1 impact of multiple micronutrient … st. patimah.pdf · (riskesdas 2010 & 2013) 0 10 20 30 40...

IMPACT OF MULTIPLE MICRONUTRIENT

SUPPLEMENTATION ON NUTRITIONAL STATUS

AND GROWTH ON FEMALE ADOLESCENT

Presented at : International & National Scientific Meeting

PERSAGI

1

Yogyakarta : 27

Nopember 2014

SITTI PATIMAH, SURYANI AS’AD, VENI HADJU

PORTRAIT OF NUTRITIONAL STATUS OF INDONESIAN ADOLESCENT GIRLS

2

South Sulawesi : 13.1%

South Sulawesi (13,4%) National (10,9%)

Female Adolescent 16-18 yrs old

NUTRITIONAL STATUS

Stunting 32.5%, Wasting 7.7%%

(Riskesdas, 2010)

South Sulawesi

Stunting : 36.4%; wasting :13.6%

(Riskesdas, 2010)

Maros Regency : wasting 16,4%

(Riskesdas, 2007)

Anemia 30% (SKRT 2001), 5-

14 years old 12.8%

(Riskesdas,

2007)

B A C K G R O U N D

FIRST AGE MARRIAGE OF FEMALE ADOLESCENT IN INDONESIA

3

0

5

10

15

20

25

30

35

40

45

2010 2013

4.8 2.6

41.9

23.9

10-14 THN 15-19 THN

First age marriage of female (RISKESDAS 2010 & 2013)

0

10

20

30

40

50

60

70

80

10-14 thn 15-19 thn

0.5

77.1

0.3

53.9

pernah hamil per 1000 perempuan kelahiran 5 tahun terakhir

Riskesdas , 2010

4

WHO, 2002; WHO, 2005

Nutritional Status of Female Adolescents Contributes to The Nutritional Status of The Community

(Parimalavalli and Sangeetha, 2011)

5

MMN SUPPLEMENTATION ON FEMALE ADOLESCENT (/WHO/UNICEF/ UNIMMAP)

GROWTH & NUTRITIONAL STATUS

(BAZ & HAZ)

?

BACKGROUND

To compare of effect MMN & IFA supplement on body weight, height, nutritional status based on BAZ-score and HAZ-score on female adolescent with anemia

6

7

Study Design Randomized, double blind controlled trial

Location Senior High School 3, 4, 6, 8 dan 9 Maros

Time of study 28 January to 23 Agustus 2013

Sample size 148 persons

Baseline Intervention Effect

Subject (Female Adolescent) R

MMN Group

IFA Group

Respon Variable

Respon Variable

⁺

-

⁺

-

8

C O M P O S I T I O N

S U P P L E M E N T

Nutrient Dose RDA 2013

16-18 years old

Nutrient supply per a day

from each supplement

Multiple Micronutrient Supplement

Vitamin A (Retinol) 800 µg 600 RE (µg) 457.1

Vitamin D (Cholecalciferol) 200 IU (5 µg) 15 µg 2.86 µg

Vitamin E (Tocopherol) 10 mg 15 mg 5.71 mg

Vitamin B-1 (Thiamin HCL) 1.4 mg 1.1 mg 0.8 mg

Vitamin B-2 (Riboflavin) 1.4 mg 1.3 mg 0.8 mg

Niacin (Nicotinamide) 18 mg 12 mg 10.29 mg

Asam Folat 400 µg 400 µg 228.57 µg

Vitamin B-6 (Pyridoxine) 1.9 mg 1.2 mg 1.09 mg

Vitamin B-12

(Cyanocobalamin) 2.6 µg 2.4 µg 1.49 µg

Vitamin C (As. Ascorbat) 70 mg 75 mg 40 mg

Zink (zinc sulphate) 15 mg 14 mg 8.57 mg

Iron (Ferrous fumarate) 30 mg 26 mg 17.14 mg

Copper (Copper sulfate) 2 mg 890 mcg 1.14 mg

Selenium (Sodium selenite) 65 µg 30 µg 37.14 µg

Iodine (potassium iodide) 150 µg 150 µg 85.71 µg

Iron-Folic Acid Supplement

Iron (ferrous sulfat) 60 mg 26 mg 17.14 mg

Folic acid 250 µg 400 µg 71.42 µg

Table 1. The composition of the multiple micronutrients (MMN) and iron-folic acid supplement,

nutrient supply from each supplements for adolescent girls

Supplement consumption : twice weekly for 26 weeks

Quality C

ontrol & E

thic Aspect

9

POWER OF RESEARCH

Standardization of field workers by training Socialization to the principal, classroom teachers, and

guidance and counseling teacher Validation anthropometric instrument Calibration

tool Weight and height body measurements conducted by

researchers assisted the enumerators Supplements are given by the class teacher

accompanied the research team

10

The progress of the

research sample

R

E

S

U

L

T

DO 37 org (25%)

IFA = 19 org (26%); MMN =

18 org (24%)

(p = 0.78)

Number of Subjects Screened (N = 1064) persons

The number of subjects who’s Anemia

(HemoCue)

(N = 148 org)

Not fulfill inclusion & exclusion criteria = 916

RANDOMIZATION

IFA (n = 73) MMN (n = 75)

Sample 1st Mo (n = 63)

Sample 1st Mo (n = 62)

Sample 2nd Mo (n = 56)

Sample 3rd Mo ( 59 )

Sample 3rd Mo

(56)

Sample 4th Mo

(n = 57)

