentration in grams % on lineargraph paper.
3. **Quantitative estimation of urinary iodine excretion: (ICCIDD, 1993)**
**Principle:** Urineis digested with ammonium persulfate. Iodide is the catalyst in the reductionof ceric ammonium sulfate (yellow) to cerous form (colourless), and is detectedby rate of colour disappearance (Sandell-Kolthoff reaction). Equipment Heatingblock (vented fume hood not necessary), colorimeter, thermometer, test tubes(13 x 100 mm), reagent flasks and bottles, pipettes, balance scales.
**Reagents**
1.Ammonium persulfate (analytical grade)
2.As2O3
3. NaCl
4.H2 SO4
5.Ce(NH4)4 (SO4)4 . 2H2O
6.Deionized H2 O
7.KIO3 Solutions
1.0M Ammonium persulfate: Dissolve 114.1 g H2 N2 O8S2 in H2O; make up to 500 ml with H2 O. Store away fromlight. Stable for at least one month. 5 N H2 SO4 : Slowlyadd 139 ml concentrated (36 N) H2 SO4 to about 700 mldeionized water . When cool, adjust with deionized water to a final volume of 1litre. Arsenious acid solution: In a 2000 ml Erlenmeyer flask, place 20 g As2O3 and 50 g NaCl, then slowly add 400 ml 5 N H2SO4. Add water to about 1 litre, heat gently to dissolve, cool to roomtemperature, dilute with water to 2 litres, filter, store in a dark bottle awayfrom light at room temperature. The solution is stable for months.
Cericammonium sulfate solution: Dissolve 48 g ceric ammonium sulfate in 1 litre 3.5N H2 SO4 . (The 3.5 N H2SO4 is made by slowly adding 97 mlconcentrated (36 N) H2 SO4 to about 800 ml deionizedwater (careful - this generates heat!), and when cool, adjusting with deionizedwater to a final volume of 1 litre). Store in a dark bottle away from light atroom temperature. The solution is stable for months. Standard iodine solution,1 µg iodine/ml (7.9 µmol/l): Dissolve 0.168 mg KIO3 in deionizedwater to a final volume of 100 ml (1.68 mg KIO3 contains 1.0 mgiodine; KIO3 is preferred over KI because it is more stable, but KIhas been used by some laboratories without apparent problems). It may be moreconvenient to make a more concentrated solution, e.g., 10 or 100 mg iodine/ml,then dilute to 1 µg/ml. Store in a dark bottle. The solution is stable formonths. Useful standards are 20, 50, 100, 150, 200, and 300 µg/l.
**Procedure**
1.Mix urine to suspend sediment.
2.Pipette 250 µl of each urine sample into a 13 x 100 mm test tube. Pipette eachiodine standard into a test tube, and then add H2O as needed to makea final volume of 250 µl. Duplicate iodine standards and a set of internalurine standards should be included in each assay.
3. Add 1 ml 1.0 M ammonium persulfate to eachtube.
4.Heat all tubes for 60 minutes at 100o C.
5.Cool tubes to room temperature.
6.Add 2.5 ml arsenious acid solution. Mix by inversion or vortex. Let stand for15 minutes.
7.Add 300 µl of ceric ammonium sulfate solution to each tube (quickly mixing) at15-30 second intervals between successive tubes. A stopwatch should be used forthis. With practice, a 15 second interval is convenient.
8. Allow to sit at room temperature. Exactly30 minutes after addition of ceric ammonium sulfate to the first tube, read itsabsorbance at 420 nm.
Read successive tubes at the same interval aswhen adding the cerric ammonium sulfate. Calculation of results
Constructa standard curve on graph paper by plotting iodine concentration of eachstandard on the abscissa against its optical density at 405 µg/l (OD405) on theordinate.
**Note: Allthe test reports will be made available to the parents on demand, wheneverrequired.**
**Quality Control:**
Theanalysis of salt’s iodine content, haemoglobin and urinary iodine will be done bytrained senior analysts at NABL accreditated Food Analysis and ResearchLaboratory, Centre of Food Technology, University of Allahabad.
