Nutritional status and some related factors among primary school children in thai nguyen and nghe an provinces in 2020

MINISTRY OF

AU NTS TRY OF HEALTH

EDUCATION AND TRAINING

HANOI MEDICAL UNIVERSITY

NGUYEN THI PHI ONG ANH

NUTRITIONAL STATUS AND SOME RELATED FACTORS
AMONG PRIMARY SCHOOL CHILDREN

IN THAI NGUYEN AND NGHE AN PROVINCES IN 2020
Specialization: Doctor of Preventive Medicine

Code: D72O3O2
THESIS OF GRADUATION' MEDICAL DOC TOR

COURSE 2015 2021

Mentors'. 1. Aisoc.Prof.PhD. Pham Van Phil
2. Alloc.Prof. PhD. Tran Thuv Nga

HANOI-2021

«s> ■>


iii

CONTENTS
*
ABBREVIATION

.................

LIST OF TABLES................. ..
vil

LIST OF FIGI KES................. ....................
ACKNO WEED GEM ENT.......
COMMITMENT....... -............

ABSTR ACT__ __ ___ _____ INTRODUCTION_______________________________ _______________ ..... 1

CHAPTER!: LITERATURE REVIEW_______________________________ 3
1.1. Nutritional status and some methods of assessment of the nutritional
status—....__________ ________________ ____ __________ _______ ____ 3

LIL Definition of nutritional status ....................

3

1 I 2 Brief reviews about methods of assessment of the nutritional status

.3

1.2. Previous studies on the nut rilional status of children__________ _____ 6

1.2.1. In the world......... .... ............

1.2.2 bl Vietnam ._....

.................

— 6

_....................

—........... ... 8

1 J. Some factors associated with the nutritional condition of children — 11
1.3.1 Eating habits ____________________ ___ _________________ ___ _ 11

1.3.2 Physical activities------------- -------

-______________ —.............. 12

13 3. Socio-economic factors..............................................

13

CHAPTER 2: RESEARCH SUBJECTS AND ME I 1101)0 LOGY................ 16
2.1. Study Subjects______________
2.2. Study location and studs time
2 J. Research Methodology________ _____
2 3.1. Study design....................

...16

------------ 16
16


iv

t••••••i••• •••••••••••••••••••• 16

2 3 2 The sample size and sampling method.......

Sample Size

16

... 17

2.3.3. Variables and indicators...—....................
2.3.4 Data collection----------- ....... —.................

_.....

18

2.5. Potential Errors and Solutions---------------------- ------------------------ —20
2.6. Data management and analysis__ ____________

_______________ ...20

2.7. Ethical Issues_________________________________________________ .21
CHAPTER5: RESULTS______________________________________

22

3.1. C haracteristics of researchsubjects_______________________

22

3.2. Nutritional status of students__________________________

26

3 J. Some factors related to nutritional status of students--------------------- 29

CHAPTER4: DISCUSSION_______________________________ _________ 38

4.1. Nutritional status of students_______________________________ __ 38
4.2. Some related factors to the nutritional statin of Students__________ 42

4.2.1. Socio-demography factors............ .............. - _________ -.............. -..42
4.2.2. Environmental factors_ _____ __ ___ ___________ ______ —............. 47
4 2 3 . Eating habits factors..... .....

47

4.2.4. Physical activity factors..... .... i...............-.... ......

50

CONCLU SION
RECOM MEND.VnON —

V

ABBREVIATION

BMI

Body Mass Index

FAO

Food and Agriculture Organization

UNICEF

United Nations Children's Emergency Fund

WTO

World Health Organization

NCHS

National Center for Health Statistics

SD

Standard deviations

BAZ

BMI-ÍOT-Age z score

HAZ

Height-for-Age Z-score

MUAC

M id Upper Arm c ircumfe rence

VND

Vietnamese Dong

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LIST OF TABLES

Table 3 1 The distribution of study subjects by provinces, age and ethnicity

22

T able 3 2 Mean weight and height of students by age and gender .................... 23

Table 3 3. Mean waist circumference and hip circumference of students by age and

Table 3 4 Mean Mid-L’pper-Arm Circumference of students bv age and gender 24

Table 3 5. Mean triceps skinfold thickness and subscapular skinfold thickness of
studenis by age and gender...................