Sample 4th Mo (n = 55)

Baseline

4 weeks intervention DO = 9 prs


12 weeks

intervention

Baseline


12 weeks

intervention

Sample 5th

Mo (no = 54)


Sample 2nd Mo (n = 59)

16 weeks intervention

DO = 2 prs

Sample 5th

Mo (n = 57)



DO = 1 prs



Sampel 7th Mo (n =57)

Sampel 7th Mo (n = 54)






11

Timing DO Reasons IFA [n, %] MMN [n, %]

1st Month

Maag/Heartburn 4 (5,5) 9 (12,0)

Nausea, Vomiting 2 (2,7) -

Abdominal paint 2 (2,7) 2 (2,7)

Headache/dizziness 1 (1,4) 2 (2,7)

2nd Month

Maag/Heartburn 1 (1,4) 1 (1,3)

Nausea, Vomiting 4 (5,5) -

Headache/dizziness 2 (2,7) 2 (2,7)

Change school 1 (1,4)

4th Month Maag/Heartburn 1 (1,4) 1 (1,3)

Dizzines, Nausea, Vomiting - 1 (1,3,)

5th Month Dizzines, Nausea 1 (1,4) -

R

E

S

U

L

T

Table 1. The reason of the subject to Drop Out (DO)

12

Table 2. Sample Characteristics Before Intervention

R

E

S

U

L

T

Variable IFA n (%) MMN n (%) Total N (%) P value

Age (yo) 16,02±0,8* 16,17±0,8* 16,09±0,8* 0,201

14

15

16

17

18

6 (11,1)

20 (37,0)

22 (40,7)

6 (11,1)

0 (0,0)

2 (3,5)

21 (36,8)

27 (47,4)

5 (8,8)

2 (3,5)

8 (7,2)

41 (36,9)

49 (44,1)

11 (9,9)

2 (1,8)

menstrual age (yo) 12,98±0,9* 13,25±0,9* 13,12±0,9* 0,082

11

12

13

14

15

1 (1,9)

17 (31,5)

23 (42,6)

8 (14,8)

5 (9,3)

1 (1,8)

9 (15,8)

27 (47,4)

15 (26,3)

5 (8,8)

2 (1,8)

26 (23,4)

50 (45,0)

23 (20,7)

10 (9,0)

Pocket Money (IDR/day) 12648±8077* 10710±5654* 11653±6975* 0,312

≥ 10,000

< 10,000

35 (64,8)

19 (35,2)

36 (63,2)

21 (36,8)

71 (64,0)

40 (36,0)

Money to buy snacks (IDR/day) 6462±4546* 5271±2208* 5851±3577* 0,582

≥ 10,000

< 10,000

13 (24,1)

41 (75,9)

4 (7,0)

53 (93,0)

17 (15,3)

94 (84,7)

Weight (kg) 45,09±7,5 45,02±7,6 45,05±7,5 0,992

Height (cm) 151,3±4,7 151,7±4,9 151,5±4,8 0,671

HAZ-score -1,69±0,7 -1,59±0,7 -1,61±0,7 0,761

BAZ-score -0,52±0,9 -0,58±0,8 -0,55±0,9 0,771

13

Table 3. Family Characteristics of Respondents

R

E

S

U

L

T

Variable IFA

n (%)

MMN

n (%)

Total

N (%)

p value

Family Size (person) 5,9±2,0* 5,7±2,2* 5,8±2,1* 0,61

≤ 4

5-6

≥ 7

15 (27,8)

28 (51,9)

11 (20,4)

17 (29,8)

23 (40,4)

17 (29,8)

32 (28,8)

51 (45,9)

28 (25,2)

Education Fathers (yo) 9,6±3,9* 8,9±3,9* 9,2±3,9* 0,47

None

Unfinished primary school

Completed primary school

Unfinished secondary school

Completed secondary school

Unfinished high school

Completed high school

Diploma/Graduate

1 (1,9)

11 (20,4)

5 (9,3)

4 (7,4)

10 (18,5)

0 (0,0)

14 (25,9)

9 (16,7)

2 (3,5)

10 (17,5)

13 (22,8)

2 (3,5)

6 (10,5)

1 (1,8)

17 (29,8)

6 (10,5)

3 (2,7)

21 (18,9)

18 (16,2)

6 (5,4)

16 (14,4)

1 (0,9)

31 (27,9)

15 (13,5)

Education Mothers (yo) 8,9±4,0* 8,3±3,5* 8,6±3,8* 0,48

None

Unfinished primary school

Completed primary school

Unfinished secondary school

Completed secondary school

Unfinished high school

Completed high school

Diploma/Graduate

3 (5,6)

13 (24,1)

3 (5,6)

0 (0,0)

14 (25,9)

0 (0,0)

15 (27,8)

6 (11,1)

1 (1,8)

10 (17,5)

19 (33,3)

3 (5,3)

5 (8,8)

1 (1,8)

14 (24,6)

4 (7,0)

4 (3,6)

23 (20,7)

22 (19,8)

3 (2,7)

19 (17,1)

1 (0,9)

29 (26,1)

10 (9,0)

