An assessment of the impact of fortification of staples and condiments on micronutrient intake in young Vietnamese children.

Targeted fortification programs for infants and young children are an effective strategy to prevent micronutrient deficiencies in developing countries, but the role of large-scale fortification of staple foods and condiments is less clear. Dietary modeling in children aged 6-60 months was undertaken, based on food consumption patterns described in the 2009 national food consumption survey, using a 24-h recall method. Consumption data showed that the median intake of a child for iron, vitamin A and zinc, as a proportion of the Vietnamese Recommended Dietary Allowance (VRDA), is respectively 16%-48%, 14%-49% and 36%-46%, (depending on the age group). Potential fortification vehicles, such as rice, fish/soy sauces and vegetable oil are consumed daily in significant amounts (median: 170 g/capita/day, 4 g/capita/day and 6 g/capita/day, respectively) by over 40% of the children. Vegetable oil fortification could contribute to an additional vitamin A intake of 21%-24% of VRDA recommended nutrient intake, while fortified rice could support the intakes of all the other micronutrients (14%-61% for iron, 4%-11% for zinc and 33%-49% of folate requirements). Other food vehicles, such as wheat flour, which is consumed by 16% of children, could also contribute to efforts to increase micronutrient intakes, although little impact on the prevalence of micronutrient deficiencies can be expected if used alone. The modeling suggests that fortification of vegetable oil, rice and sauces would be an effective strategy to address micronutrient gaps and deficiencies in young children.

Multi-micronutrient-fortified biscuits decreased the prevalence of anaemia and improved iron status, whereas weekly iron supplementation only improved iron status in Vietnamese school children.

In Vietnam, nutrition interventions do not target school children despite a high prevalence of micronutrient deficiencies. The present randomised, placebo-controlled study evaluated the impact of providing school children (n 403) with daily multiple micronutrient-fortified biscuits (FB) or a weekly Fe supplement (SUP) on anaemia and Fe deficiency. Micronutrient status was assessed by concentrations of Hb, and plasma ferritin (PF), transferrin receptor (TfR), Zn and retinol. After 6 months of intervention, children receiving FB or SUP had a significantly better Fe status when compared with the control children (C), indicated by higher PF (FB: geometric mean 36·9 (95% CI 28·0, 55·4) µg/l; SUP: geometric mean 46·0 (95% CI 33·0, 71·7) µg/l; C: geometric mean 34·4 (95% CI 15·2, 51·2) µg/l; P < 0·001) and lower TfR concentrations (FB: geometric mean 5·7 (95% CI 4·8, 6·52) mg/l; SUP: geometric mean 5·5 (95% CI 4·9, 6·2) mg/l; C: geometric mean 5·9 (95% CI 5·1, 7·1) mg/l; P = 0·007). Consequently, body Fe was higher in children receiving FB (mean 5·6 (sd 2·2) mg/kg body weight) and SUP (mean 6·1 (sd 2·5) mg/kg body weight) compared with the C group (mean 4·2 (sd 3·3) mg/kg body weight, P < 0·001). However, anaemia prevalence was significantly lower only in the FB group (1·0%) compared with the C group (10·4%, P = 0·006), with the SUP group being intermediate (7·4%). Children receiving FB had better weight-for-height Z-scores after the intervention than children receiving the SUP (P = 0·009). Vitamin A deficiency at baseline modified the intervention effect, with higher Hb concentrations in vitamin A-deficient children receiving FB but not in those receiving the SUP. This indicates that vitamin A deficiency is implicated in the high prevalence of anaemia in Vietnamese school children, and that interventions should take other deficiencies besides Fe into account to improve Hb concentrations. Provision of biscuits fortified with multiple micronutrients is effective in reducing anaemia prevalence in school children.

Complementary foods fortified with micronutrients prevent iron deficiency and anemia in Vietnamese infants.

