Tóm tắt Luận án tiến sĩ Y học: Nutritional status and effectiveness of iron and zinc fortified rice in children aged from 36 to 2 under 60 months in Vu Thu district, Thai Binh province

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INTRODUCTION
Children’s growth is governed by many factors: genetic and external
factors including nutrition. Proper nutrition is an important environmental
factor for the growth and control of health and disease in the life cycle stages.
Investing in nutrition and diet throughout the life cycle brings about not only
economic benefits but also practical social meaning such as saving the cost of
medical care, increasing the intellectual capacity and productivity of adults.
Nutrition is the foundation for the development of strength, health, wisdom,
stature of children.
When it comes to malnutrition, experts say it's not just about hunger but
also implies the notion of "latent hunger" or lack of essential micronutrients
such as Vitamin D, A, iron and zinc. This is a meaningful public health issue,
in which high-risk groups of getting malnutrition are women and children,
especially children under 5. Survey data from the National Institute of Nutrition
show that the rate of micronutrient deficiency in children is over 30%.
Micronutrient deficiencies can be completely prevented and eliminated
if those with high risk of malnutrition are constantly exposed to a small
amount of micronutrients. To prevent micronutrient deficiency, many
solutions can be implemented including solutions to enhance the
micronutrients in food. Foods that are fortified with micronutrients are often
foods that are often used by people. Micronutrient Intake is a viable and
sustainable intervention to improve micronutrient deficiency.
Thai Binh is an agricultural province and rice is the main source of food
for the people. So far, there have been no studies to evaluate the effect of
multi-micronutrient fortified rice on the health status of people in general and
children in particular. The assessment of the effectiveness of multimicronutrient fortified rice use for children is essential as a basis for the
development of appropriate policies on multi-micronutrient enhancement in
rice in Vietnam. Therefore, we conducted the topic: "Nutritional status and
effectiveness of iron and zinc fortified rice in children aged from 36 to

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under 60 months in Vu Thu district, Thai Binh province" with the following
objectives:
1. To determine the rate of malnutrition, the prevalence of anemia, in
children aged from 36 to under 60 months and some related factors in Vu Thu
district, Thai Binh province.
2. To analyzie characteristics of diets and prevalence of iron and zinc
deficiency in children aged from 36 to under 60 months
3. To evaluate the effectiveness of iron and zinc fortified rice to improve
nutritional status in children aged from 36 to under 60 months.
NEW CONTRIBUTIONS OF THE DISSERTATION
- The dissertation has provided additional data on child malnutrition
situation in Thai Binh province and identified the prevalence of zinc, iron
deficiency and low iron stores in children aged 36-60 months, which are the
basis for proposing interventions to improve childhood micronutrient
deficiencies.
- Rice is the staple food of Vietnamese people. Iron and zinc fortified rice
is a solution that can accessible to all populations.
- Research has shown that the use of iron and zinc fortified rice in
children's diets has improved their diets, increased serum zinc levels,
increased iron status and reduced the incidence of iron and zinc deficiency.
These factors contributed to the rapid improvement of the child's physical
development and served as a basis for confirming the Government's
Regulation No. 09/2016 ND-CP dated January 28, 2016 on the promotion of
micronutrient fortified in food is very important and needs to be developed on
a nationwide scale.
LAYOUT OF THE DISSERTATION

The dissertation consists of 115 pages, 31 tables, 4 charts, and 139
references including Vietnamese ones and foreign ones. There are 2 page
backgound, Literature review 31 page, Research methodology 23 pages,
research results 28 page, discussion 28 pages, conclusion and 3 page
recommendations.


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CHAPTER 1. LITERATURE REVIEW
1.1. Current situation of child malnutrition and some related factors
1.1.1. Malnutrition status of children in the world
From 576 representative surveys of the countries and territories between
1990 and 2010, it is shown that in 1990 the world rate of stunted children
under age 5 accounted for about 40%. This rate in Latin America and the
Caribbean was 24.6%. The stunting rate in Asia in 1990 was 48.4%;
developing countries 44.6%; developed countries 6.1%. By 2010, the stunting
rate in children worldwide has dropped from 39.7% to 26.7% However, there
is a significant difference in the rate of stunting among regions. In Africa, the
stunting rate is almost unchanged that after 20 years, the stunting rate has
fluctuated around 40%, while Asia has experienced dramatic changes, the
stunting rate reduced significantly 49% in 1990 to 28% in 2010. However, in
most developing countries, stunting rate remains a significant public health
problem in the present. About 80 percent of stunting children under the age of
five are in 14 countries, of which the countries with the highest rate of
stunting children under five are East Timor, Burundi, Niger and Madagascar,
Bangladesh, Cambodia, Camarun, Ethiopia. By 2012, the overall stunting rate
worldwide was around 25.0%, of which 56% is in Asia and 36% in Africa. By
2015, 156 million children suffered from stunting, accounting for 23% of all
children under 5 years of age. There is evidence that although the number of

under-five children with stunting is high, the rates are unevenly distributed
across regions of the world. Stunting is more severe than underweight. In
developing countries, rural children are 1.5 times more likely to develop
stunting than urban children. It is predicted that by 2020, stunting worldwide
will continue to decline.
1.1.2. Malnutrition status of children in Vietnam
Research results of the National Institute for Nutrition until 2014
showed that: Distribution of malnutrition in our country is uneven among
ecological regions; many mountainous areas have higher rates of malnutrition
than delta areas. The highest malnutrition rate was in the Central Highlands
(22.6% for underweight and 34.9% for stunting). In the South East, the
prevalence of malnutrition was lower than in other regions (8.4% for
underweight and 18.3% for stunting), lowest among ecological regions of the