14

R

E

S

U

L

T

Table 4. Intake of Nutrient of Female Adolescent Before Intervention

Nutrients

Age 14-15 yo p

Value# IFA

%RDA MMN

%RDA RDA

2013 mean±SD mean±SD

Energy (kkal) 1478,0±695,8 69,6 1495,1±522,6 70,4 2125 0,561

Protein (g) 46,8±18,7 67,8 54,6±29,8 79,1 69 0,284

Vit.A (RE) 366,2±565,8 61,0 367,5±403,6 61,2 600 0,920

Vit.B1 (mg) 0,2±0,4 17,5 0,3±0,4 23,7 1,1 0,570

Vit. B2 (mg) 0,6±0,6 44,4 0,7±0,6 50,2 1,3 0,663

Vit. B3 (mg) 6,1±2,6 50,9 7,3±5,8 60,5 12 0,612

Vit. B6 (mg) 0,8±0,5 70,5 0,9±0,4 76,1 1,2 0,593

Vit. B12 (µg) 2,6±1,4 107,4 2,6±1,6 106,9 2,4 0,943

Asam Folat (µg) 97,9±49,9 24,5 103,8±52,7 26,0 400 0,645

Vit. C (mg) 33,8±84,9 52,1 14,3±21,9 22,1 65 0,602

Vit. D (mg) 7,3±5,8 48,9 7,2±5,7 47,8 15 0,896

Vit. E (mg) 4,7±3,2 31,0 4,2±2,9 27,8 15 0,544

Fe (mg) 6,2±4,6 23,8 6,5±3,8 25,1 26 0,225

Zn (mg) 4,9±2,4 30,5 5,4±2,4 33,7 16 0,243

# Mann Whitney Test

15

Nutrients

Age 16-18 yo

p Value# IFA %RDA

MMN %RDA RDA

mean±SD mean±SD

Energy (kkal) 1673,8±629,7 78,8 1496,3±630,4 70,4 2125 0,198

Protein (g) 54,3±22,9 92,1 52,6±23,9 89,1 59 0,620

Vit.A (RE) 349,4±263,8 58,2 355,3±351,3 59,2 600 0,400

Vit.B1 (mg) 0,4±0,4 35,1 0,3±0,4 27,5 1,1 0,712

Vit. B2 (mg) 0,7±0,7 54,8 0,7±0,6 51,2 1,3 0,830

Vit. B3 (mg) 7,3±3,9 60,5 7,1±5,7 59,0 12 0,333

Vit. B6 (mg) 0,8±0,5 64,5 0,8±0,5 65,6 1,2 0.689

Vit. B12 (µg) 2,6±1,7 108,4 3,3±2,9 136,5 2,4 0,473

Folic Acid (µg) 120,2±58,3 30,1 109,4±69,3 27,3 400 0,229

Vit. C (mg) 16,5±21,6 22,0 15,5±16,8 20,6 75 0,483

Vit. D (mg) 7,0±5,7 46,8 7,0±4,8 46,7 15 0,701

Vit. E (mg) 4,9±3,0 32,7 3,8±2,7 25,3 15 0,087

Fe (mg) 8,2±5,4 31,5 6,9±5,0 26,4 26 0,157

Zn (mg) 5,9±2,6 42,2 5,2±2,4 37,5 14 0,290

# Mann Whitney Test

………..continue

R

E

S

U

L

T

16

R

E

S

U

L

T

Table 5. Compliance of supplement consumption on Both Intervention

Group

Variable

BAF Group

(mean±SD)

n = 54

MMN Group

(mean±SD)

n = 57

Total

(mean±SD)

n = 111

p Value

The number of supplements

taken (seed)

(min-max)

45,56±3,7

(36 – 51)

45,9±3,7

(34 – 51)

45,8±3,7

(34 – 51) 0,6121

% supplement consumption

(min-max)

87,6±7,1

(69,2 – 98,1)

88,3±7,0

(65,4 – 98,1)

87,97±7,1

(65,4 – 98,1) 0,6121

Compliance supplements

[n,(%)] 0,8112

≥ 80% 46 (85,2) 50 (87,1) 96 (86,5)

70 – 79% 6 (11,1) 6 (10,5) 12 (10,8)

< 70% 2 (3,7) 1 (1,8) 3 (2,7)

1 mann whitney; 2 chi-square

17

Nutrient

Supplement

Contribution

/day

% from

intake

total

Mean of

micronutrien

t intake

% from

intake

total

Intake Total

(Supl+Intake)

%

RDA

RDA

2013

IFA Group

Iron (mg) 17,4 77,3 5,1 22,7 22,5 86,5 26

Folic acid (µg) 71,4 42,3 97,2 57,7 168,6 42,1 400

MMN Group

Vitamin A (RE) 457,1 51,5 429,9 48,5 887 147,8 600

Vitamin D (µg) 2,86 33,8 5,6 66,2 8,46 56,4 15

Vitamin E (mg) 5,71 55,9 4,5 44,1 10,21 68,1 15

Vitamin B-1 (mg) 0,8 65,0 0,43 35 1,23 111,8 1,1

Vitamin B-2 (mg) 0,8 57,1 0,6 42,9 1,4 107,7 1,3

Niacin (mg) 10,29 58,8 7,2 41,2 17,49 145,7 12

Vitamin B-6 (mg) 1,09 57,7 0,8 42,3 1,89 157,5 1,2

Asam Folat (µg) 228,57 65,5 120,5 34,5 349,07 87,3 400

Vitamin B-12 (µg) 1,49 34,7 2,8 65,3 4,29 178,8 2,4

Vitamin C (mg) 40 67,0 19,7 33,0 59,7 91,8 65

Zink (mg) 8,57 59,6 5,8 40,4 14,37 89,8 16

Zat besi (mg) 17,14 70,1 7,3 29,9 24,44 94,0 26

Copper (µg) 1,14 800

Selenium (µg) 37,14 30

Iodine (µg) 85,71 150

Table 6. Supplement and Intake Contribution on total intake of micronutrient per

day for age group 14-15 yo after intervention

R

E

S

U

L

T

18

Table 7. Contribution of Supplement and Intake on total intake of micronutrient

per day for age group 16-18 yo after intervention

Nutrient Supplement

Contribution/d

ay

% from

intake

total

Mean of

micronutri

ent intake

% from

intake

total

Intake Total

(Supl+Intake)