—....

Table 3 6 Mean Height for Age z score and BMI for Age z score of students by

age and gender ............
Table 3. 7. The association between the nutritional status of children and the parent’s

nutrition!] status

Table 3. 8-The association between lite prevalence of stunting and the parent's
education level............. ...... .........

Table 3 9 The association between the prevalence of overweight and the parent’s
education ]e%*el

31

Table 3.10. The association between the prevalence of stunting and people who take

care of children .

___________ ____ ___ ...__ ___ ______________ ___ ___ 32

Table 3 11 The association between the nutritional status of children and the family

Table 3 12 The association between the nutritional status of children and total
household income_____ __ _______ ___ ___ —_____ _____ __ ________ __ 33
Table 3.13. The association between die prevalence of overweight and eating habits

Table 3 14 The association between the prevalence of obesity and eating habits 36
Table 3 .15. The association between the nutritional status of children and physical

activities ...............................

.........

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.................. 37


vii

LIST OF Fl GV RES

Figure 3 1 The nutritional status of students by provinces

............................. 26

Figure 3 2. The nutritional status of students by gender........... ............................... 27

Figure 3.3. The nutritional status ofStu dents by age--------- ------------ .....------ 28
Figure 3 4 The association between the nutritional status of children and the sources

of drinking cooking water.................. —................. ......... ..... —, .........

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viii

ACKNOWLEDGEM ENT

First and foremost I would like to express my deep sense of gratitude and

appreciation towards Assoc Pro: Pham Van Phu from the Department of Nutrition
and Food Safety.. Institute for Preventive Medicine and PubHc Health for his

invaluable guidance, constant encouragement, expert suggestions constructive
criticism, and supervision which was most crucial in completing this thesis work.

I am extremely grateful to Assoc Prof Tran Thuy Ng» head of Department of

Micronutrient Research and Application National Institute of Nutrition, for her keen
interest, guidance, supervision and valuable advice for thesis improvement

I would like to express mv deep thanks to the Managing Board. Department of

Training Hanoi Medical University who had created a welcoming and wonderful
environment in the school tor the past six years I wish to thank all the teachers in the

Department of Nutrition. Institute for Preventive Medicine and Public Health Hanoi

Medical University for their valuable information provided by them in their
respective fields 1 am grateful for their cooperation during the period of my

assignment

Finally, 1 want to express my gratitude to my wonderful family and friends who have
stood by my side throughout tins ordeal Your unwavering love and unwavering

support inspired me to keep going
Student
Nguyen Thí Phuong And

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COMMITMENT

To:
- Management Board of Hanoi Medical University.

- Department of Undergraduate Training Management and Department of Student
Affairs Hanoi Medical University
- Institute for Preventive Medicine and Public Health Hanoi Medical University

• Department of Nutrition and Food Safety. Hanoi Medical University
• Examination Committee for Graduation Thesis 2020-2021
I hereby declare that I am the author of this research The data collection and analysis
were carried out objectively and truthfully. These findings in this study have yet to

be published

May 2021 in Hanoi
Student
Nguyen Thí Phuong Anh

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ABSTR ACT

Background & Objectives: A cross-sectional study was conducted with the
objectives to describe the nutritional status of primary school children (7-10 years) in

Thai Nguyen and Nghe An provinces to analyze some related factors to the
nutritional status of students.

Methods: The study period was from November 2020 to December 2020 A total of

262 students from two provinces comprise the study population. Probability

proporticoal to size sampling method was used Data entry and statistical analysis
were performed with the help of STATA version 15 0 Height-for Age Z-scone
(HAZ) and BMI-for-Age z-score (BAZ) were calculated using 'VH0 Anthroplus

Software and using WHO Reference 2007 values

Results; The prevalence of overw eight and obesity was 25.6% (in which overweight

was 16 8%. obesity was 8 8%). The prevalence of stunting was 8 0% and wasting
was 6 5% Some factors related to the nutritional status of primary school students
were BM1 of parents, education level of parents, the cure of mother; family size (>5
people) total household income habit of drinking soft drinks eating instant noodles,

eating outside the home, eating at fast-food restaurants

Interpretation & Conclusion: The present study showed the prevalence of

malnutrition was relatively high Socioeconomic factors, parental factorsand eating
habits were associated with the nutritional status of students. Prompt integrated

efforts should be made to improve the nuữitional status of primary school students