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country. The highest rate of stunting was recorded in the Central Highlands
(34.9%), the Northern Midlands and Mountains (20.3%). The stunting rate
was uneven among ecological regions. The Northern Highlands and
Mountains and the Central and North Central Coast remained at a high level
of public health significance (> 30%).
Results of the study by Nguyen Thanh Ha on the micronutrient status of
stunting children aged 6-36 months in Gia Binh district, Bac Ninh province
showed that anemia, vitamin A deficiency and zinc deficiency in stunting
children was all severe according to the WHO classification. Stunted children
have high rates of micronutrient deficiency. 37.6% of stunted children are
lack of 1 kind of micronutrient, 23.5% of children lack 2 combined
micronutrients and 8.2% of total stunted children are deficient in the
combination of 3 micronutrients.

1.1.3. Several factors related to malnutrition
The three most important factors that affect malnutrition are food
security, poor nutrition practices and illnesses, which are largely influenced
by poverty.
1.1.3.1. Household food insecurity: That the food security of households
do not guarantee is the key factor leading to food shortages in both quantity
and quality - including lack of energy, protein and micronutrients. At present,
the rate of poor households in remote and disadvantaged areas remains high.
This is a potential cause of individual malnutrition. In addition, the level of
influence of each factor depends on the accessibility of food in each
household, and depends very much on nutrition knowledge, customs and
habits of each ethnic group.
1.1.3.2. Poor nutritional practice: Poor nutritional practices related to
food imbalances and preference for children and pregnant mothers. Even if
the household ensures food security, there may be food shortages for
individuals, especially for high risk individuals such as children under 5 or
pregnant women etc. which is mainly due to poor nutritional practice.
1.1.3.3. Role of illnesses: Illness is considered to be one of two direct
causes of child malnutrition. Infections increase the loss of nutrients,
anorexia and eating in smaller amounts due to decreased appetite. Studies
estimate that infection affects 30% of the decrease in height in children.


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1.2. Micronutrient deficiencies in children
Results of the national micronutrient census in 2014 and 2015 showed
that the younger the child, the higher the risk of anemia: children in the groups
of 0-12 months and 12-24 months had the highest rates of anemia with 45.0%
and 42.7%, respectively; whereas in the group of children aged 24-35 months

this proportion was 23.0%; the group of 36-47 month children was 18.8%; the
group of 48-60 months 14.3%. The prevalence of anemia in urban children was
22.2%; in rural areas: 28.4%; in mountainous areas was 31.2%.
A study on micronutrient deficiencies in six northern mountainous
provinces showed that the prevalence of anemia in children was 29.1%,
which was in the mean of public health significance. The low iron stores
ratio (Ferritin <30ng/mL) was 49.1%. Similarly, the prevalence of iron
deficiency anemia (both Hb and Ferritin) was 52.9%.
1.3. Measures to prevent micronutrient deficiencies
- Dietary diversification: is the best and most sustainable option, but it
takes the most time.
- Enhancing micronutrients in food: brings about slower effectiveness
but more effective and more sustainable.
- Micronutrient supplementation effectively improves the
micronutrient status of individuals and target populations.
CHAPTER 2. SUBJECTS AND METHODOLOGY
2.1. Study subjects
* Phase 1: Children aged from 36 to 60 months old and mothers with
children aged from 36 to 60 months in 4 communes of Minh Khai, Nguyen
Xa, Song An, Minh Lang, Vu Thu District, Thai Binh Province
* Phase 2: Children aged from 36 to 60 months old and mothers with
children aged from 36 to 60 months in 2 communes: Minh Khai
(intervention) and Nguyen Xa (control).
2.2. Research methodology
2.2.1. Research design: include two successive phases.
2.2.1.1. Cross-sectional descriptive study: Determining malnutrition rate,
anemia and some related factors in children from 36 to under 60 months of
age.

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2.2.1.2. Community interventional study with control
Children aged 36 to under 60 months were divided into two groups: the
intervention group and the control group. Prior to the intervention, children in
both groups were tested for the following indicators:- Weight, height.
- Tests: Hb, serum zinc, serum ferritin (SF), TfR, CRP.
- An interview with the mother about the child's diet
Intervention group: Children from 36 to under 60 months of age living in
Minh Khai commune and are fed with iron and zinc-fortified rice for 12
consecutive months.
Control group: Children aged 36 to under 60 months living in Nguyen
Xa commune and were served daily with normal rice, not zinc and ironfortified rice.
Children participating in the intervention were divided into two age
groups at the beginning of intervention:
+ Age group 1: children aged 36-47 months.
+ Age group 2: children aged 48 to under 60 months.
Both groups were evaluated by survey at the time points of M0; M12
and there was the comparison between the two groups.
2.2.2. Sample selection and sample size
p (1 − p )
- Sample size for assessing children’s nutritional status n = Z 2 (1− α / 2 )
d2
According to the calculations, n = 461 children, but in this study, we
selected clustered sampling, so we doubled the sample size; this is why the
sample size was 922 children but in fact we surveyed 938 children.
- Sample size for determining anemia: The total number of children
participating in the assessment of anthropometric indicators (938 infants)
were selected.
Z 2δ 2 N