To investigate whether an intervention including micronutrient-fortified complementary foods can improve iron status, we conducted a randomized controlled trial in 5-mo-old Vietnamese infants (n = 246). Villages (n = 29) were randomly divided into those receiving instant flour (FF) or a food complement (FC) both fortified with micronutrients or nothing [control (C)]. FF and FC infants received daily for 6 mo at least 2 meals of fortified complementary foods. Micronutrient status was assessed by measurement of hemoglobin (Hb) and plasma ferritin (PF), transferrin receptor, zinc, and retinol. Final Hb (mean ± SD) was higher in the FF (112.5 ± 8.0 g/L) and FC (114.0 ± 7.0 g/L) groups compared with C (109.0 ± 8.0 g/L; P = 0.006). PF (geometric mean [95% CI]) was also higher in FF (19.8 µg/L [17.5-22.3]) and FC (20.8 µg/L [18.3-23.6]) compared with C (11.1 µg/L [9.8-12.5]; P < 0.0001). Anemia prevalence decreased more in the FC group (-43.6%) compared with C (-10.3%; P = 0.006). The change in prevalence of PF < 12 µg/L was different in the FF (-16.4%) and FC (-6.7%) groups compared with C (+30.4%; P < 0.01). Endpoint prevalence of iron deficiency (ID) and ID anemia (IDA) were lower in the FF (13.4 and 6.7%, respectively) and FC (15.2 and 3.8%) groups compared with C (57.5 and 37.5%) (P < 0.0001). Retinol and zinc concentrations did not differ among groups, but endpoint prevalence of zinc deficiency was lower in FF infants (36.1%) than in C infants (52.9%; P = 0.04). Micronutrient-fortified complementary foods significantly improved iron status and decreased the prevalence of anemia, ID, and IDA in Vietnamese infants and can be an important tool to reduce ID in infancy in developing countries.

Difructose anhydride III enhances bioavailability of water-insoluble iron in anemic Vietnamese women.

Difructose anhydride III (DFAIII) is an indigestible disaccharide and has been shown to enhance iron absorption in animal studies; however, the effect has not been investigated in anemic subjects. We investigated the efficacy of co-administration of DFAIII with water-insoluble iron in the treatment of iron deficiency anemia in Vietnamese women. One hundred sixty-eight moderately anemic women (80 g/L

Impact of milk consumption on performance and health of primary school children in rural Vietnam.

This is a follow-up study to an investigation on the prevalence of malnutrition and micronutrient deficiencies among Vietnamese primary schoolchildren. A total of 454 children aged 7 to 8 years attending three primary schools in the Northern delta province of Vietnam were either provided with regular milk, milk fortified with vitamins, minerals and inulin or served as a reference control group. Children were monitored for anthropometrics, (micro)-nutritional status, faecal microbiota composition, school performance, and health indices. Both weight-for-age (WAZ) and height-for-age (HAZ) significantly improved during 6 months of milk intervention; and underweight and stunting dropped by 10% in these groups. During intervention the incidence of anemia decreased and serum ferritin levels increased significantly in all groups. Serum zinc levels increased and consequently the incidence of zinc deficiency improved significantly in all three groups. Serum retinol levels and urine iodine levels remained stable upon intervention with fortified milk whereas in the control group the incidence of iodine deficiency increased. Bifidobacteria composed less than 1% of the total faecal bacteria. After three months of milk intervention total bacteria, bifidobacteria and Bacteroides sp. increased significantly in both milk and inulin fortified milk groups. Children in the milk consuming groups had significantly better short-term memory scores. Parent reported that health related quality of life status significantly improved upon milk intervention. In conclusion, (fortified) milk consumption benefited the children in rural Vietnam including lowering the occurrence of underweight and stunting, improving micronutrients status and better learning indicators as well as improving the quality of life.

Multi-micronutrient-fortified biscuits decreased prevalence of anemia and improved micronutrient status and effectiveness of deworming in rural Vietnamese school children.

Concurrent micronutrient deficiencies are prevalent among Vietnamese school children. A school-based program providing food fortified with multiple micronutrients could be a cost-effective and sustainable strategy to improve health and cognitive function of school children. However, the efficacy of such an intervention may be compromised by the high prevalence of parasitic infestation. To evaluate the efficacy of school-based intervention using multi-micronutrient-fortified biscuits with or without deworming on anemia and micronutrient status in Vietnamese schoolchildren, a randomized, double-blind, placebo-controlled trial was conducted among 510 primary schoolchildren, aged 6-8 y, in rural Vietnam. Albendazole (Alb) (400 mg) or placebo was given at baseline. Nonfortified or multi-micronutrient-fortified biscuits including iron (6 mg), zinc (5.6 mg), iodine (35 microg), and vitamin A (300 microg retinol equivalents) were given 5 d/wk for 4 mo. Multi-micronutrient fortification significantly improved the concentrations of hemoglobin (+1.87 g/L; 95% CI: 0.78, 2.96), plasma ferritin (+7.5 microg/L; 95% CI: 2.8, 12.6), body iron (+0.56 mg/kg body weight; 95% CI: 0.29, 0.84), plasma zinc (+0.61 micromol/L; 95% CI: 0.26, 0.95), plasma retinol (+0.041 micromol/L; 95% CI: 0.001, 0.08), and urinary iodine (+22.49 micromol/L; 95% CI: 7.68, 37.31). Fortification reduced the risk of anemia and deficiencies of zinc and iodine by >40%. Parasitic infestation did not affect fortification efficacy, whereas fortification significantly enhanced deworming efficacy, with the lowest reinfection rates in children receiving both micronutrients and Alb. Multi-micronutrient fortification of biscuits is an effective strategy to improve the micronutrient status of Vietnamese schoolchildren and enhances effectiveness of deworming.

