TINH TRANp THIEU KEM VA MOT SO YEU TO , LIEN QUAN O PHU NU" CO THAI TAI T H A N H PHO
HO CHI MINH
Nguyen Thanh Danh', Trdn Thi Minh Hanh ', Phan Nguyen Thanh Binh\ Nguyen Nhdn Thdnh ^ Le Thi Kim Qui'
Muc tieu; Xac dinh ti le thieu kem va cac moi lien quan d PNCT tai TP.HCM. Doi tugng va phuong phap; Mgt dilu tra cat ngang dugc thuc hien tren 700 PNCT tai TRHCM nam 2007. Doi tugng dugc can, liy mau xet nghiem kem. Thieu kem d PNCT dugc chan doan khi kem huyet thanh <
56 pg/dl d ba thang dau, < 50 pg/dl d 3 thang giira va 3 thang cuoi. 700 PNCT dugc phong van thong tin ve kien thiic phong ngira thieu kem, tinh trang nghen va nhdm nhd 341 PNCT dugc chon ngau nhien de phong van che do an 24h. Ket qua: 39,6% PNMT cd ham lugng Zn huyet thanh thap, ti le thieu kem d ngi thanh va d ngoai thanh ngang nhau (39,4 & 39,8%); ty le thieu kem cua PNCT d ca 3 thai ky cao ngang nhau (40,0% d 3 thang dau, 37,6% 3 thang giua va 40,5% d 3 thang cuoi).
Khau phan PNCT c6 nang lugng thap, nhat la d 3 thang dau va giiia, chi dat 78,6% va 80,6% so vdi nhu cau khuyen nghi ciia Bg Y te. Nghen xuat hien chu yeu vao 3 thang dau (63,0%), thang thii nhat la 38,1%, thang thii hai la 21,0%, thang thii 3 la 3,4%. Miic tieu thu nang lugng va protein ciia nhiing ngudi nghen thap hon nhiing ngudi khong nghen (31,8 ± 11,3 so vdi 39,2 ± 14,1 Kcal/kg/24gid, p<0,01 va 1,3 ± 0,6 so vdi 1,7 ± 0,8 g protein/kg/24gid, p <0,05). Cd 88,3% PNMT khong CO kien thiic ve thiic an giau kem, chi c6 6% biet thiic an giau kem tu thiic an dgng vat. Kit luan: Thieu kem d PNCT tai TP.HCM cao, 39,6%. Tinh trang giam nang lugng va protein an vao trong 3 thang dau va 3 thang giiia cua PNCT thap so vdi nhu ciu khuyen nghj va tinh trang giam tieu thu nang lugng va protein do nghen va thieu kien thiic ve thuc pham giau kem cua PNCT co the la nhiing yeu to gop phan gay ra tinh trang thieu kem .
Tir khoa: Thieu kem, nghen, phu nii co thai.
I. DAT VAN DE
Tinh trang dinh dudng va siic khde ciia ba me cd anh hudng rat ldn den su phat tiien cua bao thai, dac biet la su phat trien the chat tiong thdi ky nay se tao nin tang cho su phat trien sue khde tim vdc cua dua tre sau khi sinh. Ben canh thieu dinh dudng trUdng diin, cac nghien cu'u tren phu nii cd thai (PNCT) cho thay tinh
'TS, BS - Tmng tam dinh duong TPHCM
^BS - Trung tam dinh duong TPHCM
^BSCKI- Trung tam dinh duong TPHCM
trang thieu c i c vi chat quan trgng nhu"
thieu mau do thieu sat, thieu kem, iod, vitamin A la rat pho bien cl cac ntidc dang phat trien, trong dd, tinh trang thieu vi chat kem d phu nii' cd thai la van de stic khoe cdng ddng phd bien d nhieu ntidc dang p h i t trien [1-3]. Phu nii cd thai bi thieu kem cd the se d i n de'n di dang b l o thai, giam can nang va chieu
dai tre sd sinh, cham phat trien tam vdc va tri tue cua tre sau nay, ddng thdi lam giam kha nang dap ting midn dich va tang nguy cO mac cac benh nhiem tning [2,4]. CIc ket qua khao sat d phu nii cd thai tai mdt sd' vung ndng thdn Bac Ninh va Ha Tay cho thay ti le kem huyet thanh thap chiem 30-60% [4-6]. Mat khac, thieu kem d cac ba me cd thai cd the gay nghen [7] la mdt yeu td lam ban che cung cap nang lugng va cac chat dinh dudng cho PNCT. Tinh trang nghen va giam an 6 cac ba me mang thai trong 3 thing dau chie'm ti le rat cao. Cd khoang 75-80% ba me cd thai bi nghen, bieu hien bdi trieu chung budn ndn hoac ndn miia [8-9], neu nang va keo dai cd the gay anh hudng rat ldn de'n sU phat trien ciia bao thai, the hien qua su cham tang can d thai phu trong 3 thing dau.
