Tài liệu The situation of increasing serum uric acid, related factors and efficacy of dietary intake in over 30 year of age subjects in rural area of thai binh province

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BACKGROUND Increased serum uric acid (hyperuricemia) is a metabolic disorder that is closely related to a series of chronic non-infectious diseases such as myocardial infarction, stroke, diabetes, gout ... This topic has attracted authors interested but new researches just focused on big cities and in hospitals. Currently there are no adequate studies in epidemiology increased serum uric acid and prevention in the community. Meanwhile, scientific evidence has shown the effectiveness of intervention programs in the community in reducing the risk of death from diseases related to metabolic disorders. Thai Binh is a province in the Northern Delta where there is also a transition of disease patterns. Therefore, early detection and control the increase in serum uric acid without clinical manifestations are essential to help reduce the risk of some chronic non-infectious diseases. At the same time, the identification of factors related to the scientific basis for the selection of appropriate and specific community interventions.As the theory of increased serum uric acid with metabolic disorders in rural areas is becoming a significant issue of public health and the consultancy of suitable diet will help control the serum uric acid level, the thesis has been carried out with 3 objectivess as follows: 1. Describing the current status of serum uric acid levels in people at the age of 30 and older in rural community in Thai Binh. 2. Identifying factors related to the condition in serum uric acid levels in the study area. 3 Assessing the intervention effects of dietary for people increased serum uric acid in the community. New contributions of the Dissertation - Giving an abundant database in serum uric acid levels which were analyzed in collaboration with a number of indexes of anthropometry, blood pressure and blood lipids in people over 30 years old in rural communities in Thai Binh. It first came up with the rate of increased serum uric acid which was not managed or cared in community, this helped warn a number of groups who often have a high risk of increased serum uric acid including obese and overweight group, big waist, high WHR index, a history of heart disease. - Through multivarible correlation analysis, logistic regression analysis using Bayesian methods the study helped build models to predict serum uric acid levels by age, sex, BMI, abdominal obesity; detect factors independently associated with age, BMI, regular use of red meat, organ meats, bone water, alcohol in males; the independent factors associated with age, BMI, regular use of red meat, organ meats in females. - Proved that "Nutrition communication, counseling for subjects to perform reasonable diet as the sample menu based on the actual diet and locally available food sources" has been remarkably effective in reducing serum uric acid concentration and reducing serum uric acid levels. Layout of the thesis The dissertation consists of 130 pages, 30 tables, 12 charts and 153 references including 106 foreign ones. Background has 2 pages, 37 page literature review, research methodology 23 pages, 34 page research results, discussion 31 pages, 2 page conclusions and 1 page recommendations. CHAPTER I LITERATURE REVIEW 1. Studies on increased serum uric acid levels Cohort study follow-up data of Medicine for 50 years showed that if the 1954 -1958 period, the average serum uric acid levels was 5 mg / dl in males and 3,9mg / dl in females, in the 1972 -1976 period, the average level rose 5,7mg / dl in men and 4,7mg / dl in women. Australian researches showed that the rate of increased serum uric acid and gout accounted for high percentage compared to some countries in the region with similar economic conditions. The rate of increased uric acid increased quickly in 1959 compared with 1980 (17% in men aged 30-40) in the original Australian populations. Correspondingly, the incidence of gout increased from 0% in 1965 to 9.7% in men and 2% of women in 2002. Chuang's study evaluated trends in serum uric acid levels in Taiwan adults in two phases from 1993 to 1996 and from 2005 to 2008 showed a different trend. Period 1993-1996, average uric acid levels were 6,77mg / dl in males and 5,33mg / dl in females, this value was reduced to 6,59mg / dl in men and 4,97mg / dl in women after 12 years. The increased uric acid ratio decreased from 25.3% to 22% in men and from 16.7% to 9.7% in women, respectively. This was explained by the change in diet which reduces consumption of organs, fresh bamboo shoots and fresh water use In Vietnam, the investigation on the subject who were military staff at the middle-aged in 1999, the rate of increased serum uric acid was 17.96%. Doan Thi Tuong Vi studied the group which had a periodic health examination at the hospital 19/8, said men aged 30-60 with hyperuricemia was 6.2%, women 2.5%; the overall incidence was 4.9%. Related factors were frequency of consumption of foods rich in protein and much alcohol, weight and high BMI. The people with increased serum uric acid were at risk for hypertension, cholesterol, serum triglycerides higher than normal. Phan Van Hop carried out research in the elderly in Nam Dinh in 2011 showed that the rate of increased serum uric acid was 9.5%, of which 16.3% in male, 5.5% female, group aged 60-90 was10.1%, group aged 70-79 was 9.7% and over 80 years was 8.1%. Le Van Doan's research on subjects of middle-aged military officers in the military zone 9 showed the percentage of increased serum uric acid was 26.2%, and the incidence tends to increase with age. Factors related to increased serum uric acid levels were age, high protein diet, hypertension, dyslipidemia, overweight and obesity. 