%

RDA

RDA

2013

IFA group

Fe (mg) 17,4 72,2 6,7 27,8 24,1 92,7 26

Folic acid (µg) 71,4 37,6 118,5 62,4 189.9 47,5 400

MMN Group

Vitamin A (RE) 457,1 59,3 313,8 40,7 770,9 221,7 600

Vitamin D (µg) 2,86 30,2 6,6 69,7 9,46 63,1 15

Vitamin E (mg) 5,71 64,1 3,2 35,9 8,91 59,4 15

Vitamin B-1 (mg) 0,8 66,7 0,4 33,3 1,2 109,1 1,1

Vitamin B-2 (mg) 0,8 61,5 0,5 38,5 1,3 100,0 1,3

Niacin (mg) 10,29 58,2 7,4 41,8 17,69 147,4 12

Vitamin B-6 (mg) 1,09 57,7 0,8 42,3 1,89 157,5 1,2

Asam Folat (µg) 228,57 68,4 105,7 31,6 334,27 83,6 400

Vitamin B-12 (µg) 1,49 31,1 3,3 68,9 4,79 220,4 2,4

Vitamin C (mg) 40 69,7 17,4 30,3 57,4 76,5 75

Zinc (mg) 8,57 59,6 5,8 40,4 14,37 102,6 14

Iron (mg) 17,14 73,1 6,3 26,9 23,44 90,1 26

Copper (µg) 1,14 890

Selenium (µg) 37,14 30

Iodine (µg) 85,71 150

R

E

S

U

L

T

19

Table 8 : Average on body weight, height, BAZ-Score and HAZ score

before and after intervention

Variable

Intervention Groups

p Value IFA

(mean±SD) n = 54

MMN (mean±SD)

n = 57

Total (mean±SD)

N = 111

Body weight (kg)

Baseline 45,09±7,55 45,02±7,58 45,05±7,53 0,993# (min-max) (34,70-76,00) (35,00-76,50) (34,70-76,50) Endline 45,55±7,78 45,49±7,56 45,52±7,63 0,839# (min-max) (34,85-73,80) (33,85-75,20) (33,85-75,20) Diffrence 0,46±2,1 0,47±2,3 0,47±2,2 0,918# p value 0,289* 0,226* 0,106*

Height (cm)

Baseline 151,3±4,7 151,7±4,9 151,5±4,8 0,6661 (min-max) (140,8-165,2) (140,5-164,4) (140,5-165,2)

Endline 151,8±4,8 152,3±4,9 152,1 ±4,8 0,6511 (min-max) (140,8-165,4) (142,5-165,1) (140,8-165,4) Diffrence 0,53±0,42 0,55±0,45 0,54±0,44 0,8471

p value 0,0002 0,0002 0,0002

BAZ-score

Baseline -0,52±0,98 -0,57±0,88 -0,55±0,92 0,7681 (min-max) (-1,99 -1,81) (-2,16 - 2,29) (-2,16 – 2,29) Endline -0,55±1,01 -0,60±0,89 -0,58,1 ± 0,95 0,7771 (min-max) (-2,43 -1,88) (-2,34 - 2,12) (-2,43 - 2,12) Diffrence -0,03±0,38 - 0,03±0,43 -0,03±0,41 0,9931

p value 0,6042 0,6482 0,4912

HAZ-score

Baseline -1,63±0,69 -1,59±0,73 -1,61±0,71 0,7561 (min-max) (-2,96 - 0,39) (-3,30 - 0,28) (-3,30 - 0,39) Endline -1,58±0,75 -1,55±0,73 -1,57 ± 0,74 0,8511 (min-max) (-3,05 - 0,39) (-3,05 - 0,35) (-3,05 - 0,39) Diffrence 0,05±0,21 0,03±0,07 0,04±0,15 0,5971 p value 0,0972 0,0012 0,0072

#Mann whitney; *Wilcoxon, 1T Independent Test; 2Paired T Test

R

E

S

U

L

T

20

Variable

Group

p Value IFA

(mean±SD)

MMN

(mean±SD)

Total

(mean±SD)

14-15 yo

Weight

(kg)

Baseline 44,98±7,82 46,47±9,58 45,58±8,41 0,739#

(min-max) (36,30-61,85) (35,00-67,55) (35,70-67,55)

Endline 46,32±9,03 47,48±10,22 46,78±9,33 0,739#

(min-max) (36,05-69,35) (34,60-67,95) (34,60-69,35)

Difference 1,34±2,47 1,01±2,05 1,21±2,27 0,935#

p value 0,073* 0,139* 0,016*

Height

(cm)

Baseline 151,7±5,29 151,9±5,14 151,8±5,12 0,924##

(min-max) (140,8-160,0) (144-159,9) (140,8-160,0)

Endline 152,3±5,48 152,4±5,2 152,4±5,26 0,984##

(min-max) (140,80-161,0) (144,5-160,5) (140,8-161,0)