Keywords: nutritional status, related factors to malnutrition. primary school children

Thai Nguyen Nghe An

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INTRODUCTION
Malnutrition has been a global public health problem In 2019 there still were

144 million children under 5 with stunting and almost 50 million with wasting- at the

same time, overweight and obesity in children and young people were continuing to

rise [I] la Vietnam, the stunting rate for children under 5 was 19 6% in 2020.
meaning that one out of every five Vietnamese children under the age of five was
stunted Th • rate of stunting malnutrition among school children (5 -19 years old) was
14.8% in 2020 (this rate was 23.4% in 2010) (2) On the other hand, overweight and

obesity had increased rapidly. National Institute of Nutrition research during 2017.

2018 revealed the overweight obesity rate of 5.000 sampled school children in a

variety of provinces was 29% [3 J

Every country in the world has been affected by one or more forms of
malnutrition and should consider combating these as one of the greatest global health

challenges Socio-economic determinants such as income, ethnicity, geographical
location, and intra-household parental factors could be related to 3 child's nutrition

level When children's nutritional status deteriorated, a vicious cycle of chronic
disease and growth failure developed As a result having a comprehensive

understanding of children's nutritional status had far-reaching consequences fOT

future generations' wellbeing |4j
The primary school years were the time of rapid physical and mental
development Low school attendance high absenteeism early dropout and

unsatisfactory' classroan perfornunce had all been related to poor nutritional status
(5] (6) Children who were well fed did well in school andreached their full physical

and mental capacity Malnutrition was an associated cause in about half of all deaths

occurring among children in developing countries and also slowed economic growth
and perpetuated poverty [7] According to estimates malnutrition in all types could
cost society up to 3.5 trillion dollars each year, with overweight and obesity costing
500 billion dollars [S]

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Many studies have been conducted worldwide on the nutritional status of
children of all ages Studies done ill rural and urban areas U1 different parts of Vietnam

have reported a high prevalence of malnutrition among children but most of these
focused on the age under five [9] (10] (11] There has been a paucity of information

based on nutritional status in primary schools from the northern and central provinces

of Vietnam. In order to provide more data to improving many nutrition-related

problems, research minted "Nutritional status and some related factors among

primarv school children in Thai Nguyen and Nghe An provinces in 2020" was
conducted with two specific aims
1. To describe the nutritional status of primary school children in Thai Nguyen

and Nghe An provinces in 2020

2. To analyse some factors related to the nutritional status among primary school
children in Thai Nguyen and Nghe An provinces in 2020

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CHAPTE R I: LITERATI RE REVIEW

1.1 Nutritional status and some methods of assessment of the nutritional status

1.1.1. Definition of nutritional status

Nutritional statu? refers to an individual's physiological stale as a result of the
interaction between nutrient intake and needs as well as the body's ability to digest
absorb, and utilize these nutrients When the human body absorbs all of the nutrients

in adequate quantities to satisfy its needs, in a state of good nutrition, which implies
normal nutritional status However, when the nutrients in the diet are insufficient or
are not adequately used, the body becomes unbalanced If this persists for an extended

period of time, it could become a serious issue perhaps fatal [12] A state of

imbalance in the body occurs when there is a deficiency' or excess intake of one or
more nutrients, as well as faulty nutrient utilization Malnutrition ora poor nutritional

state, is the term for this condition Malnutrition can be clarified into two groups
ưndemutriiion is a disorder in which a person s wellbeing suffen as a consequence

of a lack of one or more nutrients Overnutntion on the other hand occurs when
nutrients axe consumed in abundance (13).

1.1.2. Brief reviews about methods of assessment of the nutritional status

Nutritional status assessment can be defined as the process of the collection and
analysis of information and data on nutritional status and assessing the situation on

the basis of such information and data [14].

1.1.2.1.