- Sample size for Phase 2 - Intervention study n = 2
(e N ) + ( Z 2δ 2 )
According to the calculations, n = 71 children for each group, together
with 10% of those who gave up, so the number of children for diet surveying
was 80 children.
Sample size for testing

n = ( Z 1− α

δ 12 + δ 22
+ Z 1− β )
(µ1 − µ 2 ) 2
2


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Sample sizes were calculated for each of the criteria as follows: Serum
hemoglobin was 130 samples; The serum ferritin test was 136; The serum Zn
test was 135 samples.
Sample size for intervention effectiveness evaluation was 136 children
per group, which was sufficient to cover the monitoring of all indicators of
concern. In fact, there were 324 children in the two intervention groups
including 167 children in the intervention group and 157 children in the
control group.
Sampling:
+ Phase 1: Research site selection: purposively selected Vu Thu district.
- Select communes: 4 communes to study were randomly selected
including Minh Khai commune, Song Lang commune, Nguyen Xa commune
and Song An commune.

- Select the target population: Select all children aged 36 to under 60
months in accordance with sampling standards and sample size to have
enough calculated sample size.
+ Phase 2: Select the subjects in the intervention study
- Intervention site selection: In the four study communes in the first
phase, we randomly selected 2 communes. The randomly selected communes
were Minh Khai Commune as the intervention commune and Nguyen Xa
Commune as the control commune. The total number of children aged
between 36 and under 60 months of 2 communes were selected to participate
in the second phase.
2.2.3. Techniques applied in the study:
- Techniques for anthropometry, age, classification of child malnutrition
according to WHO 2007.
- Interview technique, survey and analysis of the last 24 hours
- Clinical examination technique
- Biochemistry, Hematology tests: Hb, Zinc, Ferritin, CRP and TfR
2.3.4. Data processing: Data was analyzed using SPSS 16.0 software at Thai
Binh University of Medicine and Pharmacy. Statistical tests applied in
biomedical research were used to analyze the results.


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CHAPTER 3. RESEARCH RESULTS
3.1. Malnutrition and anemia rates among children aged from 36 to
under 60 months old and some related factors in Vu Thu district, Thai
Binh province
Table 3. 1. Distribution of nutritional status of children by sex
Malnutrition Underweight
Stunting

forms
Freq
%
Freq %
Sex

Wasting

Overweight

Freq

%

Freq

%

Male (n=476)

68

14.3

140

29.4

25

5.3

17

3.6

Female (n=462)

51

11.0

106

22.9

14

3.0

11

2.4

Total (n=938)

119

12.7

246

26.2

39

4.2

28

3.0

p

<0.05

<0.05

<0.05

>0.05

The table shows that 12.7% of children was underweight, 14.3% of whom
are males, higher in females with 11.0%, the difference was statitically significant
with p <0.05. 26.2% of children was stunting, with 29.4% in males and 22.9%
in females, the difference was statitically significant with p <0.05; 4.2% of
children was wasting, with 5.3% in males, 3.0% in females, p <0.05 and 3.0%
of children was overweight and obese.
Table 3.2. Percentage of underweight children by age group and sex
Month

of age

Male
n

36 - 47

246

30

12.2

236

22

9.3

> 0.05

48 - <60

230

38

16.5

226

29

12.8

> 0.05

Total

476

68

14.3

462

51

11.0

> 0.05

Freq

Female
%

n

Freq

p
%

The table above shows that malnutrition in males was 14.3% higher than
in females with 11.0%, which was significant with p <0.05. The proportion of
underweight male children in both age groups from 36-47 months and 48-60
months are higher than in female children, but the difference is not
statistically significant at p> 0.05.


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Table 3.3. Percentage of stunting children by age group and sex
Month
of age

Male
n

Female

Freq

%

n

Freq

%

p

36 - 47

246

62

25.2

236

48

20.3

> 0.05

48 - <60

230

78

33.9

226

58

25.7

< 0.05

476

140

29.4

462

106

22.9

< 0.05

Total

It is shown that the rate of stunting male children was 29.4% higher than
in female children with 22.9%, which was significant for p <0.05. The
proportion of stunting male children in both age groups from 36-47 months
and 48-60 months are higher than in female children. However, the difference
was statistically significant (p <0.05) only in group 48-60 months.
Table 3.4. Analysis of malnutrition by three anthropometric indicators
Month of age

Malnutrition forms

36-47

48-60

Total

(n= 482)

(n= 456)

(n= 938)

26.7

30.2

28.5

Merely underweight

5.2

6.3

5.7

Merely wasting

1.2

2.2

1.7

Merely stunting

15.7

18.4

17.1

Merely overweight

2.3

2.7

2.5

Combined

13.3

15.8

14.5

Get at least one malnutrition form
Prevalence of each
malnutrition forms

The table above shows that 28.5% of children had at least one form of
malnutrition. Among them, children with stunting only accounted for 17.1%,
and this percentage in the 48-60-month-old group was higher than that in the
36-47 month group with p<0.05. The proportion of combined malnourished
children is 14.5%.