2. Factors related to serum uric acid levels The relevant factors have been reported from domestic and foreign studies included age, male gender, racial factors, genetics and gene mutations, diet, physical activity, nutritional status, puppets hyperlipidemia, hypertension, renal disease, cardiovascular disease and other chronic non-infectious diseases. Many studies have identified the clear relationship between the state of increased serum uric acid with a number of non-infectious chronic diseases especially cardiovascular diseases such as heart failure, myocardial infarction, stroke. Increased serum uric acid was found in approximately 60% of patients hospitalized with decompensated chronic heart failure. Increased serum uric acid linked to insulin resistance status, hypoxic tissue, increases the production of cytokines and free radicals so they could affect the cardiovascular system and prognosis in these patients deteriorate. The risk of hypertension also significantly higher in patients with increased serum uric acid of above 400μmol/l compared with those with serum uric acid below 200μmol/l. Among patients with untreated hypertension, deterioration phenomenon of coronary artery blood flow in people with increased serum uric acid levels was higher than people with normal serum uric acid. A number of studies have given evidence that theere was the combination between increased cholesterol, increased triglycerides and serum uric acid. Up to 80% of the triglycerides increased people may increase serum uric acid and up to 50-70% of gout patients have triglycerides increased 3. Intervention methods to decrease serum uric acid - Use of drugs: In the case of asymptomatic hyperuricemia, drug should be used only when the serum uric acid level is too high, above 12mg / dl (700 μmol / l) or when there is an increase in the level of acute uric acid production. The regularly tested cases with hyperuricemia over 10 mg / dl which resists to dietary adjustments, or have a family history of gout, kidney stones with increase serum uric acid, signs of kidney damage are required to take drugs to reduce uric acid. - Control of nutritional status: Many studies have shown that increased serum uric acid is related to obesity, overweight, diabetes, lipid disorders, metabolic syndrome. This relationship is in general illness of Insulin resistance syndrome which is essentially due to the excessive accumulation of fat cells. Therefore, to reduce the risk of chronic non-infectious diseases in general, it is necessary to maintain a weight level with ideal body mass index of 21-23. This is one of 8 independent recommendations of the World Cancer Research Fund and American Institute for Cancer Research published in 2007. A number of studies have recommended, in obese people, if weight is well controled, it will help reduce serum uric acid similar to implementing a low-purine diet - Control diet: The increased serum uric acid is closely linked to diet. Most uric acid in the body is derived from the metabolism of endogenous purine but diets with purine foods of animal origin may cause increased serum uric acid, because over 50% purine of ARN and 20% of ADN derived from food. Therefore, the cases of increased serum uric acid should reduce the consumption of alcohol, soft drinks and fructose, reduce consumption of products of animal origin rich in purines, increase the use of vegetables, fruits, milk and supplement vitamin C. CHAPTER 2. METHODOLOGY 2.1 Study participants Stage 1: First investigation among people aged 30 and older. Stage 2: Interventional study within 6 months among people with increase in serum uric acid. The control group was at 2 communes as Minhkhai and Songlang; the interventional group was at Tanphong and Viethung. 