Mat khic, tinh trang nay cdn l l m giam sU tich luy ning lUdng, cd the gay nen tinh trang giam tiet siia me sau sinh va mat siia sdm d cac ba me.
Do tam quan trgng cua van de neu tren, chiing tdi tie'n hanh nghien cu'u d l tai vdi muc tieu: " Danh gia thuc trang thieu kem va tim hieu mot so yeu to Uen quan a phu nii' co thai tai thanh phi H6 Chi Minh"
II. DOI TLTOTVG VA P H L T O N G PHAP NGHIEN Ctru
1. Doi tu'O'ng nghien cuu
Phu nir cd thai sinh sd'ng tai 30 phudng xa thugc ndi tbanb va ngoai thinh TP.HCM nam 2007.
2. Phuong phap nghien cuu
- Phticfng phap nghien ciiu: nghien Cliu md ta cat ngang.
Tieu chuan chgn mau: Phu nii cd thai cU ngu tai TP.HCM tii luc mang thai de'n thdi diem khao sat, bie't rd ngay kinh cud'i, ddng y tham gia nghien ctiu.
Tieu chuan Ioai triif: Khdng bie't ngay kinh cud'i, tu' cbd'i tham gia nghien ctiu, bi benh nhiem trung cap hoac man tinh nhu benh tim, suy than, benh Ic tinh; benh cua he tao mau. Mau huyet thanh xet nghiem kem bi lan bong cau. Budn ndn va ndn do cac benh khac nhu benh viem tiii mat, benh vien tuy cap...
Ky thuat chgn mau: Mau dugc chgn theo phuang phap ngau nhien PPS (Probability proportional to size).
Cdng thtic tinh cd mau de Udc lUdng ti le thieu kem dUdc tinh nhti sau: n
= Z2p(l-p)/d2 vdi Z=l,96; d =0,05, n = 323, P=0,30 [4-6]. Udc tinh ti le bd cugc la 10% nen tdng so' dd'i ttidng can dUdc khao sat tinh trang thilu kem la 718 PNCT.
Danh gia nang lu"rfng khau phan: n
= (Za)VA2 v&i Z= 1,96, A = 250, a
= 2234 (Ndng luang tieu tht.1 trung binh d PNCT tudn 16-22) [10]. Udc tinh ti le bd cugc la 10% nen tdng so' dd'i tUdng can dtidc khao sat khau phan la 341 PNCT.
Phtiofng phap thu thap so' lieu:
Khau phan dUdc dieu tra bang phUdng phap nhd lai 24 gid va phdng van tan sua't thUc pham. Phdng van mgt so' ye'u td' lien quan dtia vao bang cau hdi soan san. Sti dung can dien tti TANITA sai so' 200g de can PNCT. Kem huyet thanh dUdc phan tich bang phUdng phap cUc phd (Po-
larography) tai labo ciia tmdng Dai hgc khoa hgc tti nhien.
Tieu chuan chan doan va danh gia:
Nghen dtidc dinh nghia la tinh trang budn ndn v l ndn hole chin an, an it xay ra khi mang thai, dac biet la 3 thing dau, xay ra bat ky thdi gian nao trong ngay hay dem [11,12].
Thieu kem dugc chan doan khi kem huye't thanh < 56 pg/dl 6 la < 5aO pg/dl d 3 thing giua va cudi [13].
N i n g lUdng thie'u so vdi nhu cau khuyin nghi cho PNMT khi < 2450
kcal/ngay [14].
3. Phrforng phap xuT Iy so lieu:
So lieu dtidc n h a p b a n g phan m e m EPI-INFO 6.0 va xti ly bang p h a n m e m Stata 8.0. So sanh cac ti le bang test x2 va so sanh cac gia tri trung binh bang T-Test. Gia tri p < 0,05 dtiOc xem 1 co y nghia tho'ng k e .