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Table 3.5. Prevalence of anemia in children by sex, age group
Sex
Female
Male
Months of age
36-47 months of age
48-60 months of age
Nutritional status
Got at least one malnutrition form
Non-malnourished children

n

Frequency

%

p

462
476

109
115

23.6
24.2

> 0.05

482
456

120
104

24.9
22.8

> 0.05

267
671

116
108

43.4
16.1

< 0.05

The table above shows that the prevalence of anemia in female children
was 23.6%, lower than that in males with 24.2%, but the difference was not
statistically significant at p>0.05. The prevalence of anemia in children aged
36-47 months was 24.9%, higher than that in children aged 48 to under 60
months with 22.8%, but the difference was not statistically significant with p>
0.05. The prevalence of anemia in children with at least one malnutrition form
was 43.4%, higher than that of non-malnourished children (16.1%). The
difference was statistically significant with p <0.05.
* Analysis of several factors related to nutritional status
The education level and career of the mother were not significantly
related to the nutritional status of the child in the univariate analysis.
However, in the multivariate analysis, the group of children whose mothers
were workers were 1.8 times more likely to be stunted (95% CI: 1.1-3.1) than
children whose mothers were farmers. Children in the family with more than
two children and children with birth order from the 2nd or 3rd or higher tended
to be more malnourished than those in small families and the firstborn
children but the difference was not statistically significant in either univariate
or multivariate analyzes with p>0.05. Male children and children aged 48-60
months were 1.4 times more likely to be malnourished than females in both
univariate and multivariate analyzes (p<0.05). For malnutrition condition of
stunting, male children were 1.4 times more likely to be malnourished than
female children (95% CI: 1.1-1.8), this risk increased by 1.5 times (95 % CI:
1.1-2.0) in the multivariate analysis. The children in the age group of 48-60
months were 1.4 times more likely to be stunted than those in the 36-47

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month group (95% CI: 1.1 - 1.9) in both univariate or multivariate analyzes.
The difference was statistically significant with p <0.05
3.2. Dietary characteristics, prevalence of zinc deficiency, iron deficiency
in children from 36 to under 60 months of age participating in the
intervention study
Table 3.6. Food consumption of participants in the intervention study (n = 278)
Food groups
Rice
Other cereals and cereal processed products
Grease
Vegetables and ripe fruits
Meat and meat processed products
Fish and fishery products
Eggs and milk

Intervention
Control
group
group
(n=143)
(n=154)
162.8±39.2 165.6±31.5
38.95±38.8
33.6±30.5
10.9±4.4
11.1±3.25
116.3±57.2 102.7±46.9

69.5±29.2
68.4±34.1
25.4±15.9
26.2±13.2
34.9±20.8
35.7±23.6

p
> 0.05
> 0.05
> 0.05
> 0.05
> 0.05
> 0.05
> 0.05

The above table shows that there was no significant difference on
children’s consumption level of food between the intervention group and the
control group. The average consumption of rice was 162.8 g/d in the
intervention group and 165.6 g/d in the control group.
Table 3.7. Dietary energy value (Kcal per day) of children by age group and
sex (n = 278)
Variables

Total energy

Dietary energy structure
%P
%L
%G

1116.9±189.6 16.1±2.6 27.4±9.2 56.7±10.7

36-47 months
Age
group 48- <60 months 1150.1±210.8
Male
1125.9±216.3
Sex
Female
1145.2±185.2
Total
1135.1±201.9

16.6±3.0 28.5±10.1 54.9±12.2
16.7±3.0 28.3±10.4 55.1±12.5
16.0±2.6

27.7±8.9

56.4±10.4

16.4±2.8

28.0±9.7

55.7±11.5

Results from the table above show that the total dietary energy value of
children was 1135.1±201.9 Kcal, in which the energy value for boys was
1125.9±216.3; in girls was 1145.2±185.2. The dietary energy value in the age

group of 36-47 months was 1116.9±189.6; the age group of 48- <60 months
was 1150.1±210.8 Kcal. Dietary energy structure has 16.4% energy supplied
by protein, 28% energy supplied by lipid and 55.7% energy by glucide.


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Table 3.8. Percentage of children got adequate amount of dietary energy
producing substances as required (g /d) (n = 278)
Percentage
Dietary energy
Freq
%
Male
32
22.1
Energy (Kcal)
Female
46
34.6
Total
78
28.1
Male
145
100.0
Energy contributed by
Female
133
100.0

Protein
Total
278
100.0
Male
87
60.0
Animal protein / total
Female
75
56.4
protein reached 60%
Total
162
58.3
Male
62
42.8
Energy contributed by
Female
71
53.4
Lipid
Total
133
47.8
Male
30
20.7
Energy contributed by

Female
54
40.6
Glucide
Total
84
30.2
Table 3.8 shows that 28.1% of children met the recommended energy
requirement, with 22.1% for boys and 34.6% for girls. 100% of children met
the energy requirement of protein, but the rate of children got 60% animal
protein out of total protein was only 58.3%. 47.8% of children got the energy
requirement provided by lipid and 30.2% of children met the energy
requirement provided by glucide.
Table 3.9. The content of some minerals in the diet (n = 278)
The rate reached the
recommended demand
X ± SD
Some minerals
n
%
Calci (mg)
67
24.1
477±204.5
Zinc
141
50.7
4.2±1.5
Phosphorus
228

82.0
669.7±192.3
Iron
132
47.5
4.9±2.3
Results of the above table show that the average content of calcium. Zinc,
phosphorus and iron of children was: 477±204.5 mg; 4.2±1.5 μg; 669.7±192.3
mg; 4.9±2.3mg, respectively. The recommended rate for Calcium is 24.1%;
zinc is 50.7%; phosphorus is 82% and iron is 47.5%.


