Al Azhar University – Gaza College of Pharmacy Deanship of Postgraduate Studies and Research Nutrition Assessment of Palestinian Children Less than Three Years Old with Rickets in Gaza Strip A thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master in Clinical Nutrition By Rula F. Abu Zuaiter Supervisors Dr. Jehad H. Elhissi Dr. Mazen A. El Sakka Ass. Prof. of Public Health Ass. Prof. of Pharmacognosy Health Consultant Al-Azhar University Gaza-Palestine (March, 2011) i Deanship of Postgraduate Studies and Research Nutrition Assessment of Palestinian Children Less than Three Years Old with Rickets in Gaza Strip By Rula F. Abu Zuaiter This thesis was defended successfully on 28 / 03 / 2011 Approved by Committee Members Signature Dr. Jehad H. El-Hissi ---------------- Dr. Mazen A. El-Sakka ----------------- Dr. Sulaiman El Jabour ----------------- Dr. Luay M. Nasser ----------------- ii {فَتَعَالَى اللَّهُ الْمَلِكُالْحَقُّ وَلَا تَعْجَلْ بِالْقُرْآنِ مِهْ قَبْلِ أَنْ يُقْضَى إِلَيْكَ وَحْيُهُ وَقُلْرَبِّ زِدْوِي عِلْمًا{ ]طه : 114] iii Dedication I dedicate this thesis To my mother and father who are enlightening my way. To my dear husband who supports me To my sons Ahmad and Yousuf, who are the light in my life. To soul of my father in low, and to my mother in low To my brothers and sisters for their endless love and support. To all of them I dedicate this work Rula F. Zuaiter iv Declaration I declare that this thesis submitted for the fulfillment of the requirements for the award of Master of Clinical Nutrition, Faculty of Pharmacy, Al-Azhar University- Gaza, is wholly my own work unless otherwise referenced or acknowledged, and that this document has not been submitted for qualifications at any other university or academic institution. Signed: Rula F. Abu Zuaiter Date: March, 2011 v Acknowledgement I would like to express my gratitude and appreciation in my great acknowledgement to those whose contribution to this research deserved a special mention. In the first place, I would like to record my deepest gratitude to my supervisors Dr. Jehad El Hissi & Dr. Mazen El Sakka for their patient guidance, original ideas, constructive criticism on my research and most of all their exceptional professionalism and attention to detail, which has been my reference point from the preliminary to the concluding level of this research. It is also a pleasure to pay honor to Dr. Adnan Al Wahidi, the medical director of Ard El Insan Society and his staff for their willingness to support this thesis and for the valuable time they had spent. Special thanks are due to my colleagues, Mohamad Oukal, Osama Abu Nada, and Basel Kanoa‟ for their indispensable help in many occasions which is perpetually memorable. Thanks for children and their mothers for their approval to participate in this study, without their help, this study could not be accomplished. Rula F. Abu Zuaiter vi Abstract Nutritional rickets is a disorder of growing children due to defective mineralization of newly formed bone matrix because of vitamin D deficiency. Vitamin D is made available to the body by photosynthesis in the skin (endogenous vitamin D from ultra violet ray exposure) and