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The Efficacy of Spirulina in Comparison with Multivitamin Supplements Amongst Children Attending Ard El Insan Association Clinic in Gaza Strip

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The Efficacy of Spirulina in Comparison with Multivitamin Supplements Amongst Children Attending Ard El Insan Association Clinic in Gaza Strip Al-Azhar University – Gaza Deanship of Postgraduate Studies & Scientific Research Faculty of Pharmacy Master Program of Clinical Nutrition The Efficacy of Spirulina in Comparison with Multivitamin Supplements amongst Children Attending Ard El Insan Association Clinic in Gaza Strip By Mahmoud A. El-Sheikh Ali Supervised by Dr. Suliman Eljabour Dr. Abed El-Raziq Salama Ass. Professor of Pharmaceutical Ass. Professor of Food Science and Technology and Medicinal Chemistry Faculty of Agriculture Faculty of Pharmacy Al-Azhar University - Gaza Al-Azhar University - Gaza A thesis Submitted in Partial Fulfillment of the Requirements for the Master Degree in Clinical Nutrition Gaza – Palestine 1435 / 2014 Dedication I would like to express my gratitude to my family, my father and my mother. Special and warm appreciation to my wife and my children Who supported me all the way. To everyone who contributed to completion of this study …… thank you. Mahmoud A. El-Sheikh Ali i Declaration I certify that this thesis is a result of my own research, except where otherwise acknowledged, and that this thesis (or any part of the same) has not been submitted for a higher degree to any other university or institution. Mahmoud A. El-Sheikh Ali Signed ………………. September 2014 ii Acknowledgement Above all, I want to thank profoundly and humbly the almighty God for giving me such a great strength, patience, courage and ability to complete this research, and peace and blessings of Allah be upon the noblest of all Prophets and messengers, our prophet Muhammad, all thanks for Allah who granted me the power and capability to complete this thesis. To Dr. Sulaiman Eljabour and Dr. Abd El Raziq Salama, I am very grateful for their guidance and instructions during preparation of this study. Thank you very much for all the trust and confidence you have given me. I would like to thank all the academic and administrative staff of Al-Azhar University for the knowledge and information they gave me during my study. Many thanks to Dr. Ihab Naser for his help and encouragement. Special thanks and appreciations to Dr. Adnan Al-Wheedy, the director of Ard El Insan (AEI) Benevolent Association, and the team of AEI for their cooperation and help during implementation of interventions. I would like to express my thanks to all people who have contributed to the completion of this thesis. Mahmoud A. El-Sheikh Ali September 2014 iii Table of Contents Dedication i Declaration ii Acknowledgements iii Table of Contents iv List of Tables vii List of Figures viii List of Annexes ix Abbreviations ix Abstract (English) xi Arabic Summary xii Chapter (1) Introduction and Background 1.1 Background 1 1.2 Research problem 3 1.3 Justification of the study 3 1.4 Objectives of the study 4 1.4.1 General objective 4 1.4.2 Specific objectives 4 1.5 Questions of the study 5 1.6 Context of the study 5 1.6.1 Demographic context 5 1.6.2 Socio-economic context 6 1.6.3 Ard El Insan Palestinian Benevolent Association (AEI) 6 1.7 Definition of terms 7 Chapter (2) Literature Review 2.1 What is spirulina 9 2.2 Classification of spirulina 10 2.3 Biochemical content of spirulina 11 2.4 Malnutrition 14 2.4.1 Definition of malnutrition 14 2.4.2 Types of malnutrition 14 2.4.2.1 Protein-energy malnutrition (PEM) 14 2.4.2.2 Kwashiorkor "displaced child" 14 2.4.2.3 Marasmus "to waste away" 15 2.4.2.4 Micronutrient deficiency 15 2.4.3 Epidemiology of malnutrition 16 2.4.4 Malnutrition among children in Palestine 17 2.4.5 Burden of malnutrition 18 2.5 Anthropometry 20 2.5.1 Anthropometric indicators 21 2.5.1.1 Underweight 21 2.5.1.2 Stunting 23 2.5.1.3 Wasting 24 2.6 Standards of measurements 25 2.7 Biological measures 27 2.8 Management and treatment of malnutrition 32 2.9 Anemia 34 iv 2.10 Beneficial effects of spirulina 36 2.10.1 Nutritional effects 36 2.10.2 Immunological effects 38 2.10.3 Antiviral effects 38 2.10.4 Effects on biochemical parameters 39 Chapter (3) Material and Methods 3.1 Study design 41 3.2 Population of the study 41 3.3 Study site and sample size 41 3.4 Period of the Study 41 3.5 Eligibility criteria 42 3.5.1 Inclusion criteria 42 3.5.2 Exclusion criteria 42 3.6 Tools of the study 42 3.6.1 Study questionnaire 42 3.6.2 Anthropometric and hematologic measures 42 3.7 Validity of the questionnaire 43 3.8 Data collection 43 3.8.1 Weight and height measurement 43 3.8.2 Blood sample collection 45 3.8.2.1 Steps for taking blood sample 46 3.9 Intervention Protocols 46 3.9.1 Case group (Spirulina group) 47 3.9.2 Control group (vitamin and minerals group) 48 3.10 Spirulina analysis methods 48 3.10.1 Preparation of Spirulina samples 48 3.10.2 Chemical analysis 48 3.10.2.1 Proximate composition 48 3.10.2.2 Amino acid analysis 49 3.10.2.2.1 Amino butyric acid 49 3.10.2.2.2 Protein