2.2. Methodology 2.2.1. Study design a. Stage 1: Cross-sectional descriptive study in order to: - Describe mean of serum uric acid concentration and increase serum uric acid rate in relation to age group, gender, nutritional situation, level of physical activities. - Identify some factors related to serum uric acid concentration and rate of increase serum uric acid as: gender, age, overweight, obesity, waist circumference, waist-hip ratio, hypertension, high blood glucose, blood lipid metabolic disorders, use of alcohol drink, food consumption. b. Stage 2: Community interventional study with control: People with increase in serum uric acid levels were divided into two groups of interventional and control groups, we followed up along 6 month period to evaluate the effectiveness of dietary intervention on serum uric acid levels. Evaluation results were taken 2 times before and after intervention. Interventions: Method 1: Mass media on nutrition Training people with increased serum uric acid content includes general knowledge about the consequences of increased serum uric acid, advice on diet to people with increase in serum uric acid focusing on the selection and use properly of common food sources available locally. Organize training in CHCs one time each three months. The first time is at the start of the intervention (M0), the second time was at 3 months after conducting research. Compiled communication materials "Community Guidelines for Prevention of Gout," and each object was distributed this document after the first training. Method 2: Nutrition counseling We based on dietary habits, dietary practice, based on the source of food and nutrition habits of the local people to build and provide menus for a week, a month participants. We developed menus for people with increase in serum uric acid based on nutritional needs for Vietnamese recommended by gender, age, level of physical activity, nutritional status, medical history and based on actual portions of objects. Energy build must ensure a stable weight for people with normal weight, creating cumulative positive energy with the thin and energy reduction with overweight people. The menu was based on the principle of reducing the use of protein, especially animal protein, animal protein accounted for approximately 30%. The recommended dietary protein level 1g / kg / day and 12-14% to meet energy needs. Demand for lipid occupies 20-25% of total energy. We performed nutritional counseling 1 time / month for 6 months. Control group: Applying nutritional communication approaches Intervention group: Apply both nutrition communication approaches and monthly nutritional counseling, as well as dietary building for participants. 2.2.2. Sampling procedure and sample size + Identify the percentage of increase in serum uric acid and related factors: combining some sampling method, randomly selected 4 communes of Vuthu District and make a list to randomly selected subjects with proper age by R software, sample sizes was as follows: p(1  p) n  Z (21 / 2 ) (p) 2 (Formula 1) The sample size for the cross-sectional survey as calculated was 1727 participants, in reality we has studied among 1910 people. + Intervention study: we used intentionally sampling to select all the object with increase in serum uric acid levels. Sample size applied for an interventional group as follows: nZ 2 ( , ) 2s 2 ( 1  2 ) 2 (Formula 2) We calculated the minimum sample size of 68 subjects / 1 group. In reality we has taken all eligible subjects included 77 subjects in intervention group and 72 subjects in control group to participate in the study. 2.2.3. Techniques applied to the study Assessment of nutritional status through BMI, waist circumference, waist/hip circumference. Investigation dietary of the last 24 hours, interview to determine the frequency of food consumption, eating habits, medical history, physical examination, blood pressure, blood biochemistry tests. 2.2.4. Data processing Data were analyzed using R software. We calculated average value, the ratio, percentage, the statistical test applied in biomedical research to analyze the results. Odds ratio OR was calculated to evaluate the factors related to the increase in serum uric acid levels. We used multivariate linear regression and logistic regression to identify associated factors, to exclude of confounding factors and to identify interaction effects. The study used a Bayesian method to select the optimal model for multivariate analysis. 2.2.5. Ethical consideration The study complied with the Declaration of Helsinki of the World Medical Association on ethical issues in Biomedical Research. The research proposal was adopted Council Ethics in Biomedical Research at the National Institute of Hygiene and Epidemiology before conducting research. Research ensured the voluntary participation of subjects. Safety issues and benefits of the study subjects had been assured during the research process. Chapter III. RESULTS 3.1. Situation of increasing in serum uric acid among people aged 30 and older at rural ThaiBinh Table 3.1. Socio-demographic characteristics of participants male female total Age group (n=935) (n=975) (n=1.910) n % n % n % 30-39 118 12.6 121 12.4 239 12.5 40-49 165 17.6 178 18.2 343 18.0 50-59 246 26.3 254 26.1 500 26.2 60-69 245 26.2 254 26.1 499 26.1 70-79 124 13.3 127 13.0 251 13.1 80 + 37 4.0 41 4.2 78 4.1 total 935 49.0 975 51.0 1910 100.0 Occupation Farmer 696 74.4 851 87.3 1547 81.0 Worker 148 15.8 52 5.3 200 10.5 businessman 43 4.6 24 2.5 67 3.5 Civil servant 32 3.4 36 3.7 68 3.6 Other 16 1.7 12 1.2 28 1.4 Table 3.1 showed that in total of 1.910 participants, male was accounted for 49.0%. Participants were distributed based on age groups were gender equally. 