from dietary intake (exogenous vitamin D from dietary or specific supplementation). Vitamin D deficiency remains the major cause of rickets among young infants in most countries, because breast milk is low in vitamin D and its metabolites and social and religious customs climatic conditions often prevent adequate ultraviolet light exposure, Without vitamin D supplementation for the baby, prolonged exclusive breastfeeding, lack of sunlight exposure inappropriate dietary intake and poor housing would contribute to the development of rickets. The present study was undertaken to understand the nutritional status and its role in increasing rickets in Palestinian children under three years old in the Gaza Strip to determine to identify the nutritional determinants contributing to the development of nutritional rickets in children less than three years old, identify the role of the socioeconomic factors in development of nutritional rickets and to raise recommendations for policy makers to regulate a public health policy to increase surveillance and limiting the growth of the disease. A case-control study was conducted from July 2009 to October 2010, 200 children aged from 6 to 36 months participated in the study, 100 were rachitic children (the case group), and the other 100 were healthy children (the controls group) using several parameters, anthropometric measurements, such as height, weight, head circumference, body mass index BMI, height for age (Stunting), height for weight (wasting) and laboratory analysis, like serum albumin, serum calcium, serum phosphate and serum alkaline phosphatase. To assess their dietary intake, food frequency questionnaires FFQ were taken for the children from their mothers or care-giver. The present study showed that 53% of the rachitic children were poor, 59% were males, And 41% were females, the mean height for rachitic children was 79.85cm less than the mean height of controls which was 82.7cm, the mean weight for cases group was 10.82kg lower than that of controls 11.66kg, with higher mean for head circumference for the cases group 47.53cm than of controls 45.9cm, most of diseased children had normal serum vii calcium level, serum albumin, hypophosphatemia, and high levels of alkaline phosphatase. Prolonged exclusive breastfeeding and lack of sun exposure were having strong evidence on the development of the disease, cases group were not taking sufficient amounts of food contains high amount of calcium and vitamin D and they were malnourished, also taking of calcium and vitamin D supplementation during pregnancy and breastfeeding had an important effect on mothers and their infants. viii انتقييم انتغذوي نﻷطفال انفهسطينينن اﻷقم من ثﻻث سنواث انمصاببين بانكساح في قطاع غزة مهخص اندراست يزض انكظبح ػُذ اﻻطفبل: ْٕ ػببرة ػٍ يزض ٚصٛب انؼظبو َخٛجت خهم فٙ حزطٛب يؼبدٌ انؼظبو يثم انكبنظٕٛو, انفظفٕر َٔقض فٛخبيٍٛ د يًب ٚخظبب فٙ اَحُبءاث ٔحشْٕبث شكهٛت ببنؼظبو كًب حصبخ نُٛت ْشت ٔطٓهت انكظز. ٚخٕفز فٛخبيٍٛ د نهجظى بطزٚقخٍٛ, اﻷٔنٗ ػُذيب ٚخؼزض انجظى ﻻشؼت انشًض انؼًخذنت بحٛث ٚصُغ داخهٛب ببنجظى ٔانثبَٛت بٕاططت حُبٔل اﻷغذٚت انغُٛت بفٛخبيٍٛ د, ٔحكًٍ أًْٛخّ بأٌ َقصّ ْٕ انظبب اﻻطبطٙ فٙ َشٕء يزض انكظبح. يٍ انؼٕايم انخٙ حشٚذ َظبت