Anthropometric methods

Anthropometry is the measurement of the size weight and proportions of the body

Common anthropometric measurements include weight, height, mid-upper arm
circumference, skin fold thickness head and chest cucumferences and calculation of
the 2 scores of appropriate indices It is frequently used to assess nutritional status as

well as growth and developmeni of school-aged children and adolescents As a public


4

health tool anthropometric measurements have been widely used for the assessment
of the nutritional status of both children and adults This has also been underlined by

Jelliffe who described its use in the nutritional assessment as 'measurements of the
variations of the physical dimensions and the gross compostion of the human body

at different age levels and degrees of nutrition" [15] At the level of the individual
child, anthropometry is not only useful fox detecting those who are at risk of

malnutrition and for the selection of affected children for nutritional intervention
programs but also useful for assessing the effectiveness of such programs [ 16]

In the community, anthropometv is useful in the determination of the prevalence of
malnutrition Although anthropometric methods can be relatively- insensitive to short
term nutritional status, these are precise and accurate provided standardized
techniques are utilized. The procedures are simple, safe, and non-invasive. The

equipment required is inexpensive portable, durable and can be made or purchased

locally. In addition, relatively unskilled personnel can perform measurement

procedures The information generated is based on past nutritional history and can be
used to monitor and evaluate changes in nutritional status overtime Anthropometry

can also be used to quantity the degree of nutrition and provide a continuum of
assessment from under to over-nutrition. It pemiits the stratification of survey results
according to age. sex. region mral urban. or other sociodemographic characteristics

of the population (17]

Hence, it aids in providing more information for detecting

vulnerable tjoups and for a better understanding of the situation

Heights aid weights of children are accepted as measures for monitoring their growth

and nutritional status They are also considered as indicators of the nutritional Status
of the entire community- The indicators used for classification by comparison with a

reference population include weight-for-height (WH). weight-for age (XV”A),

height for-age (H A) Body Mass Index (BMI) for age Although they are by no
means the only ones that have been used, they are the most commonly used

anthropometric indicators for children

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Weight-for-age (W A) reflects body mass relative tô age. Extreme cases of low w A

relative to children of the same sex and age in the reference population are commonly

referred to as ••underweight” [18] Underweight is defined as low weight for age
below 2 standard deviations ỊSD) of the median value of the National Center for
Health Statistics (N CHS) WHO international growth reference w A is frequently

used to track growth and evaluate changes in the magnitude of malnutrition overtime

[16] [18] However w A is a composite measure of height-for-age and weight-for-

beight. making interpretation difficult in the effects of short and long-term health
and nutrition problems

Height-for-age The ratio (H A) denotes cumulative linear growth H A deficits
indicate past Of chronic nutritional deficiencies, as well aschrouKor frequent illness,
but they are unable to detect short term changes in malnutrition [15] [19] Extreme

cases of low H A relative to children of the same sex and age in the reference
population arc referred to as “stunting
'
**

w hich IS an index of chronic malnutrition

Stunting is defined as low height for age which is below 2SD of the median value of

the NCHS WHO international growth reference [16] H A is primarily used as a
populaticn indicator rather than for monitoring individual growth

weight-for-height

H) is a method of determining body weight in relation to height

that does not require age information W/H is typically used as a measure of current

nutritional status and can be useful for identifying at-risk children as well as tracking

short-term changes in nutritional status [20] Extreme cases of low w H are
commonly referred to as "wasting." Wasting is defined as having a low weight for

height that is less dian two standard deviations below the N'CHS WHO international
weight for height reference [16] It may be the consequence of starvation, chronic

conditions or severe diseases such as diarrhea
Body OĨŨSÍ index: The B>n is calculated by dividing the weight in kilograms by the

square of height in meters BXO can be used to determine a child s weight status and
is a good indicator of body fat levels It is used to determine whether a person is

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underweight overweight or at rũk of becoming overweight The weight for height

chart doe# not reflect age-related change#, whereas the BMI for age chart doe#
Obesity IS defined as a BMI of greater than *
2 z scores forage Overweight IS defined

as a BM1 of -1 to ’2 z scores for age [13],
Anthropometric indices are created by comparing relevant measures to those of

comparable individuals (in terms of age and sex) in reference populations, regardless
of the reference data used There are several wavs to express these comparisons; one

is the z-score (standard deviation score), which is defined as the difference between
an individual's value and the median value of the reference population for die same

sex and age (or height) divided by the reference populations standard deviation (21)
1.1.2.2.