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Table 3.10. Mean value of some test indicators in children before
intervention
Test indicators

Control group Intervention
group (n=143)
(n=154)

Hb (g/dl)

p

114.3±8.6

114.5±8.4

> 0.05

8.4±2.9

9.0±2.8

> 0.05

Serum ferritin (µg/L)

45.1±26.7

57.9±31.2

< 0.05

TfR serum (µg/L)

2.76±0.63

2.79±0.81

> 0.05

Serum CRP

0.75±0.85

0.88±1.11

> 0.05

Zinc (µmol/l)

Results of the above table showed that there was no difference in average
concentration of Hb, zinc, serum TfR, serum CRP in the control group and in
the intervention group, there was no difference with p> 0.05. Serum ferritin
levels in the intervention group were higher than those in the control group.
The difference was statistically significant with p <0.05.
Table 3.11. Prevalence of anemia, zinc deficiency in children before
intervention
Control group
(n=154)

Intervention
group (n=143)

Freq

%

Freq

%

Anemia

42

27.3

43

30.1

> 0.05

Zinc deficiency

102

66.2

94

65.7

> 0.05

Both anemia and zinc
deficiency

28

18.2

35

24.5

> 0.05

Indicators

p

It is showed that the prevalence of children suffering from anemia, zinc
deficiency, and both anemia and zinc deficiency in the control group was
28.3%; 65.9% and 19.5% respectively. The prevalence of anemia, zinc
deficiency, combined prevalence of zinc deficiency among children in the
intervention group was 27.1%; 60.7% and 20.0%, respectively. The difference
between the two groups was not statistically significant with p> 0.05.


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Table 3.12. Situation of iron stores in children before intervention
Control group
(n=154)
Freq
%

Indicators
Depleted iron stores
(Ferritin <10µg/L)
Low iron stores
(Ferritin <30 µg/L)
Iron deficiency in tissues
(TfR> 8.6 µg/L)

Intervention
group (n=143)
Freq

%

9

5.8

0

0.0

34

22.1

40

28.0

1

0.6

2

1.4

p
>
0.05
>
0.05

Table 3.12 showed that the percentage of depleted iron stores, low iron
stores and tissue iron deficiency in children in the control group was 5.8%,
22.1%; 0.6%, respectively. The percentage of depleted iron stores, low iron
stores and tissue iron deficiency in children in the intervention group was 0.7%;
28.0% and 1.4% respectively. The differences were not significant with p> 0.05.
3.3. Effectiveness of some interventions to improve the nutritional status
of children aged 36-60 months at the study site
Table 3.13. Effectiveness of interventions on weight and nutritional status
of underweight children
Indicators

M0

Control group
Intervention
(n=167)
group (n=157)
Average weight (Kg. X ± SD)
14.5±1.95
14.7±2.3

M12
M12 - M0
M0

16.2±1.96
1.67±0.23

16.5±2.3
1.77±0.43

Rate of underweight malnutrition W/Y: n (%)
21 (12.6)
20 (12.7)

M12
p before and after
Performance indicator
Intervention effectiveness

p

> 0.05
> 0.05

> 0.05

21 (12.6)

12 (7.6)

> 0.05

>0.05

0.0

<0.05
40.0

< 0.05

40.0


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Results of the above table showed that after intervention, the weight
gain in the control group was 1.67 (kg), lower than that in the intervention
group (1.77 kg), the difference was statistically significant at p <0.05. The
rate of malnutrition in the intervention group decreased from 12.7% in M0 to
7.6% in M12, while there was no difference in the control group. The
intervention effectiveness is 40%
Table 3.14. Effectiveness of interventions on height and nutritional status of
stunting children
Indicators

Control group Intervention
(n=167)
group (n=157)
Average height (cm.

X±

p

SD)

M0

97.5±5.2

98.4±5.97

> 0.05

M12

102.7±5.3

105.4±5.99

< 0.05

M12 - M0

5.2±1.07

6.98±0.84

< 0.05

Rate of stunting malnutrition CC/T (Freq. %)
New incidence

4 (2.6)

0 (0.0)

< 0.05

Recovery

5 (3.3)

16 (10.2)

< 0.05

M0

49 (29.3)

45 (28.7)

> 0.05

M12

48 (28.7)

29 (18.5)

< 0.05

>0.05

<0.05

< 0.05

2.0

35.5

< 0.05

p before and after
Performance indicator
Intervention effectiveness

33.5

Results of the above table showed that the average height of children in
the intervention group was 6.98 cm, higher than that in the control group
(5.2cm), the difference was statistically significant with p<0.05. The
recovery rates of the intervention group after the intervention were higher
than those of the control group (10.2% vs. 3.3%), the difference was
statistically significant at p <0.05. The intervention effectiveness was
33.5%.