III. KET QUA NGHIEN ClTU
I. Cac dac diem dich te va Iam sang ciia phu nu- co thai tai TP. HCM
Bdng 1. Dac diem djch te va nhan trac cua doi tu'ong
Toan bo 3 thang dSu 3 thang giira 3 thang cuoi n(%)' n(%) n(%) n(%)
Noi cu ngu Noi thanh Ngoai thanh
Nhom tuoi
< 2 0 20-29 30-39
> 4 0
401 (57,3) 299 (42,7)
39 (5,6) 382 (54,5) 271 (38,7)
8(1,1)
22(3,1) 3 (0,4)
2 (0,3) 12(1,7) 11(1,6) 0 (0,0)
130(18,6) 96(13,7)
8(1,1) 124(17,7)
90(12,9) 4 (0,6)
249 (35,6) 200 (28,6)
• . : -. . . •
29 (5,6) 246(35,1)
170(24,3) 4 (0,6)
0,006
0,6
TONG SO n=700 25 (3,6) 226 (32,2) 449(64,1)
Khao sat 700 phu nii cd thai tai TP.
HCM cho thay ti le phan bd cua mau dugc chgn khdng ddng deu: 3 thing dau va dudi 20 tadi cd ti le thap, nhat la vung ngoai thinh, ti le cao d 3 thing cudi (64,1%) v l tadi tap trung cao nhat la 20- 39 tadi la 85,6%.
2. Phan bo phu nu co thai theo ti le thieu kem theo khu vuc va thoi gian mang thai
Ti le thieu kem d ddi tagng khao sat rat cao (39,6%), ti le nay phan bd deu cho ca 2 khu -virc ngi va ngoai thanh va cic giai doan mang thai (Bang 2).
Bang 2. Ti le thilu kem ciia PNCT theo 3 giai doan cua thai ky.
TI LE THIEU KEM Giai doan mang thai
Khu vuc Chung
n (%) 3 thang Dau 3 thang Giua 3 thang Cuoi n (%) n (%) n (%) Noi thanh
Ngoai thanh TS
401 299 700
158(39,4) 119(39,8) 277 (39,6)
8 (36,4) 2 (66,7) 10(40.0)
47(36,2) 38 (39,6) 85 (37,6)
103 (41,4) 79 (39,5) 182(40,5)
0,3
n = tdng sd thieu kem, %= ty li thiiu kem
Ham lugng kem huyet thanh trung binh cd xu hudng giam dan khi tadi thai tang len nhung khdng cd y nghia thdng ke do do lech chuan ctia kem trong nghien ciiu nay khi ldn.
Bdng 3. Dac diem ve tieu thu.
Dac diem Toan bo
Kem trung binh n =700
nangluong,proh jin va tang can ciia doi tucmg*
Thoi gian Mang 3 thang dau
n = 25 62,0 ±21,9
3 thang giii'a n = 226 60,2 ±19,8
thai
3 thang cuoi n = 449 59,4 ± 19,5
P
0,7
n = 325 Nang lugng (Kcal)/ngay
Protein (g)/ngay Tang can (kg)* *
n = 10 1925 ±1247
72,7 ±47,1 1,4 ± 3 , 3
n=107 1975 ± 647 81,5±31,0
4,5 ± 3,5
n = 208 2211 ± 7 6 8 93,8 ±43,3 9,4 ± 3 , 9
0,02 0,015
<0,001 'Sd liiu trinh bdy: trung binh ± do lich chudn."Tdng cdn tinh den thai diem diiu tra.
Muc tieu thu nang lugng v l protein cd xu hudng tang khi tadi thai tang len. BMI trudc khi cd thai ctia cic nhdm PNCT khdng khic nhau va d muc trung binh thap.
Bang 4: Cac dac diem cua doi tifgfng nghen Dac diem
Thoi gian bat dau xay ra nghen:
Thang thii nhat Thang thii 2 Thang thii 3 Thang thir 4
Thang thu 5 ' Thang thii 6
TS (n = 700)
Tyle n 267
147 24 . 2
1 1 442
nghen
% 38,1 21,0 3,4 0,3 0,1 0,1 63,1
Nghen xay ra tap tmng trong 3 thing diu (62,6%), thing diu tien 11 38,1%
Bang 5: Tieu thu nang luong, protein va ty le thieu kem ciia cac doi tuong dang nghen trong nhom CO khao sat khau phan tir thang thii-1 den thang thir 4.
Chl so
Tieu thu nang lugng (Kcal/kg/24gi6) Tieu thu protein (g/kg/24gid) Protein Dv/Ts protein Ty le thieu kem (%)
Co n = 30 31,8 ± 11,3
1,3 + 0,6 0,55 ±0,16
33,3
Nghen Khong n=163 39,2 ± 14,1
1,7 ± 0 , 8 0,56±0,17
38,7
P
0,01 0,04 0,7 0,6
PNCT cd tinh tiang nghen co muc tieu thu nang lugng thap ban 19% va protein thap hon khoang 23,5%o so vdi nhiing ngudi khong nghen.