350 0 Uric acid (micromol/l) 50 150 250 male female 30-39 40-49 50-59 60-69 Age group 70-79 80+ Figure 3.2. Average serum uric acid concentration based on age group and gender Figure 2 showed that average serum uric acid concentrations were not different between 2 genders between age group of 30-39 and 40-49. However, after 50 years old, the concentration increased with age and reached the highest at age group of 80 and more. The difference was significant at p <0,001. Average serum uric acid concentration in male was higher than in female at all age group with p<0,001. Table 3.5. Average values and rate of increasing in serum uric acid based on age group and gender n Average Increasing in serum uric acid concentration Gender (µmol/l) n % (95%CI) Male 935 316.1±79.7 112 12.0 (10.0-14.2) Female 975 247.1±64.1 63 6.5 (5.0-8.2) Total 1910 280.9±79.9 175 9.2 (7.9-10.5) p<0.001 p<0.001 Table 3.5 showed that average serum uric acid concentrations was 280,9 µmol/l, in which male was 316.1 µmol/l, female was 247.1 µmol/l. Rate of increasing in serum uric acid was 9.2% (95%CI:7.9-10.5%), in which male was 12% and female was 6.5%. Average serum uric acid concentration in male was significant higher than female with p<0,001. Figure 3.3. Increasing in serum uric acid following age group Result from figure 3.3 showed that serum uric acid increased with age. Female had lower rate of increasing uric acid as compared to male. However after age of 60, there was an increasing in serum uric acid and they were similar to those among male aged 80 and more. 3.2. Factors associated with situation of increase in serum uric acid Table 3.12. The correlation coefficient between serum uric acid concentration and anthropometry, blood pressure and blood biochemistry Variables correlation coefficient p Age 0.21 <0.001 BMI 0.28 <0.001 hip 0.33 <0.001 WHR 0.34 <0.001 Diastolic blood pressure 0.18 <0.001 Systolic blood pressure 0.16 <0.001 Blood glucose 0.02 >0.05 Cholesterol 0.2 <0.001 Triglycerid 0.26 <0.001 Table 3.12 showed that Waist/hips (WHR) index had a high positive correlation coefficient with serum uric acid levels (r = 0.34), followed by waist circumference (r = 0.33), then to BMI, triglycerides, age, blood cholesterol, and blood pressure. The variables of age, anthropometric and blood pressure were positively correlated with serum uric acid levels with p <0.001. We used Bayesian method to select the optimal model to prognostic uric acid levels according to the associated factors. Results were 2 models as follows: 1. Uric acid (μmol / l) = 48.7 to 62.2 * gender (1: male, 2 female) + 1.17 * age (years) + 5.9 * BMI (kg / m 2) + 161 , 8 * WHR 2. Uric acid (μmol / l) = 102.7 to 63.2 * gender (1: male, 2 female) + 1.22 * age (years) + 4.92 * BMI (kg / m 2) + 1 , 37 * waist (cm). Table 3.14. Association between increase in uric acid with age and gender group Variable n UA Univariate analysis increase OR (95%CI) p Gender Female 975 6.5 1 Male 935 12.0 1.9 (1.4-2.7) < 0.001 Age 30-39 239 4.6 1 group 40-49 343 5.8 1,2 (0.6-2.7) >0.05 50-59 500 9.8 2,2 (1.1-4.4) <0.05 60-69 499 10.0 2,3 (1.2-4.5) <0.05 70-79 251 12.4 2,9 (1.4-5.9) <0.01 80+ 78 17.9 4,5 (1.9-10.5) < 0.001 Male was at risk of increase in uric acid 1.9 times as higher compared to female (95% CI: 1.1 -2.7). The risk of high uric acid levels increased gradually with age. Age group of 40-49 was at risk of increase in uric acid 1.2 times as higher than 30-39 age group, but the difference was not statistically significant with p> 0.05. Age groups of 50-59 and 60-69 year were at increased risk of uric acid at 2.2 and 2.3 times as higher compared to the age group of 30-39. The difference was statistically significant with p <0.05. This risk increased to 2.9 times and 4.5 times in the age group of 7079 and 80 and older. Table 3. 15. Relation between uric acid levels with anthropometric indicators Variable n UA Univariate analysis increase OR (95%CI) p BMI Normal 1378 9.2 1 Overweight/obesity 183 23.0 2.9 (2.0-4.3) < 0.001 hip Normal 1758 7.7 1 High 152 24.1 3.8 (2.5-5.6) < 0.001 WHR Normal 1751 9.0 1 High 159 11.3 2.8 (2.1-3.9) < 0.001 Results from table 3.15 showed that overweight subjects had risk of hyperuricemia at 2.9 times higher than the normal group, the difference was statistically significant with p <0.05. The high waist and the high waist / hips participants were at higher risk of increasing serum uric acid levels of 3.8 and 2.8 times higher than the normal group respectively. The difference was statistically significant with p <0.001. Table 3.16. Relationship between hyperuricemia with hypertension Variable n UA Univariate analysis increase OR (95%CI) p Hypertension No 1320 6.7 1 Yes 590 14.6 2.4 (1.7-3.2) < 0.001 Hypertension Normal 1503 7.9 1 level Level 1 255 12.5 1.7 (1.1-2.6) <0.05 Level 2 152 16.4 2.3 (1,5-3.7) < 0.001 Table 16 indicated that hypertensive group showed an increased risk of elevated serum uric acid at 2.4 times higher than the normal group. The difference was statistically significant with p <0.001. The risk of hyperuricemia increases with hypertension level. The risks of hypertension in the group level 1 were 1.7 times and 2.3 times increase in group level II respectively. The differences are statistically significant at p <0.05 and p <0.001. Table 3.17. Association