انخؼزض نهًزض ْٕ سٚبدة فخزة انزظبػت انطبٛؼٛت انخبنصت نهًٕنٕد ػٍ 6 أشٓز يغ حأخٛز انبذء ببﻷغذٚت انخكًٛهٛت يغ ػذو انخؼزض ﻷشؼت انشًض ٔانؼٕايم اﻻقخصبدٚت ٔ اﻻجخًبٛػت انظٛئت نهطفم ٔاﻷو. ٔقذ حًج ْذِ انذراطت فٙ قطبع غشة نخقٛٛى انحبنت انخغذٚٔت نﻷطفبل انًصببٍٛ ببنكظبح يٍ ػًز 6 انٙ 36 شٓز ٔأجزٚج ػهٗ 200 طفم, 100 طفم كبَٕا يصببٍٛ ببنكظبح 100ٔ غٛز يصببٍٛ بب٘ يزض. ٔخهصج انذراطت انٙ اٌ يخٕطط انطٕل ػُذ اﻻطفبل انًصببٍٛ ببنكظبح كبٌ 79.8طى أقم يٍ يخٕطط انطٕل ػُذ اﻻطفبل غٛز انًصببٍٛ 82.7طى, كًب اٌ يخٕطط انٕسٌ ػُذ اﻷطفبل انًصببٍٛ اٚعب كبٌ أقم 10.8 كجى يٍ اﻷطفبل انغٛز يصببٍٛ 11.6 كجى , ٔيحٛط انزأص ػُذ اﻻطفبل انًصببٍٛ كبٌ أػهٗ يٍ انغٛز يصببٍٛ بحٛث كبٌ 45.9 طى ػُذ اﻷطفبل انغٛز يصببٍٛ بهٍٛ انؼظبو 47.53ٔ طى ػُذ اﻷطفبل انًصببٍٛ. كًب أشبرث انذراطت انٙ اٌ يؼظى اطفبل انبحث انًصببٍٛ ببنكظبح كبٌ نذٚٓى يظخٕٖ طبٙؼٛ حقزٚبب يٍ انكبنظٕٛو ببنذو يغ يظخٕٖ يُخفط يٍ انفٕطفبث ؼٚٔبٌَٕ يٍ طٕء انخغذٚت ٔقهت حُبٔل اﻷغذٚت انغُٛت بفٛخبيٍٛ د ٔانكبنظٕٛو فٙ ظم انحبنت اﻷقخصبدٚت انظٛئت ٔيؼبَبة اﻻيٓبث يٍ اﻻو انظٓز ٔانؼظبو ػٔذو حُبٔنٍٓ ﻷ٘ يٍ أقزاص انكبنظٕٛو أٔ فٛخبيٍٛ د اثُبء انحًم أ انزظبػت. ix List of abbreviation 25-OHD Total Hydroxyl Vitamin D 25-OHD2 25-Hydroxyvitamin D2 25-OHD3 25-Hydroxyvitamin D3 AI Adequate Intake ALP Alkaline Phosphatase BMC Bone Mineral Content BMI Body Mass Index Ca Calcium CDC Center for Disease Control CHD Coronary Heart Disease CHO Carbohydrate CVD Cardiovascular Disease DBD Vitamin D Binding Protein DM Diabetes Mellitus DRI Daily Reference Intake EBF Exclusive Breast Feeding. FFQ Food Frequency Questionnaire Kcal Kilocalorie Kg Kilogram LBW Low Birth Weight x LBW Low Birth Weight MCH Maternal and Child Health MOH Ministry of Health NAC Nutrition- Associated Complications NGOs Non-Governmental Organizations P Phosphorus PAPFAM Pan-Arab Project for Family Health PCBS Palestinian Central Bureau of Statistics PNA Palestinian National Authority PTH Parathyroid Hormone RDA Recommended Dietary Allowance SPSS Statistical Package For Social Science UL Tolerable Upper Intake Level UNFPA United Nations Population Fund UNICEF United Nations International Children‟s Emergency UNISPAL United Nations Information System on The UNRWA United Nations Relief and Work Agency USD United States Dollars WC Waist Circumference WHO World Health Organization WHR Waist to Hip Ratio μL Micro-Liter xi List of tables Serum 25-Hydroxyvitamin D [25(OH)D] Concentrations and Table 1 27 Health Table 2 Recommended Dietary Allowances (RDAs) for Vitamin D 28 Table 3 Selected Food Sources of Vitamin D 29 Table 4 Socio-demographic variability of the study participants 41 Table 5 Household characteristics of the study participants 44 Table 6 General characteristics of the study participants 46 t-test comparing the means of children anthropometric measures Table 7 48 among cases and controls Table 8 Child medical history 49 Table 9 Child food intolerance 51 The relationship between of family medical history among cases Table 10 52 and controls Table 11 Bone pain and calcium intake 53 Table 12 Children who were breastfed and had taken complementary feeding 55 Table 13 Sun exposure and rickets 56 Table 14 laboratory analysis for study population 57 Comparison of means for serum calcium, albumin, phosphorus