Other methods

Nutritional status can also be assessed bv the following methods [19):
Biochemical assessment The test levels of nutrients in a person's blood urine or

stools are known as biochemical evaluation Laboratory findings may provide
qualified medical practitioners with important information about medical conditions
that can influence nutritional status

Clinical assessment Looking for or asking about signs of illness that may increase

nuuitional requirements (e g., lever) and nutrient loss (e.g. diarrhea and vomiting)

as well as medical conditions (e.g HIV, celiac disease) that hinder digestion and
nutrient absorption and increase the likelihood of malnulriticti are both part of a

clinical nutrition evaluation
Dietary assessment The measurement of food and fluid intake is an important part

of the nutrition assessment process It prorides details on dietary quantity and

consistency, appetite changes, food allergies and intolerance, and explanations for
insufficient food intake during or after illness

1.2. Previous studies on the nut ritional status of children
1.2.1. In the world

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Malnutrition in all of its formi has continued to be unacceptably high in all parts of
the globe Despite progress 111 million children under the age of five were stunted

(21.3%). 47 million children under five years were warted (1) . and 20 million
newborn babies were estimated to be underweight (22]. while 38.3 million children
underunder five years of age were overweight [1]
Stunting affected a large proportion of children in many countries. With around 35%

of primary school children in Northern Bangladesh (23). 40% in Southeast Nigeria

(24] and 38 8% in Northern Sumatera Indonesia (25) Despite a decrease in the
prevalence of stunting in Africa, the number of stunted children in the continent had
steadily increased from 49.7 million in 2000 to 57.5 million in 2019. South Asia had
the highest burden of stunted children in the world accounting for 38.8% of all
stunted children worldwide [1Ị. Wasting and stunting were linked to an increased risk

of death, especially when they occured in the same child (26)

In 2013. wasting was responsible for around 13% of all deaths among children under
the age of five worldwide resulting in 875.000 child deaths that could have been

avoided (27) South Asia has been also a global hotspot for wasting. With 15 2% of
under>5s affected, a proportion classified as "high" by international agencies (28).

Not only that children with severe acute malnutrition were nearly 12 times more
likely than healthy children to die if they were not treated (29) Severe wasting has

been still prevalent around the world with an estimated 14 3 million children under

the age of five suffering from it in 2019 [30]

Obesity. as well as being overweight should be taken into account. Obese girls and

boys between the ages of 5 and 19 had increased 10 to 12-fold globally since the
mid-1970s [31] Nearly halfofthe world’s overweight under-5s lived in Asiain2018.

and a fifth in Africa (1]. Malaysia had a severe double burden of malnutrition: 20.7

percent of children under the age of five were stunted and 11 5% were wasting while
15.7% of children (5-9 years old) were obese (32] [33] In poor urban areas where

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malnutrition rales were higher than the national average the situation was even more
complicated [34] China had seen a remarkable shift in malnutrition as a result of

rapid econonoc growth and urbanizatM® Although the rate of stunting among

schoolchildren decreased from 16% in 1985 to 2% in 2014. the rate of overweight
and obesity rose from 1% to 20% [35]

Overweight and obese children accounted for more than 40% ofN’orth American and

Mediterranean children. 38% of European children. 27% of Western Pacific children,
and 22% of Asian children [36] la Argentina, a study of 1,588 children aged 10-11

years from 80 public schools in Buenos Aires found that 35 5 percent of the children
were overweight or obese [3 7] By the time they finished primary school one in three

children in England had been overweight or obese (38] The prevalenceofoverweight
and obesity was 26% in the Alice Goisis study of 9.384 11 -year-olds in the UK [39].