Bang 6: Lien quan giCfa thie'u kem va nghen
n TINH TRANG THIEU KEM OR CI.95% P Thieu n (%) Khong n(%)
Nghen
Co Khong T i n g
30 163 193
10(33,3) 63 (38,7) 73 (37,8)
20(66,7) 100(61,3) 120(62,2)
,26 0,55-2,78 0,6
Khdng cd mdi lien quan giua tinh trang nghen va thieu kem.
Bang 7 : Kien thufc ve nguonthyc phamchufa kem
STT Thuc an %
1. Hau 13 1,9 2. Thiic an co nguon goc dong vat 42 6,0 3. Thiic an khac 27 3,9 4. Khong bigt 618 88,3
TS 700 100
Hau het cic b l me thieu kien thu'c ve thu'c an giiu kem.
IV. BAN LUAN
Mau dugc chgn theo phuong phap ngau nhien theo cum de cd the dai dien cho PNCT dang sdng tai cac vung sinh thii d ngi va ngoai thanh thanh phd Hd Chi Minh, nhung do nhiing PNCT trong
3 thing dau, nhat la mdi cd thai trong thing dau rat khd xac dinh chac chan va thu'dng chua di dang ky khim tai dia phuang nen khdng the lap danh sach day du de dua vao nghien ciiu. Vi the, toln bg sd mau tay chgn du ve mat ly thuyet (98%) nhung phan bd khdng ddng deu, chu yeu d 3 thing giiia va cudi. Dieu niy cd the tao ra sai sd nhat dinh do lam giam sd mau dai dien cho ddi tagng la PNCT tiong qui dau v l lam tang sd mau dai dien cho cic PNCT tiong 2 qui cdn lai d ca hai khu vuc ngi v l ngoai thinh. Sd PNCT tap trung d do tali tii' 20-39 tadi (93,3%). Chi sd khoi CO the (BMI) trung binh tru'dc klii mang thai cua ele ddi tagng d 3 giai doan mang thai d muc trung binh thip v l tang can trung binh d ca 3 ky thai cung chi dat
d muc tmng binh va cd do lech chuan kha ldn. Dieu nay the hien su tdn tai cua tinh trang thieu dinh dudng trudng dien cua nhieu ddi tagng trong nhdm nghien cun (bang 3). Trong nlidm nghien ciru cd den 39,6% sd PNCT cd ham Iugng Zn huyit thanh thap, the hien tinh trang thieu kem d PNCT tai TPHCM rit cao, day 11 mdt van de sue khde cdng ddng rat dang dugc bao dgng nhu tinh trang thieu kem d cac nudc dang phat trien hien nay [2,3], ti le nay tuong duong vdi cic ket qua khao sit 5 phu nii cd thai tai mgt so' vung ndng thdn Bac Ninh va Ha Tay (30- 60%) [5-6], trong dd ti le thieu kem d PNCT ndi thanh va PNCT d ngoai thanh ngang nhau, du muc sdng d PNCT ngi thanh thudng kha ban nhung van chua cd sir cli thien ve tinh trang kem so vdi PNCT d ndng thdn. Kem trung binh cd xu hudng thap dan va thap nhat d 3 thing cudi nhung ti le thieu kem theo thdi gian mang thai d cic 3 thing dau, giua va cudi cd ty le cao ngang nhau, dieu nay do cleh chgn tieu chuan chan doan thieu kem cho 3 thing giiia va cudi thap hon (< 50 mg/dl mdi dugc coi la thieu kem). Trong khi dd nghien ciiu d ngoai d bang Haryana An do nam 2001 cd 64,6% thieu kem vdi tieu chuan chan doan thieu kem khi ham lugng kem huyet thanh < 66pg/dl [15], va mgt nghien ciiu md ta phan tich tren 400 PNCT den kham tai benh vien Zebedan Ghods cua Iran cd 49% thieu kem vdi tieu chuan chan doan thieu kem khi ham lugng kem huyet thanh < 70pg/dl [16].
Nhu vay, neu sti' dung tieu chuan chan doln thilu kem theo cic tieu chuan da su' dung trong cac nghien cuu nay thi ti le thilu kem d PNCT tai TP HCM cao ban rat nhieu.