**Disposal of Bio-hazardous wastes:**
At the end of eachblood collection and haemoglobin measurement, all materials used during thetesting (gloves, lancets, alcohol swabs, and gauze pads have to be placed insharps container (a wide-mouth plastic jar) and kept there until the end of theworking day. The following are the steps that would be followed in disposing ofbio- hazardous materials. First, a health investigator needs to determine aplace where the waste disposal will be destroyed. An open field area with loosesoil is preferable, since the materials need to be burnt and buried. Because ofrisk of fire, drought areas, as well as proximity to flammable materials,should be avoided.
1) At the end of each working day, bringthe sharps container (plastic jar) with bio- hazardous materials to the areaselected for the waste disposal. Add a half liter of 4 percent sodiumhypochlorite solution into the sharps container (plastic jar) with the bio- hazardousmaterials .After adding, close the container (jar) so it is airtight. The jarwould be kept in an upright position for five minutes. After that, the plasticjar would be inverted and kept in that position for an additional five minutes.This step is necessary to ensure that all of the materials in the sharpscontainer (plastic jar) are disinfected by complete immersion in the 4 percentsodium hypochlorite solution.
2) The contents of the plastic jar,including the sodium hypochlorite solution would be transferred to a thickpolyethylene bag.
3) A forceps can be used if any materialadheres or sticks to the walls of the plastic jar to transfer it to thepolyethylene bag.
4) With the help of Scissors, a hole willbe made at the bottom of the polyethylene bag.
5) The hypochlorite solution will bedrained off from the polyethylene bag.
6) A small hole will be dug with a spade toput the polyethylene bag containing the bio- hazardous materials in the pit.
7) The waste paper will be placed on thepolyethylene bag containing bio- hazardous.
8) Some kerosene would be poured on thebag.
9) Burn the polyethylene bag containing thebio hazardous materials in the pit.
10) Afterall of the contents are burned the pit will be covered with soil. It is thehealth investigator’s responsibility to ensure proper disposal of bio hazardouswaste.
It is unacceptable that the materials usedduring the testing in one fieldwork cluster are carried by the team to the nextcluster. Bio hazardous materials must be destroyed within 48 hours.
**Note:**Our department Centre of Food Technology runs a NABLaccreditated Food Analysis and Research Laboratory. The Ferro (waste collector)is appointed for this purpose and takes away the waste from the centre.
**StatisticalAnalysis:**
Theobtained data would be entered in MS-Office 2007Excel Worksheet and statistical analysis will be done using SPSS-12.0. Forcalculations of dietary and nutrient intake software DIETCAL will be usedaddition to the food tables. After categorization of data, the descriptivestatistics (frequency, distribution and percentages) will be calculated.
- Detailed Description
Not available
Recruitment & Eligibility
- Status
- Open to Recruitment
- Sex
- All
- Target Recruitment
- 571
children within the aforesaid age group will be included having authentic age proof records for verification of age.
- Complete Morbidity surveillance would be done by diagnosing the morbid condition like Diarrhea, Respiratory Infection, Ring Worm, Measles, Mouth Ulcer, Dysentery, Fever and Upper Respiratory Tract Infection (URTI) etc., during last 24 h of the time of interview.
- The children suffering from any morbidity at the time of survey were excluded.
- Subjects having presence of infection or inflammation or excessive bleeding due to bleeding disorders or injuries will be excluded from the assessment of status of both the minerals.
- Diagnostic tests would not be done clinically but yes the signs of symptoms if visible would definitely be taken into account (for example loose motions, vomiting, severe cough, fever etc.).
- It would be asked by the parents that if a child has been receiving medical treatment or medicines then that subject would not be interviewed further because in such condition the food preferences and anthropometric indices might give unrealistic values.
Study & Design
- Study Type
- Observational
- Study Design
- Not specified
- Primary Outcome Measures
Name Time Method To assess the nutritional status of the children (4-12 years) and identify the prevalence of PEM. 5 years To assess the prevalence of anaemia. 5 years To find out the prevalence of clinical signs and symptoms of common micronutrient deficiencies. 5 years To assess the dietary adequacy of micronutrients and correlate it with biochemical indices. 5 years
- Secondary Outcome Measures
Name Time Method To evaluate the efficiency of nutrition education and counselling on the previously assessed parameters of the primary outcomes 5
Trial Locations
- Locations (1)
University of Allahabad
🇮🇳Allahabad, UTTAR PRADESH, India
University of Allahabad🇮🇳Allahabad, UTTAR PRADESH, IndiaNeelam YadavPrincipal investigator05322460289neelam_aidu@yahoo.com