16

Table 3.15. Intervention effectiveness on serum Hb, serum zinc and ferritin,

TfR over the intervention times
Indicators

Average
Hb (g/L)

Average
zinc
(µmol/dL)

Ferritin
(µg/L)

TfR (mg/L.
X ± SD)

Periods

Control
group
(n=151)

Intervention
group (n=140)

p

M0

114.3±8.6

114.5±8.4

> 0.05

M12

118.6±13.5

120.3±7.6

> 0.05

M12 -M0

4.4

5.7

p
(before/after)

<0.05

<0.05

M0

8.5±2.9

9.0±2.85

> 0.05

M12

9.7±2.2

10.8±2.07

< 0.05

M12 - M0

1.18±3.1

1.83±3.27

< 0.05

p
(before/after)

>0.05

<0.05

M0

44.9±26.9

57.87±31.54

< 0.05

M12

58.4±31.2

65.9±36.6

< 0.05

M12 - M0

13.5±27.0

8.02±40.8

< 0.05

p
(before/after)

<0.05

<0.05

M0

2.77±0.64

2.8±0.82

> 0.05

M12

2.81±1.11

2.54±0.57

< 0.05

M12 - M0

0.044±1.00

-0.26±0.83

< 0.05

p
(before/after)

>0.05

<0.05

It is shown that after the intervention, the average Hb concentration,

serum zinc and ferritin levels were all higher than before. The difference was
statistically significant with p <0.05. The increase of these indicators in the
intervention group was significantly higher with p <0.05. TfR levels were
statistically significantly lower in both groups, but the intervention group had
a greater reduction.


17

Table 3.16. Intervention effectiveness on reducing the incidence of anemia
and zinc deficiency
Control Intervention
Indicators
Periods
group
group
p
(n=151)
(n=140)
M0

40 (26.5)

42 (30.0)

> 0.05

M12

35 (23.5)

21 (15.0)

< 0.05

Anemia reduction level (%)

3.0

15.0

< 0.05

Performance index (%)

12.5

50.0

< 0.05

Anemia (%)

Intervention effectiveness (%)

37.5
M0

99 (65.6)

92 (65.7)

> 0.05

M12

73 (48.3)

37 (26.4)

< 0.05

Zinc deficiency reduction level (%)

17.3

39.3

< 0.05

Performance index (%)

26.3

59.8

< 0.05

Zinc deficiency (%)

Intervention effectiveness (%)

33.5

Results of Table 3.16 showed that the rates of anemia and zinc deficiency
in both groups had a reduction, but the reduction in the intervention group was
higher than the control group. The intervention effectiveness of reducing
anemia and zinc deficiency was 37.5% and 33.5%, respectively.
Table 3.17. Intervention effectiveness for children's iron stores over the
intervention times.
Control Intervention
p
Indicators
Periods
group
group
(n=151)
(n=140)
% Lack of iron stores (low
and exhausted)
Reduction (%)
Performance index (%)
Intervention effectiveness (%)

M0
M12

42 (27.8)
35 (23.2)
4.6

16.7

40 (26.8)
17 (12.1)
14.7
57.5
40.8

> 0.05
< 0.05
< 0.05
< 0.05

The table above shows that children's iron stores have improved
significantly after intervention. Intervention effectiveness in improving
children's iron stores is 40.8%.


18

CHAPTER 4. DISCUSSIONS
4.1. Characteristics of malnutrition, anemia in children aged 36 to under 60
months and some related factors.
The results of the study conducted in 4 communes of Vu Thu district,
Thai Binh province showed that: The prevalence of underweight children
among children aged 36 to under 60 months was 12.7% with 14.3% in male
children, higher than in female children (11.0%), the difference was
statistically significant with p<0.05. This rate in our study is lower than the
national average rate of underweight children in 2014 (14.5%), in Thai Binh
province with 13.8%. Compared to some studies at the same time, the

prevalence of underweight children in our study was also lower than that of
some mountainous and central highland areas. In Kon Tum, the rate of
underweight children was 23.9%, in Gia Lai was 24.3%, in Lai Chau was
23.2%, in Ha Giang was 23.1%.
The stunting rate in our study was at an average level (26.2%),
equivalent to the national rate of 24.9% in 2014. The stunting children were
mainly at grade 1 with 22.1%. The rate of stunting children in grade 2 was
4.2%, much lower than the national rate of 10.5%, and that of Thai Binh
province in 2010 with 10.3%. The rate of stunting in male children was 29.4%
higher than that in female children with 22.9%. The difference was significant
with p <0.05. The proportion of underweight male children in both age groups
from 36-47 months and 48-60 months were higher than in female children,
but the difference was not statistically significant at p> 0.05. This result in our
study is similar to the one in the study by Khuc Thi Tuyet Huong in Nghe An
in 2011.
The prevalence of children at the age group of 48 to 60 months with at
least one malnutrition form was 30.2% while the prevalence of children at
the age group of 36-47 months was lower with 26.7%. This result is
consistent with the results of Vietnam nutrition monitoring information in
2014. The results in our study showed that 5.7% of children got merely
underweight malnutrition, 2.5% of children got merely overweight and obese
malnutrition, merely stunting children accounted for 17.1%, the rate of
children with combined malnutrition forms was 14.5%. This suggests that


19

interventions to reduce malnutrition should focus primarily on preventing
stunting and combined malnutrition forms.
Micronutrient deficiencies are one of the leading causes of malnutrition,