Southeast Asia was one of the regions that was suffering from a double nutritional
burden [40], while the prevalence of malnutrition remained high the rate of

overweight and obesity continued to rise, particularly among school-aged children in

ASEAN countries The rate of overweight and obesity in ASEAN countries was

9.9%. With men (11.5%) outnumbering women (8.3%). Brunei had the highest rate
of overweight and obesity (36 1%), followed by Malaysia (23.7%), the lowest was

Myanmar (3 4%) and Cambodia (3 7%) [41] According to other studies conducted

in Indonesia the obesity rate among children aged 6 to 12 years was 11.5% [42], and
the rate of overweight among school-aged children was extremely high (20 4%) [43]

1.2.2. In Vietnam
Unlike several other countries in the region Vietnam has seen a substantial reduction
in child malnutrition Stunting among children under the 3ge of five had gradualK
*

decreased, from 56.5% in 1990 to 36.5% in 2000. a record dropped of nearly 20% in
a decade In 2010, the figure was 29.3%. and in 2020.. it was 19.6%. According to
WHO appraisal criteria, this was a medium degree [2] [44]. Malnutrition prevalence

varied significantly across ecological regions. In general, the rate of malnourished

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children under the age of five ã the Souủi was lower than in other regions (the rate
of stunting in the Mekong Delta was 28.2% in 2010 and 23 5% in 2015 : the rates of

underweight were 16.8% and 122 %. respectively), indicating that the stuntingrate
in this area was still very high [45] [46]

The prevalence of malnourished children aged 6 -10 years old was 26.6% in 2000.

accordingto the National Nutrition Institute with rural areas having
*
higher rate than
urban areas (28 2% compared to 19 6%) [47] In 2006 the stunting rate for students
aged 6 8 yean at Yen Tliuong Primal V School in Gia Lam. Hanoi, was 14.1% [48J.

according to Nguyen Thi Mai Anh In 2007, die stunting rate of students aged 6 8 in
Hanoi’s Soo Son district was 28% [49J accorđng to Ho Thu Mai et al According to

the National Institute of Nutrition's Nutrition Survey 2009-2010. 23 4% of children
aged 5-10years old were stunted (male 27 5% and female 19 5%) [50] Stuntingrates

of high school students in urban agricultural and mountainous areas in the three

northern provinces were 6.1% . 20.7%. and 23.9%. respectively.according to Le Thi

Hop and Le Nguyen Bao Khanh in 2012 [51] In 2017, a cross-sectional analysis of

750 children aged 6-10 years old in 3 communes Van Giang district Hung Yen

province revealed that the prevalence of underweight, stunting, and wasting in the
study children was 6 8% 5 9% and 11.3%. respectively [52ị According to Nguyen

Song Tu et al's 2017 survey the stun ting rateof 7-10 year old primary school students

in 5 communes of Phu Binh county, Thai Nguyen province was 17.2%, the

underweight rate was 24 5%, and the wasting rate was 7 9% [53]
Vietnam was among a group of 20 countries with the highest number of stunted

children in the world, as well as some countries, especially in Southeast Asia, where
the nutritional burden was doubled Although stunting was still prevalent, the number
of overweight and obese people was rapidly rising especially in urban areas [54]

Until 2000. there was almost no overweight or obesity in children under the age of
five, but over the next ten years (2000-2010) this prevalence had tripled in aduks

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and increased by nine limes in children under the age of five (from 0.68 % to 5.6%)

(551
The rate and rate of increase overweight and obesity among primary school students

varied by area particularly in large cities and cities with centralized government
control. The prevalence of overweight and obesity among children aged 5-19 years
in the Red River Delta area was 9%. 13.4% in the Central region, and 23.3 % in the
Southeast according to the 2010 National Census (55]

HoChi Minh City
*
had the high rates of overweight and obesity in the country, as well

as an alarmmg increase in overweight and obesity
*
among pre-school and school
children particularly in the inner city
* and among children of preschool age (54 5%
in Ho Thi Ky inner-city primary school and 31 2% in Phu Hoa Dong suburban
primary school) ($6]. After a six-year period (2002-2008), the incidence of

overweight and obesity among primary school students in District 10 rose by more
than three times (9 4% and 28 5%) (57). reaching 41.4% in 2014 (19% are obese)

(SSJ Haiphong city also had a high prevalence of overweight and obesity The rate

of overweight and obesity for students aged 6-11 in Hong Bang district was 10.4% in
2000, 31.3% in 2012, and 50.4% in 2014 (59]