analysis 50 3.10.3 Microbiological analysis 50 3.10.3.1 Sample preparation 50 3.10.3.2 Media used 50 3.10.3.3 Total plate count method and total aerobic count 50 3.10.4 Media used for isolation and enumeration of Coliform bacteria 51 3.10.4.1 Violet red bile agar (g/L) 51 3.10.4.2 Brilliant green lactose bile (BGLB) broth 2% (g/L) 51 3.10.5 Isolation and identification of Salmonella 52 3.10.5.1 Media used for isolation and identification of Salmonella 52 3.10.5.2 Pre-enrichment (FDA, 2001) 52 3.10.5.3 Enrichment (FDA, 2001) 52 3.10.5.4 Identification (FDA, 2001) 52 3.10.5.5 Confirmation test (FDA, 2001) 53 3.10.6 Isolation and enumeration of Staphylococcus coagulase 53 3.10.7 Isolation of Clostridium perfringens at 370C (ISO 7937) 54 3.11 Data management and statistical methods 54 3.12 Ethical and administrative considerations 55 v 3.13 Limitation of study 55 Chapter (4) Results of the Study 4.1 Analysis of spirulina contents 56 4.1.1 Chemical analysis of spirulina 55 4.1.2 Microbiological studies 59 4.2 Socio-demographic characteristics of children’s household 60 4.3 Anthropometric characteristics of children 64 4.4 Changes in the anthropometric characteristics of the children 67 4.5 Changes in the Ferritin and serum iron levels among the children 71 4.6 Changes in the immunological indicators (WBC, LYM, GRA) 73 4.7 Changes in the hematological factors in the children 75 4.8 Changes in the hematological factors (MCV, MCH and MCHC) 77 4.9 Changes in the anemia status among the children 79 4.10 Mothers' compliance to treatment program 80 Chapter (5) Discussion and recommendations 5.1 Discussion 82 5.2 Recommendations 88 5.3 Suggestions for further research 89 References 90 Annexes 100 vi List of Tables No. Table title Page 2.1 Taxonomy of Spirulina 11 2.2 Biochemical Content of Spirulina 13 2.3 Costs of Malnutrition 20 Z-score and its Interpretation for the Nutritional Status of the Children 2.4 26 (WHO 2006) 2.5 Normal Values of Blood cells Contents 31 2.6 Protocol for Management of Malnourished children in AEI Association 33 2.7 Daily requirement intake of vitamins and minerals 34 2.8 Causes of anemia in infancy and toddlerhood 36 4.1 Approximate Chemical Contents of Spirulina from Marcelia-France (% wet weight basis) 56 4.2 Vitamin Composition of Spirulina 57 4.3 Minerals Composition of Spirulina 58 4.4 Amino Acids Composition of Spirulina (g.AA/100 g protein) 59 4.5 Microbial contents of Spirulina 59 4.6 Distribution of Sociodemographic Characteristics of Study Participants 61 4.7 Comparison of the Socio-demographic Factors Between the Two Groups 62 4.8 Differences Between the Two Groups Related to Age and Household Size 63 4.9 Anthropometric Characteristics of Study Participants 65 4.10 Comparison of Anthropometric Measures Before and After Intervention 68 Differences in Weight and Height in the Vitamins and Mineral Group (Paired Sample T 4.11 68 test) 4.12 Differences in weight and height in the Spirulina group (Paired Sample T test) 69 4.13 Comparison of Weight for Age Between the Two Groups 70 4.14 Comparison of Height for Age Between the Two Groups 70 4.15 Comparison of Weight for Height Between the Two Groups 71 4.16 Comparison of Ferritin and Serum Iron Supplement Between the Two Groups 72 4.17 Differences Between the Two Groups Related to Ferritin and Serum Iron 73 4.18 Comparison of Leukocytes Between the Two Groups 74 Differences in Leukocytes Between the Two Groups Before and After Receiving 4.19 75 Supplement Comparison of Hematology Profile Between the Two Groups Before and After Receiving 4.20 76 Supplement Differences in Hematology Profile Between the Two Groups Before and After Receiving 4.21 77 Supplement vii Comparison of MCV, MCH, MCHC Between the Two Groups Before and After 4.22 78 Receiving Supplement Differences in MCV, MCH, MCHC Between the Two Groups Before and After Receiving 4.23 79 Supplement 4.24 Differences of Anemia Between the Two Groups 80 4.25 Compliance with Treatment Program 81 List of Figures No. Figure Title Page 2.1 Spirulina Algae 10 2.2 Composition of Spirulina 13 2.3 prevalence of Stunting Among Children Under-five in Palestinian Territory, 2000 – 2010 17 2.4 Prevalence of Underweight Among Children Under-five in Palestinian Territory, 2000 – 2010 18 2.5 Estimated Prevalence of Underweight Globally 22 2.6 Estimated Prevalence of Stunting Globally 23 2.7 Estimated Prevalence of Malnutrition in Neighboring Countries 24 2.8 Neutrophil granulocyte 29 2.9 Eosinophil under the microscope (400X) 29 2.10 Basophil granulocyte 30 2.11 A stained lymphocyte surrounded by RBCs 30 2.12 Therapeutically Important Compounds of Spirulina and its Effect 40 3.1 Measuring Height / Length in Children 2 - 4 Years of Age 45 3.2 Giving the Child Spirulina Complement 47 4.1 Proximate chemical analysis of dry spirulina 57 4.2 Distribution of study participants by gender 63 4.3 Distribution of study participants by type of household 63 4.4 Distribution of children by weight for age 66 4.5 Distribution of children by height for age 66 4.6 Distribution of children by weight for height 67 viii List of Annexes No.
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