especially stunting. The overall prevalence of anemia in children was 23.9%.
Anemia in children with at least one malnutrition form was 43.4% much
higher than that of non-malnourished children with 16.1%, the difference was
statistically significant at p <0, 05. Compared to the prevalence of anemia in
children aged 6-36 months in Quang Tri (44.3%), the prevalence of anemia in
our study was lower due to children’s geographical location and age.
Malnutrition associated with anemia is very common in developing
countries. The study by Hoang Van Phuong in Ha Nam showed that the
prevalence of anemia among children aged 36-59 months was 26.4%, the
average level of public health significance, mainly children with mild anemia
(22.2%). The average hemoglobin concentration was 115.9g/l. The prevalence
of anemia is highest among children aged 36-41 months (30.1%). This result
of Hoang Van Phuong is similar to the results of our study.
4.2. Dietary characteristics, prevalence of zinc deficiency, iron deficiency
in children from 36 to under 60 months of age participating in
intervention studies
Children malnutrition, especially stunting and micronutrient deficiencies
are still common and all share the same reason that children of all age groups
were not provided with appropriate diets in both the quantity and quality of
food. Therefore, our study analyzed the diets of children. Results showed that
the total dietary energy value of children was 1135.1±201.9 Kcal, in which the
male children’s energy intake was 1125.9±216.3; female children’s energy
intake was 1145.2±185.2; the age group of 36-47 months was 1116.9±189.6;
the age group of 48- <60 months was 1150.1±210.8 Kcal. Children’s dietary
energy structure had 16.4% energy supplied by protein, 28% energy supplied
by lipid and 55.7% energy by glucide. Percentage of children reached 60%
Animal Protein out of the total Protein was only 58.3%. 47.8% of children
met the energy requirement provided by lipid. The average content of
calcium, zinc, phosphorus, iron in children was 477±204.5mg; 4.2±1.5µg;
669.7±192.3mg; 4.9±2.3mg. The rate of children achieving the recommended

Calcium requirement was 24.1%; zinc wa 50.7%; phosphorus was 82% and
iron demand was 47.5%


20

The prevalences of anemia, zinc deficiency and combined anemia and
zinc deficiency in the control group were 27.3%; 66.2% and 18.2%
respectively. In the intervention group, these were 30.1%; 65.7% and 24.5%.
The difference between the two groups was not statistically significant with
p> 0.05. The proportion of subjects with exhausted iron stores, low iron stores
and tissue iron deficiency in the control group was 5.8%; 22.1%; 0.6%
respectively. These proportions in the intervention group were 0.0%; 28.0%
and 1.4% respectively. The differences were not significant with p> 0.05.
Many studies have also shown similar results to our study results. Tran
Thi Quynh Anh, a researcher in Thanh Son, Phu Tho, found that vitamin A
content in the diet of 12-23 month children only met 65% of the child’s
vitamin A requirement. Iron, zinc, calcium, and vitamin D levels in the
diets were found to meet the requirement of children aged 6-11 months and
12-23 months with 50.0% and 29.1%; 68.3% and 70.7%; 46.5% and 47%;
9% and 6% respectively. It can be concluded that the prevalence of anemia
among children aged 6-23 months was high. Supplemental dietary energy
and micronutrient have not met the recommended needs.
4.3. Effectiveness of some interventions to improve the nutritional status
of children aged 36-60 months at the study site
The initial cross-sectional descriptive study showed that the prevalence of
stunting in children aged 36 to under 60 months remained at a high level of
public health significance. One of the direct causes of child malnutrition in this
study was that the child's diet was not adequate. In order to prevent
micronutrient deficiencies, diversification of meals and use of on-site food

sources are considered one of the long-term, sustainable strategies to eliminate
micronutrient deficiencies. Thus, from the analysis of the child's actual diet in
the study, we conducted direct nutrition counseling sessions on the diet of
infants for mothers, caregivers and nursing mothers of both control and
intervention groups. All mothers were counseled directly about their child’s
nutritional status, diet recommendations based on daily rations. In the
intervention group, in addition to communication activities and nutritional
counseling, children are served daily rice mixed with premix rice (iron and
zinc fortified rice for 12 consecutive months).
Results after 12 months of intervention, weight gain in the control group
was 1.67 (kg), lower than that in the intervention group (1.77 kg), the


21

difference was statistically significant at p<0.05. The rate of malnutrition in
the intervention group decreased from 12.7% in M0 to 7.6% in M12, this rate
had no difference in the control group. Intervention effectiveness is 40%. The
intervention group had an increased average height of 6.98 cm, higher than
that of the control group (5.2 cm), the difference was statistically significant at
p<0.05. The recovery rate after the intervention of the intervention group was
higher than that of the control group (10.2% versus 3.3%), the difference was
statistically significant at p<0.05. The intervention effectiveness was 33.5%.
This showed that improved communication and diets in the intervention group
had better effectiveness in weight gain and height gains than the ones in the
control group with communication only. Weight gain and height of children in
the intervention group is equivalent to WHO standards.
Intervention by feeding children with clam porridge weekly within 1 year
of Tran Quang Trung on the entire group of children aged 24-48 months in
Tien Hai showed that after 1 year, children’s average weight gain was 1.5 kg

and the average height increased by 6.9 ± 1.1 cm. For children of stunting
group, their height increased by 7.7 ± 0.9 cm and 39.2% children escaped
from the stunting condition .
Improved levels of micronutrient deficiencies are also clearly reflected in
our research. After intervention, mean Hb, serum zinc and ferritin levels of
malnourished children were all higher than before. The difference was
statistically significant with p<0.05. The increase of these indicators in the
intervention group was significantly higher with p <0.05. TfR concentration
has a statistically significant reduction in both groups, but the intervention
group had a greater reduction. The prevalence of anemia also reduced in the
control group. The prevalence of anemia and zinc deficiency after intervention
was lower in the two groups but the reduction in the intervention group was
higher than in the control group. The intervention effectiveness of reducing
anemia and zinc deficiency was 37.5% and 33.5% respectively. The level of
iron stores of children has improved significantly after intervention. The
intervention effectiveness in improving children's iron stores was 40.8%.
There are a number of current studies on the use of micronutrients to
improve the nutritional status of children under five years of age. Nguyen Duc