In Hanoi, a major city, the prevalence ofoverweight and obesity among people of all

ages was gradually growing with 41.7 % of primary school students becoming

overweight orobese in 201' and44 7 % in 2018 [60]
Overweight and obesity were less common among primary school students in non­
central cities than in central cities. This rate was 6.1% in four cities 31 Tay Nguyen
region (Buon Ma Thuot was 9.1% PleiKu was 7 8% Gia Nghia town and city Kon

Two was 3 6%) [61]

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13. Some factors associated with the nutritional condition of children
The nutritional needs and diet-related behariors of children developed and changed
throughout childhood, from the womb to adulthood Week by week, an infant’s

physiological state had changed dramatically. Children’s eatinghabits and diets could

drastically change once they started school The nuưữional status of children was

influenced by changes in what they consumed, decreased physical activity, and
socioeconomic conditions (62Ị.

13 1 Eating habits

Far too many school-aged children around the world consumed insufficient amounts
of fruits and vegetables and consumed far too many unhealthy snacks high in sugar,
saturated út. sodium, and salts such as bread, cookies sweets ice cream and

sweetened beverages frequently marketed to and popular among school-age children

(€3] No children aged 7 8 years met the diet quality index for vegetables in a
Brazilian study [64] Children in developing countries particularly those from poorer
families and in rural areas hid diets that consisted primarily of a few staples such as

cereals, roots, and tubers, with little protein |65J.

Breakfast patterns should be taken into consideration as well Despite the strong

evidence of its benefits many school-aged children lacked or delayed breakfast
around the world, depriving them of a meal that was especially beneficial to
cognition especially among undernourished children (66) Children who delayed or

postponed breakfast had a higher BMI than their peert in certain environments
Accoiding to a 2007 study conducted in New Zealand, children who skipped

breakfast consumed more snacks between meals, such as chocolate, cakes, chips or
crisps and sweetened carbonated beverages that were rich in calories but low in

nutrienu [67Ị.

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Al -Domi HA et al found that students who ate a regular meal and snacks from

school cafeterias were risk factors for overweight and obesity in 977 students (473
males and 449 females) aged 7-18 years old m three major cities in Jordan (Amman.
Irbid. and .Xlafraq) [68] According to Tran Thi Xuan Ngoc's research there was a

connection between eating patterns and the state of disorder (gluttony and junk food)

[69]. Consumption of thermogenic nutrients, soft beverages, and foods high in
sugar bile, parental care practices of children or families that did not regulate their

sugarv sweet food intake were all factors that raised the risk of overweight and

obesity, according to another report by Le Thi Hop et al [70]. Sugarv snacks, which

failed to provide children with the nutnents they needed for healthy growth while
providing excess calories to the mother were being blamed by Egyptian researchers
m
13.2. Physical activities
The American Physical Activity Advisory and Guidance Committee recommended

in 2008 that children under the age of 18 devoted 60 minutes a day engaging in mild
to extreme physical activity in order to decrease the prevalence of overweight and
obesity [72].

However. only 48.99
*
of boys and 34 7% of girls aged 6 to 11 had access to these

physical activity recommendations Physical activity time decreased by around 37.6
minutes a year between the ages of 9 and 15 according to longitudinal studies, with

just 11 9% of boys and 3.4% of girls in the 12-15 age group knowing the physical
activity guidelines [73], Sedentary habits, as well as the exercise of fewer than 30

minutes a day, were risk factors for overweight and obesity according to a studv
conducted by Al-Domi HA et at on 977 students aged 7 to 18 years in three major

cities in Jordan [68]. Blanco et al. found that children with obesity were less

physically active than children of normal weight in a study comparing the physical
activity levels of 50 children with obesity aged 8-12 years to children of normal

weight [74]. According to a studs’ conducted by Nguyen Minh Phuong et al on more

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B

thar. 1.000 students in Can Tho stunted children accounted for 9 s* . of those who
participated in physical activity or sports which was lower than the community who

did not exercise or participate in sports <25 4%) (75]
13.3. Socio-economic factors

The most critical causes for malnutrition according to several reports, were the
economic and social conditions