Ket qua khio sit khau phan PNCT cho thay gil tri sinh nang lugng thap, nhat la d 3 thing dau va giu'a, chi dat 78,6% vl 80,6%) so vdi nhu cau khuyen nghi cua Bd Y te. Keo theo cung cap protein thap d 3 thing dau va giua ( bang 3). Thinh phan thu'c an cua PNCT kha da dang, bang thanh phan dinh dudng thu'c an Viet Nam cd nhieu thuc pham chua cd thanh phan kem nen chung tdi khdng the tinh dugc ham lugng kem trong khau phan trong nghien ciiu nay nhung lugng protein trong khau phan ctia nhiing PNCT d 3 thing diu va PNCT bi nghen thap so vdi nhu cau khuyen nghi ctia Bd Y te ^'"'^ day cd the la mgt yeu td gdp phan gay thieu kem d PNCT - ddi tagng cd nhu cau kem dang gia tang. Mat khac, tinh trang nghen xuat hien vdi ty le rat cao trong 3 thing dau la 62,5% vdi muc tieu thu nang lugng thap ban khoang 19% va protein thap ban khoang 23,5%) so vdi nhiing ngudi khdng nghen, dieu nay cd the la mdt yeu td gdp phan gay thieu kem va thieu nang lugng rat dang luu y d PNCT . Thieu kem cd the gay ra tinh trang budn ndn [7], the hien tinh trang nghen d ddi tugng nay, cung nhu tinh trang, chan an, an it the hien bang tinh trang suy giam tieu thu nang lugng [18], nhung tiong nghien ciiu nay chting tdi chua tim thay mdi lien quan giiia tinh tiang nghen va thieu kem, ty le thieu kem d nhdm cd tinh trang nghen thap ban nhdm khdng nghen nhung khdng y nghTa thdng ke, cd le do sd mau trong nhdm cd tinh trang nghen trong 4 thing dau cua ddi tugng nghien cun cdn thap. Mat khic, hau bet PNCT khdng cd kien thuc ve thu'c an giau kem la ly do rat ding quan tam trong viec tim hieu nguyen
nhan gay ra tinh trang thieu kem d PNCT.
Nhiing y i u to tren cd the tao ra mgt vdng l u i n q u i n gay bat lgi cho sue khde ctia PNCT va su p h i t trien cua bao thai.
V. KET LUAN
Thilu kem d PNCT van 11 van de cd y nghia sue khde cdng ddng tai TP.HCM, ty le thilu kem d P N C T nam 2007 la 39,6%, ti le t h i l u kem d ngi thanh v l d ngoai thanh cung nhu ty le thieu kem cua PNMT d 3 giai doan mang thai gan taang duong nhau.
Muc tieu thu nang lugng va protein trong 3 t h i n g dau va 3 t h i n g giua cua P N C T thap so vdi nhu cau khuyen nghi va tinh trang giam tieu thu nang lugng va protein do nghen va thieu kien thuc ve thuc pham giau kem cua PNCT cd the la nhung yeu td gdp phan gay ra tinh trang thieu kem d ddi tagng nay.
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Summary
ZINC DEFICIENCY AND RELATED FACTORS IN PREGNANT WOMEN IN HOCHIMINH CITY
Objective; To identify the rate of Zinc deficiency and related factors in pregnant women in HCM city. Meth- ods: Across sectional survey was conducted among 700 pregnant women in HCM city in 2007. The subjects were weighted and their blood was taken for Zinc analysis. Zinc deficiency in pregnant women was iden- tified when blood Zinc < 56 pg/dl in the 1 st trimester and < 50 pg/dl in the 2nd and 3rd trimester. Interviews were taken to collect data on knowledge on Zinc deficiency control, and morning sickness. A sub-group of 341 pregnant women was randomly selected to collect 24-hour dietary recall. Results; 39.6% of the pregnant women had Zinc deficiency, this rate was the same ui urban and sub-urban area (39.4 and 39.8%); Zinc de- ficiency were at the same rate in 3 trimesters (40.0% in the 1st, 37.6% in the 2nd and 40.5% in the 3rd trimester). Pregnant women had low energy intake, particularly in the 1st and 2nd trimester, meeting only 78.6% and 80.6% of the Vietaam RDA. Morning sickness mostly appeared in the 1 st ttimester (63.0%), of which 38.1% in the 1 st month, 21.0% in the 2nd month and 3.4% in the 3rd month. Energy and Protein in- take of those women was lower than that of those without morning sickness (31.8 ± 11.3 vs. 39.2 ± 14.1 Kcal/kg/24hours, P<0.01 and 1.3 ± 0.6 vs. 1.7 ± 0.8 g protein/kg/24hours, P = 0.04). 88.3% of pregnant women did not have knowledge on Zinc rich foods, only 6% knew that animal source foods were rich in Zinc. Conclusion; Zinc deficiency in HCM city is 39,6%. Low energy and protein intake in pregnant women in the 1st and 2nd ttimester due to morning sickness and lack of knowledge about Zinc rich foods of those women were possible contributing factors to Zinc deficiency in this group.
Keywords; Zinc deficiency, morning sickness, pregnant women.