22

Vinh conducted a community intervention study with before and after
intervention evaluations aiming at evaluating the effects of micronutrients
fortified fresh milk on improving the nutritional status of preschoolers in
Nghia Dan district, Nghe An province. In the study, children are given
micronutrients fortified fresh milk with 180ml per day for 5 days a week for 5
months. The results showed a statistically significant improvement in Z-score
of weight/age (0.04 increased, p = 0.002), Z-score of BMI/age (0.05
increased, p = 0.021) and Z-score of weight/height (0.07; p <0.001), and a

significant reduction in the prevalence of underweight (2.8% decreased) and a
tendency to reduce the prevalence of stunting and wasting malnutrition.
Dietary supplements are currently a trend in countries around the world.
A parallel study at two sites in China and Australia showed that there were
different options for complementary diets. In China, the most commonly
dietary supplements are calcium (58.5%) and zinc (40.4%), while in Australia,
the most commonly used dietary supplements are mixtures of vitamins,
minerals (46.2%) and fish oil (42.3%). A study in New Zealand has conducted
a trial diet for 20 weeks to evaluate the effectiveness of supplementing red
meat and micronutrients rich milk for children with mild zinc deficiency. The
results showed that the zinc diet increased sharply to 0.8 mg /d in the red meat
group and 0.7 mg /day in the dairy group, but the serum zinc and zinc levels
in the hair did not increase correspondingly.
A study evaluating the diets of women and children in rural Bangladeh
showed that daily intake of zinc was only 2.5 mg in children and 5.4 mg in
women. Of these, 49% and 69% of zinc in children and women were supplied
from rice. Therefore, researchers have recommended choosing rice varieties
with high zinc content to prevent zinc deficiency for subjects.
In our study, we supplemented iron and zinc into rice in the diets of
children in the intervention group, which significantly helped increase the iron
and zinc content of the diets for the children, and promote the development of
weight and height. At the same time, the rate of children with zinc deficiency,
anemia, increase iron reserves also reduced. This is a good intervention for the
current malnutrition prevention program.


23

CONCLUSION
1. Prevalence of malnutrition and anemia in children aged 36 to under 60

months and some related factors
The malnutrition rate of children aged 36 to under 60 months was high
(28.5%), in which stunting accounted for 26.2%, underweight was 12.7%,
wasting was 4.2% and only 3% of children were overweight or obese. Male
children and children aged 48- <60 months had a higher risk of malnutrition
than female children and the children aged 36-47 months, the difference was
statistically significant with p <0.05.
The prevalence of anemia was very high, up to 23.9%
No correlation was found between mother's education, mother's occupation,
and the number of children in the family to the nutritional status of the children.
2. Dietary characteristics, zinc deficiency, iron deficiency in children from
36 to under 60 months of age
The proportion of P: L: G in the diet was 16.4%: 28.0%: 55.7% but it did
not meet the recommended demand for children, of which only 28.1% of
children met their recommended energy needs; 47.8% of children met the
energy requirement provided by lipids and 30.2% of children met the energy
requirement provided by glucose 28.1% of children met the energy
requirement of lipids and 30.2% of children met the energy requirement of
glucid. Proportion of children consuming recommended demand for vitamins
and minerals was low:, in which calcium was 24.1%; zinc 50.7%; phosphorus
82.0%, iron 47.5%, vitamin A 26.6% and vitamin C 34.2%
Before the intervention (M0), the prevalence of anemia was very high in
the control group (27.3%). in the intervention group it was 30.1%. The
prevalence of children with zinc deficiency was 66%. The prevalence of
children with combined anemia and zinc deficiency in both control and
intervention groups was high, at 18.2% and 24.5%, respectively. The
difference was not statistically significant at p> 0.05
The rate of children with low iron stores was very high; in the control
group this rate was 22.1% and it was 28.0% the intervention group; The
difference was not statistically significant with p> 0.05.

24

3. Effectiveness of some interventions to improve the nutritional status of
children aged 36-60 months
Using iron and zinc-fortified rice with 4 mg iron and 1 mg zinc/1 g
premix) daily helped improve the status of malnutrition in children. In the
intervention group, malnutrition rate decreased from 12.7% (M0) down to
7.6% (M12), achieving 40% intervention efectiveness, while in the control
group, the change rate was not statistically significant. The recovery rate of
stunting malnutrition after 12 months of intervention group was higher than
that of the control group (10.2% versus 3.3%), the difference was statistically
significant at p<0.05.
Using zinc and iron-fortified rice significantly improves the iron stores
in children, levels of hemoglobin, serum Ferritin and Transferrin receptors in
the intervention group compared with the control group increased with p
<0.05; Incidence of anemia and iron deficiency in the intervention group had
a statistically significant decrease, ranging from 30.0% and 26.8% at M0 to
15.0% and 12.1% at M12 in the intervention group compared with the control
group (p <0.05), reaching intervention efficiency of 37.5% and 40.8%

RECOMMENDATIONS
1. It is necessary to expand the iron and zinc supplementation to rice in
order to improve the nutritional value of rice in preventing malnutrition and
micronutrients deficiency in children and the community, as these are
effective measures and feasible in the conditions of rural and agriculture areas
like Thai Binh.
2. Longer-term studies on different populations should be undertaken to
confirm the effectiveness of community-based measures in preventing

malnutrition and micronutrient deficiencies in the community and got
accepted by the community.