There was no question that a family's income had a significant impact on a childfc
health and nutrition Children from low-income households were more likely to be

overweight Overweight in children declined as families' education and income levels
grew in the United States, for example (76). In Europe, a correlation between obesity

and socioeconomic deprivation had been identified Obesity was related to parental

socioeconomic status and lack of education in children in Czechia Portugal and

Sweden according to 3 report based on data from the WHO Childhood Obesity
Surveillance Initiative in Europe in 2008 (77]

Geographic isolation could also affect a family's ability to obtain essential foods as

well as healthcare and nutrition services Burundi. Honduras, and Mali had twice as
many stunted children as metropolitancounteiparts. and Peru had three times as many
[1] Obesity and overweight were still more common in wealthier families (78]. and

concentrations were substantially higher among schoolchildren in urban areas,
though the gap was narrowing and had even convergfd in some affluent areas

Children living in urban areas had been found to be taller than their peers of the same

generation [79]. In addition to other socioeconomic factors. Bharat) et al discovered
that the impact of spatial disparity, especially the rural urban divide was important

in terms of health status (SO] Urban children regardless of gender w ere more obese
than their rural counterparts, according to Ghosh, due to an urban lifestyle and lack

of physical activity [81]

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14

In the United States, researchers examined the effects of race and ethnicity on die tar,'
consumption Malnutrition was described as being overweight in this studs
*
Children
with African ancestry bad a higher risk of being oversight than other children

according to studies Furthermore African girls were 6% to 7% more likely than
Mexican-American boys to be overweight (82]

According to Mohseni et al- socioeconomic factors such as gender, father’s

occupation, and mother's education level had a major impact on children’s nutrition
in ban (83]. Age. gender mothers BMI mother's educational status, fathers

educational status place of residence, socioeconomic status community status

religion and region of residence were ail significant factors in childhood
malnutrition according to a 2016 survey in Bangladesh (84]

In a sample of disadvantaged Colombian children living in small municipalities.
Hackett et al conducted a studv to classify determinants of child anthropometries

They explored the role of household assets in determining a child's nutritional status

and discovered that thev were significant determinants The study also discovered

that, if the parents were traứied. unavailability ofa community^ piped water network
had a positive impact on a child's health [85] In India, Bassolé discovered that access

to bealthv drinking water enhances HAZ

in other words, stunting was reduced [86J.

Increased latrine coverage was effective in reducing fecal pathogen exposure and
disease prevention as well as reducing malnutrition in the long run A research

conducted in Orissa proved this [87Ị.
The connection between a mother's educational and employment status and her
child's nutritional status has been studied extensively Several studies have shown
that a mother's educational level and her child's nutrition level were linked [88] [89]

(90] Children of Uained mothers were found to be better fed than children of illiterate

mothers (91 ] According to an Indonesian analysis, a mothers educational level was

a good predictor of her child's nutritional success over time (92] Ozaltin et al

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15

de mo Hitruled that higher maternal education had a small protective effect against

childhood stunting (93] Glewwe discovered that if a mother lacked specific health
skills. her education had no effect on her child's nutrition level (94] As a result, the
mothers basic health experience, rather than her conventional education level, had a

greater effect on her child's nutritional status Despite tile fact that it was sometimes
overlooked, a father’s educational level was linked to bis child's nutritional status

[95]

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CHAPTER 2: RESEARCH SUBJECTS AND METHODOLOGY

2.1. Study Subject5

Children aged 7-10 years old were students from primary schoob in Thai Nguyen

and Nghe An provinces
■

Inclusion Criteria
Primary school children aged 7-10 years old residing in the research

locations and attending school at the time of the study

Children whose parents had given informed consent
• Exclusive criteria

-

Children did not have accurate dates of birth

-

Children

with

physical

and

mental

deformities

affecting

anthropometric
2.2. Study location and study rune: Theresearch took place at three pri mars’schools

in Nghe An province and three primary schools in Thai Nguyen province from
November 2020 to December 2020.

2.3. Research Methodology

2-3.1. Study design: Using a cross-sectional study
23.2. The sample size and sampling method

Sample size:

The formular has been used to calculate the sample size (Estimating a population
proportion with specified relative precision) as follows