Difference 0,65±0,51 0,49±0,42 0,59±0,47 0,407##

p value 0,001** 0,005** 0,000**

16-18 yo

Weight

(kg)

Sebelum 45,14±7,96 45,65±7,75 45,42±7,78 0,713#

(min-max) (34,70-76,00) (35,40-76,50) (34,70-76,50)

Sesudah 45,09±7,43 45,85±7,44 45,51±7,39 0,529#

(min-max) (34,85-73,80) (33,85-75,20) (33,85-75,20)

Selisih -0,05±1,9 0,20±2,3 0,09±2,1 0,697#

P value 0,690* 0,993* 0,793*

Height

(cm)

Sebelum 151,3±4,4 152,4±5,4 151,9±4,96 0,366##

(min-max) (144,0-165,2) (140,5-164,4) (140,5-165,2)

Sesudah 151,7±4,5 153,0±5,3 152,4 ±4,95 0,305##

(min-max) (144,6 -165,4) (142,5-165,1) (142,5-165,4)

Selisih 0,4±0,4 0,6±0,5 0,5±0,4 0,166##

P value 0,000** 0,000** 0,000**

*ujwilcoxon; # Mann Whitney; ** T berpasangan; ## T independent

Table 9. Anthropometric measurement subject before and after

intervention based on age group

R

E

S

U

L

T

21

1= paired T Tes 2= Independent T Test

Groups

BAZ

Baseline

(mean±SD)

BAZ Endline

(mean±SD)

Difference

(mean±SD)

Median BAZ Baseline

(min-max)

Median BAZ Endline

(min-max)

p

Value

IFA -0.52±1.1

(n = 15)

-0.41±1.2

(n = 15) 0.11±0.5 -0.65 (-1.98 - 1.73) -0.60 (-2.41 - 1.88) 0.3661

MMN -0.24±1.1

(n = 10)

-0.26±1.2

(n = 10) -0.02±0.3 -0.21 (-1.60 - 2.19) -0.07 (-1.77 - 2.08) 0.8751

Total -0.41±1.1

(n = 25)

-0.35±1.2

(n = 25) 0.06±0.4 -0.61 (-1.98 - 2.19) -0.54 (-2.41 - 2.08) 0.4621

p Value 0.5502 0.7662 0.7232

Table 10. BAZ-score Baseline and End line Age 14 – 15 yo Between Group

Intervention, Before and After Intervention

22

1= paired T Test 2= T Independent Test

Groups HAZ

baseline (mean±SD)

HAZ

endline (mean±SD)

Difference

(mean±SD)

Median HAZ

baseline

(min-max)

Median HAZ

endline

(min-max)

p

Valu

e

IFA

(n = 15) -1.44±0.7 -1.35±0.9 0.09±0.4 -1.41 (-2.92 – (-0.30)) -1.32 (-3.05 – 0.31) 0.3741

MMN

(n = 10) 1.42±0.8 -1.44±0.8 -0.02±0.1 -1.09 (-2.66 – (-0.28)) -1.12 (-2.65 – (-0.27)) 0.3711

Total

(n = 25) -1.43±0.7 -1.39±0.8 0.05±0.3 -1.38 (-2.92 – (-0.28)) -1.30 (-3.05 - 0.31) 0.4401

p Value 0.93 0.812 0.612

Table 11. HAZ-score Baseline and Endline Subject Age 14-15 yo Between

Group Intervention, Before and After Intervention

23

Indikator Kel. BAF Kel. MGM Total

Sebelum Sesudah Sebelum Sesudah Sebelum Sesudah

Status Gizi (IMT/U) [n, (%)] Obes 0 0 1 (10,0) 1 (10,0) 1 (4,0) 1 (4,0)

Gemuk 2 (13,3) 3 (20,0) 0 0 2 (8,0) 3 (12,0)

Kurus 0 2 (13,3) 0 0 0 2 (8,0)

Normal 13 (86,7) 10 (66,7) 9 (90,0) 9 (90,0) 22 (88,0) 19 (76,0)

Status Gizi (TB/U) [n, (%)] Sangat pendek 0 1 (6,7) 0 0 0 1 (4,0)

Pendek 3 (20,0) 2 (13,3) 3(30,0) 3(30,0) 6 (24,0) 5 (20,0)

Normal 12 (80,0) 18 (64,3) 7 (70,0) 7 (70,0) 19 (76,0) 19 (76,0)

Status Gizi (IMT/U Dan TB/U) Subyek Umur 14-15 Tahun

Sebelum dan Setelah Intervensi

24

Indikator Kel. BAF Kel. MGM Total

Sebelum Sesudah Sebelum Sesudah Sebelum Sesudah

Status Gizi (IMT/U) [n, (%)] Obes 0 0 1 (2,9) 1 (2,9) 1 (1,6) 1 (1,6)

Gemuk 2 (7,1) 2 (7,1) 0 1 (2,9) 2 (3,2) 3 (4,8)

Kurus 0 1 (3,6) 1 (2,9) 1 (2,9) 1 (1,6) 2 (3,2)

Normal 26 (92,9) 25 (89,3) 32 (94,1) 31 (91,2) 58 (93,5 56 (90,3)

Status Gizi (TB/U) [n, (%)] Sangat pendek 0 0 1 (2,9) 1 (2,9) 1 (1,6) 1 (1,6)