between hyperuricemia and some biochemical blood indices Variable n UA Univariate analysis increase OR (95%CI) p No 1296 5.2 1 Cholesterol increase Yes 614 17.6 3.9 (2.8-5.4) <0.001 No 1362 7.3 1 Triglyceride increase Yes 548 13.9 2,1 (1.5-2.8) <0.001 HDL-C decrease LDL-C increase Dyslipidemia Metabolic syndrome No Yes No Yes No Yes No 1643 267 1438 472 839 1071 1536 9.3 8.6 6.5 17.2 4.2 13.1 8.2 1 0.9 (0.6-1.5) 1 2.9 (2.1-4.1) 1 3.5 (2.4-5.1) 1 < 0.001 Yes 374 13.1 1.7 (1.2-2.4) <0.01 >0.05 < 0.001 Table 3.17 showed that increased cholesterol, triglycerides and LDL-C would increased the risk of hyperuricemia at 3.9, 2.1 and 2.9 times higher than the normal group respectively. The difference was statistically significant with p <0.001. The level of HDL-C did not show relation to serum uric acid levels with p> 0.05. Participants with at least one blood lipid disorders had an increased risk of serum uric acid at 3.5 times (95% CI: 2.4 to 5.1) as compared with a group without any lipid disorders. Subjects with metabolic syndrome had an increased risk of serum uric acid at 1.7 times (95% CI: 1.2 to 2.4) as compared with those not suffering from metabolic syndrome. The difference was statistically significant with p <0.01. Table 3.18. Association between increased uric acid and smoking and alcohol use Variable n UA Univariate analysis increase OR (95%CI) p Smoking Use wine No 1449 8.2 1 Yes 461 12.1 1.5 (1.1-2.2) of Rarely 1444 7.2 1 Monthly 22 9.1 1.3 (0.3-5.6) >0.05 Weekly 240 15.0 2.3 (1.5-3.4) <0.001 Daily 204 16.2 2.5 (1.6-3.8) <0.001 1542 7.8 1 Monthly 71 12.7 0.7 (0.3-3.5) >0.05 Weekly 253 13.0 1.8 (1.2-2.7) <0.01 Use of beer Rarely <0.05 Daily 44 29.5 4.9 (2.5-9.7) <0.001 Table 3.18 showed that smoking group was at risk of high uric acid levels than the non-smokers at 1.5 times. The difference was statistically significant with p <0.05. The risk of increasing uric acid increased with the level of using alcohol. Group which used alcohol weekly was at increased risk of 2.3 and 1.8 times as compared with groups that did not drink or rarely drink alcohol. This risk increased to 2.5 and 4.9 times in participants who used alcohol at daily level respectively. Table 3.19. Association between increase in uric acid and the frequency of using some food groups Usual consumption n UA Univariate analysis increase OR (95%CI) p No 1773 6.9 1 Red meat Yes 137 38.7 8.5 (5.7-12.6) <0.001 Viscera of animals Fisheries Tofu Beans Bone soup Milk Soft drink Green tea No 1748 6.4 1 Yes 162 39.5 9.6 (6.7-13.9) No 1371 8.5 1 Yes 539 10.9 1.3 (0.95-1.9) No 1443 9.0 1 Yes 467 9.6 1.1 (0.8-1.5) No 1466 9.0 1 Yes 444 9.7 1.1 (0.7-1.6) No 1807 7.4 1 Yes 103 40.8 8.7 (5.6-13.3) No 1864 9.2 1 Yes 46 8.7 0.94 (0.3-2.7) No 1828 9.1 1 Yes 82 11.0 1.2 (0.6-2.5) No 1222 10.3 1 <0.001 >0.05 >0.05 >0.05 <0.001 >0.05 >0.05 Yes 688 7.1 0.7 (0.5-0.9) < 0.05 Table 3.19 showed that regularly use (daily, weekly) of red meat and animal viscera and bone soup increased the risk of hyperuricemia at roughly 9 times. The difference was statistically significant with p <0.001. Regularly use of seafood, tofu, beans and soft drink increased uric acid levels compared with not regular use, but the difference was not statistically significant with p> 0.05. Frequently use Table 3.21. Analysis of multivariate logistic regression between serum uric acid levels and gender Factors Unit Female Male OR (95%CI) p OR (95%CI) p Age (year) 10 2.5 (1.6-3.7) <0.001 1.6(1.2-2.1) <0.01 2 BMI (kg/m ) 1 2.2 (1.5-3.1) <0.001 3.8(2.6-5.4) <0.001 Red Yes=1 2.9 (1.8-3.9) <0.001 2.2(1.2-4.0) <0.01 meat Visceral Yes=1 13.9(4.8-40.7) <0.001 4.2 (2.4-7.8) <0.001 Bone Yes=1 3.9 (2.2-7.1) <0.001 soup Alcohol Yes=1 1.8(1.1-2.8) <0.05 Table 3.21 showed that independent factors related to serum uric acid levels in men were age, BMI, use of red meat, organ meats, bone soup and use of soft drink regularly. In female, we eliminated 2 factors of using alcohol and using bone soup in the analysis as less frequent use of these. For each unit of 10 years old would increase the risk of hyperuricemia at 2.5 times in female and 1.6 times in male. Increasing one unit of BMI would increase the risk of hyperuricemia to 2.2 times in female and 3.8 times in male. 3.3. Effectiveness of dietary to reduce serum uric acid levels Table 3.23. Effective of dietary to reduce serum uric acid after 6 month intervention Indicator Intervention Control group (n=77) p group (n=72) Average serum uric acid concentration: (µmol/l) M0 448.8 ± 61.7 446.7 ± 54.3 >0.05 M6 425.9 ± 55.7 365.8 ± 63.5 <0.001 M0 - M6 22.9 80.9 p before-after <0.001 <0.001 Uric acid increase : n (%) M0 72 (100.0) 77 (100.0) M6 63 (87.5) 34 (44.2) <0.001 Effective 12.5% 55.8% index Intervention 43.3% effectiveness Table 3.23 showed that before the intervention, 2 groups of control and intervention had average serum uric acid concentrations was similar. After 6 month intervention, in the intervention group, the uric acid level reduced at 80.9 μmol/l while the control group decreased less as compared with the counterpart. The difference was statistically significant with p <0.001. More than 50% participants in the intervention group and 12.5% in