Pendek 11 (39,3) 10 (35,3) 8 (30,0) 6 (17,6) 19 (30,6) 16 (25,8)

Normal 17 (60,7) 18 (64,3) 25 (70,0) 27 (79,4) 42 (67,7) 45 (72,6)

Status Gizi (IMT/U dan TB/U) Subyek Umur 16-18 Tahun

Sebelum dan Setelah Intervensi

25

Nutritional Status Subject of Age 14 – 15 yo Before and After Intervention

0

20

40

60

80

Severe stunted -->stunted

Stunted --> Stunted Normal --> Normal

6.7 13.3

80

0

30

70

IFA MMN

Chi-square IFA (p=0.001); MMN (p=0.008)

Chi-square IFA (p = 0.010); MMN (p = 0,002)

0

20

40

60

80

100

Normal -->Normal

Normal -->Thinnes

Normal -->Overweight

Overweight -->Overweight

Obes --> Obes

66.7

13.3 6.7

13.3

0

90

0 0 0 10

IFA MMN

26

Groups

BAZ

Baseline

(mean±SD)

BAZ

Endline

(mean±SD)

Difference

(mean±SD)

Median BAZ

Baseline

(min-max)

Median BAZ

Endline

(min-max)

p

Value

IFA

(n = 28) -0.57±0.9 -0.66±0.9 -0.08±0.3 -0.67 (-1.88 - 1.81) -0.78 (-2.14 - 1.59) 0.2161

MMN

(n = 34) -0.59±0.9 -0.66±0.8 -0.06±0.4 -0.70 (-2.16 - 2.29) -0.66 (-2.34 - 2.12) 0.3741

Total

(n = 62) -0.58±0.9 -0.66±0.8 -0.07±0.4 -0.70 (-2.16 - 2. 29) -0.69 (-2.34 - 2.12) 0.1411

p Value 0.9402 0.9962 0.9942

Ket 1= paired T Test 2= T Independent Test

Table 12. BAZ-score Baseline and End line subject Age 16-18 yo Between

Group Intervention, Before and After Intervention

27

Groups

HAZ

Baseline

(mean±SD)

HAZ

Endline

(mean±SD

Difference

mean±SD

Median HAZ

Baseline

(min-max)

Median HAZ

Endline

(min-max)

p

Value

IFA

(n = 28) -1.71±0.7 -1.68±0.7 0.03±0.05 -1.88 (-2.79 - 0.39) -1.82 (-2.74 - 0.39) 0.0081

MMN

(n = 34) -1.53±0.8 -1.48±0.8 0.05±0.07 -1.62 (-3.30 - 0.28) -1.53 (-3.05 – 0.35) 0.0001

Total

(n = 62) -1.61±0.7 -1.57±0.7 0.04±0.06 -1.66 (-3.30 - 0.39) -1.65 (-3.05 - 0.39) 0.0001

P Value 0.3552 0.2962 0.2252

Ket 1=T Independent Test 2= paired T Test

Table 13. HAZ-score Baseline and End line Subject Age 16-18 yo Between Group,

Before and After Intervention

28

Nutritional Status Subject of Age 16 – 18 yo Before and After Intervention

0

10

20

30

40

50

60

70

80

Severe stunted -->stunted

Stunted --> Stunted Stunted --> Normal Normal --> Normal

0

35.7

3.6

60.7

2.9

17.6

5.9

73.4

IFA MMN

0

20

40

60

80

100

Normal -->Normal

Normal -->Overweight

Thinnes -->Thinnes

Overweight -->Overweight

Obes --> Obes

89.3

3.6 0

7.1 0

91.2

2.9 2.9 0 2.9

IFA MMN

Chi- square IFA ( p = 0,000); MMN (p = 0,000)

Chi- square IFA (p = 0.000) ; MMN (p = 0,000

29

D

I

S

C

U

S

S

I

O

N

Changes in Nutritional Status (BAZ-score & HAZ) 14-15 yo)

IFA MMN

Mean BAZ-score ↑ (p>0.05) Mean BAZ-score ↓

(p>0.05)

BAZ-score

o earlier menstruation age (12.80±0.7

yo) (r = 0.515; p = 0.049),

o Increased body weight by 1,34±2.47

kg (r = 0.954; p = 0.000).

oDecreased levels of IGF-1 endline by

2.34±3.15 ng/ml (r = -0.657; p =

0.039)

oNeutrofil level baseline 54.1± 9.0% (r

= -0.766, p = 0.010)

oMonosit level baseline 6.9±1.5% (r =

0.765, p = 0.010).

30

o Earlier menstruation age (12.80±0.7 yo) (r = 0.567

p = 0.028) Earlier menstruation age IGF-1 concentrations

higher stimulates the proliferation and

differentiation of cells the growth of cells

and tissues

Menstrual delay leaving less time physiological

and anatomical maturation before becoming

pregnant, because bone growth is not perfect until a

few years after menstruation

o Increase the body weight Increasing Weight: IFA> MMN group

IFA

D

I

S

C

U

S

S

I

O

N

31

o Decreased level of IGF-1

IGF-1 The main regulator of somatic

growth and cell proliferation working

through the IGF-1 receptor. o The presence of inflammatory (neutrofil & monosit)

Increased inflammatory markers decreased levels of IGF-1 through the

suppression of GH-IGF-1axis mediate

failure of linear growth and nutritional status

disorders (Prendergast et al., 2014). interaction between the immune system and

endocrine is essential maintaining a balance

(Maggio M et. al., 2013).

MMN

D

I

S

C

U

S

S

I

O

N

32

∆ BAZ-score 14-15 yo → IFA = MMN (p = 0.723)

ANCOVA

Test

Weight gain

(effect size = 0,338; p = 0,011)

Height gain (effect size = 0,379; p = 0,009

Confounding

Factor

∆ Weight IFA (1.34±2.47 kg) vs MMN (1.01±2.05 kg)

∆ Height IFA (0.65±0.51 cm) vs MMN (0.49±0.42)

D

I

S

C

U

S

S

I

O

N

33

Change of Nutritional Status (BAZ score) 16-18 yo

BAZ-score MMN IFA

BAZ Score ↓ (p>0.05)

BAZ score ↓ (p>0.05) >

Correlation Test o Thiamine intake endline

(r = 0.348; p = 0.044) o Folic acid intake endline

(r = 0.394; p = 0.021) o Monosit level endline (r

= 0.379; p = 0.020) o ∆ BW (r = 0.950; p =

0.000) o ∆ Height (r = -0.436 p =

0.010)

Correlation Test o Energy intake endline (r = -0.383; p = 0.044) o Vit. A intake endline (r = -0.510; p = 0.000) o Vit E intake endline (r = -0.441; p = 0.019) o Vit B1 intake endline (r = -0.543; p = 0.003) o Folic Acid intake endline (r = -0.579; p = 0.001) o Fosfor intake endline (r = -0.451; p = 0.016) o Fe intake endline (r = -0.379; p = 0.047) o Decreased of body weight -0.05±1.9 kg (r

= 0.970; p = 0.000)

o Increased of height 0.20±2.3 cm (r = -

0.501; p = 0.007)

D

I

S

C

U

S

S

I

O

N

34

o Energi intake endline Energy cells functional system (synthesis of cell

components) synthesis and growth Energy deficiency weight loss and tissue damage Chronic energy deficiency loss of energy

reserves and lean mass o Vit B Intake Vit. B coenzyme paired with cell enzyme control

of energy metabolism and tissue build

D

I

S

C

U

S

S

I

O

N

35

o Vit E Intake Vit E antioxidant (Vit E, C, glutation peroxydase)

protect cells and tissues from free radical

damage by breaking the chain reaction of

oxidation oChanges in body weight and height BMI standard for evaluating the weight to height.

Weight loss is correlated with total body fat, muscle

mass, or the extracellular fluid and bone mass that

may contribute to the high weight.

D

I

S

C

U

S

S

I

O

N

36

↓BAZ-score 16-18 yo → IFA = MMN (p = 0.994)

ANCOVA test

o

o∆ Body Weight (ES = 0.960; p = 0.000)

IFA (-0.05±1.9 kg) vs MMN (0.20±2.3 kg)

o ∆ Body Height (ES = 0.426; p = 0.000)

IFA (0.4±0,4 cm) vs MMN (0.6±0.5 cm)

Reduced in BAZ-score is higher in IFA groups – increasing in height lower in IFA group (0.4 ± 0.4 cm) compared to subjects in MMN group (0.6±0.5 cm), the size of body weight decreased after the intervention by 0.05 ± 1.9 kg in IFA group, otherwise, for MMN group, the size of body weight increased by 0.20±2.3 kg. Decreased in BAZ-score in both treatment groups due to the

change of body height (m2) as the denominator BAZ faster than body weight (numerator).

D

I

S

C

U

S

S

I

O

N

Based on the age of subject that obtained of same supplement :

IFA Supplement

Increased of BAZ-score in 14-15 yo VS 16-18 yo decreased

in the younger age groups in conjunction growth spurt in adolescents and increased iron requirements

MMN Supplement

impairment HAZ-score in both age groups is not due to the effect of treatment but due to other factors such as intake of various nutrients are reduced, levels of IGF-1 decreased and the presence of inflammation

37

D

I

S

C

U

S

S

I

O

N

38

Kanani et. al (2000) IFA supplementation in girls aged 14-

18 years for 3 months did not have a significant effect on BMI

change the subject FA

Systematic review of 201 studies conducted by Das et. al.

(2013) that the fortification multi micronutrient not

associated with WAZ (weight for age z-scores) and WHZ

(weight for height z-scores)

D

I

S

C

U

S

S

I

O

N

39

HAZ-score

Mean HAZ-score ↑ (p>0.05)

o Early Menstruation age (2.93±0.7 hari) (r = 0.567 p = 0.049) o Protein intake endline ↓ : 40.6±18.7 g (r = -0.536,

p = 0.040) o Increasing of body height by 0.65±0.51 cm (r =

0.970, p = 0.000)

14-15 yo

(IFA)

D

I

S

C

U

S

S

I

O

N

40

o First menstruation age

Early menstrual age IGF↑ working through the

IGF-1 receptor proliferation of bone chondrosit enhance the growth of long bones

Protein intake endline ↓ Def. energy & Protein restrict of IGF-1 synthesis

significantly causing 50% reduction of IGF-1 concentration in circulation

o Increasing of body height

Height parameter of measurement HAZ-score

Height ↑ HAZ-score

D

I

S

C

U

S

S

I

O

N

41

HAZ-score

Mean HAZ-score ↓ (p>0.05)

o

oProtein intake endline ↓ ( 50.4±22.9 g) (r = -0.845, p = 0.050) oThiamin intake endline↓ (0.4±0.2 mg) (r = -0.632, p = 0.050) o Riboflavin intake tendline ↓ (0.5±0.4 mg) (r = -0.796, p = 0.006) o Niacin intake endline ↓ (7.4±4.6 mg) (r = -0.748, p = 0.013) o Pyridoxine endline ↓ (0.8±0.7 mg) (r = -0.790, p = 0.007) o Folic acid endline ↓ (105.7±65.9 µg) (r = -0.692, p = 0.027) o Cyanocobalamine intake endline ↓ (3.3±2.7 µg) (r = -0.869, p =