control group showed serum uric acid returned to normal after 6 months. The difference was statistically significant with p <0.001. Effective intervention after 6 months was 43.3%. Table 3.24. Effectiveness of reducing serum uric acid by age group Indicators ≤ 60 age (a) > 60 age (b) p Control group (n=39) Intervention group (n=34) Control group (n=33) Intervention group (n=43) Average serum uric acid concentration: (µmol/l) M0 461.7 446.2±52.1 433.5±61.4 447.1±56.7 p(a)>0.05 ±59.8 p(b)>0.05 M6 436.2±54.3 369.3±70.7 413.9±55.8 363.0±57.9 p(a)<0.001 p(b)<0.001 p before< 0.001 < 0.001 < 0.001 < 0.001 after Increase in serum uric acid : n (%) M0 39 (100.0) 34 (100.0) 33 (100.0) 43 (100.0) M6 35 (89.7) 17 (50.0) 28 (84.8) 17 (39.5) p(a)<0.001 p(b)<0.001 Effective 10.3% 50.0% 15.2% 60.5% index Intervention 39.7% 45.3% effectivenes s Evaluation of the effect of serum uric acid decreased with age, the results showed in table 3.24 that in intervention group, two age groups of under and over 60 reduced serum uric acid levels as compared to control group. These difference were statistical significance with p <0.001 compared with the control group. Group of more than 60year old had the rate of returning uric acid to normal higher as compared to the age group of less than 60 in both control group and the intervention group. Effective intervention after 6 months in the group of over 60 years was 45.3%, in group of 60 years and younger had lower efficiency (39.7%). Figure 3.10. Frequency of consumption of foods according to uric acid group after intervention Figure 3.10 showed that participant who did not use of alcohol, beer, red meat, organ meats and bones soup regularly had higher rate of serum uric acid levels returning to normal after 6 month intervention as compared to the counterpart. The difference was statistical significance with p <0.05. Table 3:26. Effective intervention to regular frequency of consumption of some food groups Food Before intervention control intervention (n=72) (n=77) After intervention control (n=72) intervention (n=77) Wine 37.5 42.9(a) 36.1 31.2(a) Beer 20.8 32.5(a) 18.1 16.9(a) Soft drink 5.6 6.5 5.6 3.9 Red meat 31.9 28.6(a) 34.7** 11.7**.(a) Visceral 43.1 33.8(a) 37.5** 16.9**.(a) Seafood 34.7 35.1 38.9 32.5 Bone soup 25.0 24.7(a) 26.4* 11.7*.(a) Beans 25.0 27.3 25.0 26.0 Tofu 27.8 27.3 27.8 27.3 Milk 1.4 3.9 1.4 3.9 Green tea 30.6 27.3(a) 30.6 37.7(a) Coffee 1.4 3.9 1.4 3.9 Table 3.26 showed that, before the intervention, the frequency of regular consumption of food group between control and intervention group were similar. The difference was not statistically significant with p> 0.05. After the intervention, the frequency of consumption of food groups in control group was significant difference as compared to pre-intervention. In the intervention group, the frequency of regular consumption of wine, beer, red meat, organ meats, bone soup significantly reduced as compared to preintervention (p <0.05). After intervention, the frequency of consumption of red meat, organ meats, bone soup in intervention group was statistically lower as compared with the control group and compared with preintervention with p <0.01 and <0, 05 respectively. Table 3.29. Compare the nutritional value of diets between the 2 groups of before and after intervention at age group of 30-60 years old Indicators Before intervention Control Intervention (n=39) (n=34) 2116.6±345.0 2206.9±325.5(a) Energy (Kcal) Protein(g) Total 91.6±29.4 Animal 47.9±27.6 Protein 49.7±13.2 animal/Total (%) Lipid (g) Total 50.0±24.8 Animal 32.0±18.4 Animal 65.6±18.8 Lipid / Total(%) Vitamin A (µg) 570.0±358.5 Caroteno 6265±4800 C(mg) 140.8±100.5 Mineral (mg) Calcium 514.2±260.1 phosphorus 1121.5±372.1 Fe 16.9±8.8 Dietary 6.5±2.1 Fiber After intervention Control Intervention (n=39) (n=34) 2085.3±228.6* 1906.0±220.5*.(a) 91.2±19.7(a) 44.4±19.7(a) 47.3±14.2(a) 96.9±19.1* 53.3±16.2* 54.6±10.4* 72.6±9.7*.(a) 28.6±1.9*.(a) 39.9±5.1*.(a) 55.4±18.1(a) 36.6±17.3(a) 65.3±20.4(a) 56.6±19.6* 36.0±18.0* 62.2±17.3 45.4±11.5*.(a) 26.1±10.1*.(a) 57.9±18.6(a) 742.7±591.6(a) 6881±3837.6(a) 133.0±72.1(a) 666.8±370.9 6720±3335.6 130.6±79.6 577.7±310.7(a) 7727±3374.1 (a) 120.0±71.6 (a) 613.8±455.7(a) 1075.8±236.4(a) 16.0±4.4(a) 7.1±2.9 595.6±418.2 1129.1±220.5 16.7±7.8* 6.1±1.7 467.3±184.7(a) 893.6±136.9 (a) 14.1±4.4*.(a) 5.6±1.3 Table 3.29 showed that, at the beginning of investigation there was no significant difference in dietary energy, protein, lipids, vitamins, minerals and fiber between the 2 groups control and intervention. After 6 month intervention, total protein, especially animal protein, protein levels in intervention group were significantly reduced as compared with the control group and compared to itself before intervention. Table 3.30. Comparing the nutritional value of diets between the 2 groups of before and after intervention at the age of over 60 years Indicators Before interention Control Intervention (n=33) (n=43) 1878.3±215.9 1879.4±227.9(a) Energy (Kcal) Protein(g) Total 78.1±19.6 Animal 35.6±16.5 Protein 44.0±14.3 animal/Total (%) Lipid (g) Total 46.1±15.2 Animal 28.5±12.9 Animal 62.0±21.1 Lipid/ total (%) Vitamine A (mcg) 475.6±308.1 Caroteno 5535±3742.9 C (mg) 97.5±62.1 Mineral (mg) Canxi 403.1±142.6 Phospho 911.4±197.0 Fe 13.3±3.2 5.4±1.8 Fiber (g) After intervention Control Intervention (n=33) (n=43) 1888.9±99.0 1841.8±216.6(a) 77.8 ± 19.2(a) 36.9±17.0(a) 46.4±13.5(a) 77.8±9.0* 39.7±8.2* 50.9±6.6* 66.1±9.9*.