0.001) o Fe intake endline ↓ (6.3±3.9 mg) (r = -0.754, p = 0.012) o Zn intake endline ↓ (5.8±5.2 mg) (r = -0.839, p = 0.002)

14-15 yo

(MMN) D

I

S

C

U

S

S

I

O

N

42

oVit B1, B2, B3, B6, asam folat & B12 intake endline ↓ B1 Coenzyme that controls energy metabolism. B1 Deficiency loss body weight B2 Coenzyme FMN & FAD metabolism energy ,

protein, carbohydrate and fat acid ATP cellular

respiration in mitochondria. B2 ↓ FMN and FAD concentrations in tissue reduced changes in the structure and function B3 synthesis of protein (histone) in the cell nucleus bound

to DNA help repair DNA strand fragments resulting from

the oxidation, radiation and environmental stressors. Def. B3 disorders of growth and nutritional status

oProtein intake endline ↓ Protein ↓ limiting the synthesis of IGF-1 concentrations

of IGF-1 and GH receptor decreases in circulating linear

growth disturbance

D

I

S

C

U

S

S

I

O

N

43

B6 plays a role in the synthesis of RNA and

DNA, coenzyme (PLP) metabolism of

proteins, fats, and glucose , nucleic acid

Def. B6 impaired growth and nutritional

status Folic Acid DNA & RNA Production in growth &

cell differenciation growth & developlment B12 co-factor metionin sintetase and

metilmalonin-KoA mutase enzyme normal

function of all cells metabolism & synthesis of nucleic acid & DNA

D

I

S

C

U

S

S

I

O

N

44

oIron Intake synthesis Hb supply/transport O2 growth of

cell & tissue. not influence growth directly through hormone

system BUT encourage growth when iron reserve depleted sickness growth failure

Def. delivery of O2 to tissue↓ & functional activity of enzyme containing iron in various tissue ↓

D

I

S

C

U

S

S

I

O

N

45

o Zinc Intake plays a role in cell proliferation through: enzyme system division & cell proliferation (DNA

polymerase, RNA polymerase ) & regulate synthesis of DNA & RNA

hormone regulation (GH & IGF-1) signaling of IGF-1 hormone induction of proliferation and division cell

zinc containing nucleoprotein gen expression of protein growth

D

I

S

C

U

S

S

I

O

N

46

∆ HAZ-score 14-15 Yo → IFA = MMN (p = 0.384)

ANCOVA Test

oFirst age of menstruation(ES : 0.457; p = 0.032)

o Protein intake endline (ES: 0.409; p =0.046)

oVit. B3 intake endline (ES : 0.402; p = 0.049)

Menstruation Age faster in IFA group (12.80 ± 0.7 yo)

vs. the MMN group (13.20 ± 1.2 yo) followed at

increase in the value of the HAZ-score Intake of protein and vitamin B3 endline higher in

MMN group vs. IFA group

D

I

S

C

U

S

S

I

O

N

47

HAZ-score

16-18 yo IFA MMN

Mean HAZ-score

↑(p<0.05 Mean HAZ-score

↑(p<0.05 <

Correlation Test

Height (r = 0.990, p =

0.000)

Family size (r = 0.380; p =

0.046)

Correlation Test

Height (r = 0.983, p =

0.000)

D

I

S

C

U

S

S

I

O

N

48

↑ HAZ-score of 16-18 yo → IFA = MMN (p = 0.225)

ANCOVA test

∆ Height (ES = 0.984; p = 0.000) IFA Group (0.4±0.4) vs MMN Group (0.6±0.5)

Family Size (ES = 0.108; p = 0.000) (IFA Group 5.96±2.0) vs MMN Group (6.09±2.3)

Female mature height attained at the age of 16 -

18 years (Lee, 2007). Lee (2007) cites the opinion of

Lindsay and Cosman (2005) linear growth of the

skeleton occurs in adolescence, - the bone is

continuously changing in size and shape in response

to pressure applied to the skeleton in a process

remodeling (Lee, 2007).

D

I

S

C

U

S

S

I

O

N

49

D

I

S

C

U

S

S

I

O

N

o Ramakrishnan et al (2004) systematic review

intervention only vitamin A or iron had no effect on the

growth of the child, but the multi-micronutrient

interventions every day increases the linear growth of

children aged <18 years

o Huy et al (2009)

multiple micronutrient supplements contribute to the

prevention of stunting

o Sivakumar et. al. (2006)

provision of healthier beverages containing multiple

micronutrients for 14 months in children aged 6-16

years in school have an impact on changes in the HAZ-

scores were significantly (p value = 0.016; power =

0.739

50

MMN supplement have better effect than IFA Supplement on linear growth (height and HAZ-scores) but not for muscle growth. So, its required effectiveness study to assess the effect of micronutrient supplementation on growth and nutritional status of girls adolescent

1 impact of multiple micronutrient … st. patimah.pdf · (riskesdas 2010 & 2013) 0 10 20 30 40...

Documents