(a) 20.6±7.2*.(a) 31.3±9.7*.(a) 43.8±13.9(a) 28.5±13.8(a) 64.1±20.5(a) 46.4±9.2* 29.6±11.4* 62.5±15.9 39.4±13.6*.(a) 21.3±9.5*.(a) 54.8±19.9(a) 532.1±406.7(a) 5935±3934.8(a) 111.3±93.7(a) 559.6±323.9 6813.0±4152.2* 108.6±60.7* 493.6±248.8(a) 9593.0±4974.3*.(a) 156.2±93.9*.(a) 471.8±223.6 934.1±228.6(a) 13.5±4.0 5.9±2.0(a) 597.8±459.9 936.1±131.6* 13.3±2.9 5.6±1.7* 487.7±142.5 828.4±103.9*.(a) 13.4±2.6 6.5±1.5*,(a) Similar to the age group of under 60, table 3.30 showed that, at the beginning of the investigation there was no significant difference in dietary energy, protein, lipids, vitamins, minerals and fiber between two groups of control and intervention among age group above 60. After 6 month intervention, total protein, especially animal protein, lipid content were significantly reduced in intervention group as compared with the control group and with itself before intervention. Levels of vitamin C and fiber in intervention group were also higher than the control group and higher than before the intervention (p <0.05). CHAPTER IV. DISCUSSION 4.1. The increase in serum uric acid among people 30 years and older in rural communities in Thaibinh This study was conducted in a rural area of northern delta region in the context as the World Health Organization indicated that non-infectious diseases are of serious impact on household incomes and national economies especially in middle and low income countries. Average serum uric acid levels of the adult in this study was 280,9μmol / l, in which male was 316,1μmol/l, higher than female (247,1μmol / l). The difference was statistical significance at p <0.01 (table 3.5). These average values at all ages were higher in male than in female and increased with age in both male and female but average serum uric acid concentrations were no significant differences between age groups of 30 and 40 (Chart 3.2). The rate of increase in serum uric acid level in this study was 9.2% (95% CI: 7.9 to 10.5%). This proportion among male was 12% (95% CI: 10 to 14.2%) higher than females 6.5% (95% CI: 5.0 to 8.2%). The difference was statistically significant with p <0.001. Study about the biological values of Vietnamese adult at years of 90s of the 20th century showed that the average concentration of serum uric acid was 293,05mol / l in male and 197.0 mol / l in female, which were lower than the results of our research. Thus, the concentration of uric acid in the community also has a similar increasing trend as indicated in a number of overseas studies. However, when compared to the results of research on the subject with the task of health management at the Huunghi Hospital in 2006, the average concentration of uric acid in our study was lower by 50mol / l. This also makes sense because these objects were in the big city, where common metabolic disorders were observed more. Author Phan Van Hop on elderly subjects aged 60 years and over in Nam Dinh - a province in the Red River Delta which was similar to our study area also showed the rate of increase in serum uric acid was 9.5% which accounted for 16.3% in males and 5.5% in female. A study in Taiwan on elderly subjects aged 65 years and older indicated that average serum uric acid concentration in male was 437.6 μmol/ l and in female was 376 μmol / l. Increase in serum uric acid were common among these objects. The prevalence among male was 57.3% and among female was 40.9%; and tends to be stable with age groups. The incidence among the elderly was much higher than among adult people in the community which was about 20% in male and 10% in female. Many studies in China showed that the rate of increase in serum uric acid vary according to geographic conditions, climate and economic conditions. Yu conducted a study among 7,403 subjects aged 20 or older at Foshan of Guangdong Province in 2010, the rate of increasing uric acid was 15.09%, which accounted for 19.9% in male and 10.54% in female. Nan’s research investigated among 2438 subjects age 20-70 in Qingdao, the rate of increasing uric acid was 25.3%, which accounted for 32.1% n male, 21.8% in female. Author Miao performed study on 5,003 adult subjects in 5 coastal areas of Shandong Province in China, the rate of increasing uric acid was 13.19%, in which the incidence in males was 18.3% which was 8.56% higher than females. Increased uric acid was more common in male over 30 of age and in female over 50 of age, the incidence was higher in urban areas than in rural areas (14.9 and 10.1%). Liu conducted a systematic analysis of epidemiological studies on serum uric acid levels in China, results showed that the rate of increase in serum uric acid was 21.6% in male and in female was 8.6%. The risk of increased serum uric acid begins at age of 30 for male and of 50 for female. 4.2. Identify factors related to the condition of increasing serum uric acid level Serum uric acid levels had positively correlation with a number of variables such as age, anthropometry, blood pressure and blood biochemistry. The correlation coefficient was highest in the group of anthropometric (0.28 to 0.34), then the triglyceride (0.26), age (0.21), cholesterol (0.2), the maximum blood pressure (0.18) and the minimum blood pressure (0.16) (table 3.12). From these correlations, our research has developed two models to predict uric acid with 3 similar factors as age, sex, and BMI, the different factor was factor to assess abdominal obesity (one model using index waist circumference, another model using waist / hips index). With these 4 factors, both 2 models could explained about 30% of the differences in uric acid levels between participants. Research conducted by Pham Ngoc Kieu in Angiang has also identified a closely positive correlation between the anthropometric indices, blood pressure and serum uric acid concentration. Male had risk of increasing serum uric acid at 1.9 times higher than female (95% CI: 1,1-2,7). The risk of high uric acid levels increased gradually with age. Age group of 40-49 had risk of increasing serum uric acid higher than age group of 30-39 by 1,2 times, but the difference was not statistically significant with p> 0.05. Age group of 50-59 and 60-69 were at increased risk of uric acid of 2.2 and 2.3 times higher than the age group of 30-39. The difference was statistically significant with p <0.05. The risk of increasing serum uric acid was 2.9 times in the age group of 70-79 and 4.5 times in the age group of 80 and older as compared to the age group of 30. Our results were consistent with epidemiological studies in Vietnam and oversea. Assessment of the relationship between the anthropometric characteristics showing nutritional status with rate of increasing in serum uric acid, the results of our study showed that overweight, obesity, waist circumference and waist /hip was risk factors of increasing serum uric acid. Obesity subjects had risk of increasing serum uric acid at 2.9 times higher than normal group (95% CI: 2.0-4.3), the difference was statistically significant with p <0, 05. The larger waist people were at risk of serum uric acid levels of 3.8 times higher than the normal group, and subject with high waist / hips index also had risk of increasing serum uric acid of 2.8 times higher than the normal group. The difference was statistically significant with p <0.001. Hypertension was closely associated with increased serum uric acid. Group with hypertension had increased serum uric acid was 2.4 times higher than the normal group. The difference was statistically significant with p <0.001. The risk of increasing serum uric acid was increased according to level of hypertension. This risk in group of hypertension level I increased 1.7 times and in group of hypertension level II increased 2.3 times as compared to the normal group. The differences are statistically significant, p <0.05 and p <0.001 respectively (Table 3:16). Research of Doan Thi Tuong Vi indicated that hypertension may double uric acid level as compared to the normal group. This result was similar to studies of Le Van Doan, Bui Duc Thang and a number of oversea studies. Study the relationship between dyslipidemia with increased serum uric acid, our study showed that subjects with high cholesterol increased the risk of increasing uric acid, LDL-C and triglycerides (3.9; 2,9 and 2.1 times respectively higher than the normal group). The difference was statistically significant with p <0.001. Groups with metabolic syndrome have an increased risk of uric acid of 1.7 times higher than the normal group (no metabolic syndrome). The difference was statistically significant with p <0.01. These results were similar to study by Doan Thi Tuong Vi which indicated that increased serum uric acid had closely relationship with dyslipidemia. Subjects with increased serum uric acid had the risk of high cholesterol at 4.5 times and increased risk of high triglyceride levels at 3.7 times as compared to those who did not increase serum uric acid. The difference was statistically significant with p <0.001. Comparing serum uric acid levels in relation to dyslipidemia in male age over and under 45 years, a study in India found that male under 45 with higher uric acid levels were at risk of increased uric acid, increased cholesterol, increased triglycerides, decreased HDL-C, increased LDL and increased VLDL as compared with male with normal uric acid levels. These differences were statistical significance. However in those aged 45 years or older, only triglycerides and VLDL were different between 2 groups of increased and not increased uric acid levels. To evaluate the relationship between the frequency of using some food groups and increased uric acid, results showed that the risk of increasing uric acid would increase following the increased level of using alcohol. The group of using alcohol weekly had the risk of increasing uric acid of 2.3 and 1.8 times higher as compared to group without using alcohol. This risk increased to 2.5 and 4.9 times among participants with daily use of alcohol.
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