Association of low serum selenium with anemia among adolescent girls living in rural Vietnam.

OBJECTIVE: We investigated the prevalence of anemia and deficiency in trace elements in adolescent girls living in rural Vietnam. METHODS: Two hundred forty-five adolescent girls 11-17 y of age from three schools in rural province of Ha Nam, Vietnam, were assessed. RESULTS: The prevalence of anemia was 20.4%. The incidences of low serum selenium (Se), zinc, and copper in subjects were 15.9%, 26.5%, and 4.1%, respectively. The parameter significantly associated with anemia was the low serum levels of Se and vice versa (odds ratio [OR] 5.36, 95% confidence interval [CI] 2.57-11.18, P < 0.0001). Other risk factors for anemia were a body mass index <17.00 kg/m(2) (OR 2.72, 95% CI 1.37-5.37, P = 0.004) and years of age (OR 1.35, 95% CI 1.14-1.59, P < 0.001). A body mass index <17.00 kg/m(2) (OR 2.65, 95% CI 1.25-5.61, P = 0.011) was also found to be a risk factor for low serum Se. CONCLUSION: The findings of the present study demonstrate that low serum Se is independently associated with anemia in adolescent girls living in rural Vietnam. Interventions are required to gain insight into the potential role of Se on prevention and control of anemia.

Development of a semi-quantitative food frequency questionnaire for dietary studies--focus on vitamin C intake.

The present work aimed to provide a basis for examination of intake of selected food items determined with a semi-quantitative food frequency questionnaire (SQFFQ) and planned-food selection (PFS). From February to July of 2003, ninety one cancer patients and 90 matched (same sex and age within 5 years) non-cancer patients were directly interviewed by trained interviewers using the designed questionnaire at the inpatient-department of Viet Duc hospital, Ha Noi City, Viet Nam. Study subjects consumed more SQFFQ-food items than PFS-food items, so that the latter method might not accurately reflect dietary habits regarding estimation of nutrient intake, especially vitamins. Because these are beneficial factors acting against cancer development at many sites, the absence of food items selected by SQFFQ may result in a poor database regarding possible confounding factors. For futher clarification we then focused on vitamin C contributions of Vietnamese food and analyzed data of the National Nutritional Household Survey in 2000: 7,686 households throughout the country (vitamin C intake status) and 158 households with 741 persons of the population of Hanoi city (individual food items contributing to vitamin C). Direct interview using a validated questionnaire with an album of current Vietnamese food items-recipes and weighing checks was conducted to obtain information regarding all types of food intake over the last 24-hours. Contribution analysis using the Nutritive Composition Table of Vietnamese Foods, revision 2000, and stepwise regression analysis was applied. Average intake adjusted by ages of vitamin C per person per day was estimated. In total, the study subjects were found to currently consume 184 food items. Average intake of vitamin C was 72.5 mg per person per day at the national level: 57.9% from leafy vegetables, 33.4% from fresh fruits, and 6.4% from non-leafy vegetables. For vitamin C contribution, the highest 25 food items contributed to a cumulative 95.3% of vitamin C intake with a cumulative R2=0.99.

Micronutrient deficiencies and anemia among preschool children in rural Vietnam.

The prevalence of trace elements deficiencies, vitamin A deficiency, anemia, and their relationships were investigated in a cross sectional study involving 243 children aged from 12 to 72 months in rural Vietnam. Serum levels of copper, zinc, selenium and magnesium were determined by inductively coupled plasma mass spectrometer and that of retinol by high performance liquid chromatography. Hemoglobin concentration in whole blood was measured by the cyanmethemoglobin method. The prevalence of deficiencies in zinc, selenium, magnesium, and copper was 86.9%, 62.3%, 51.9%, and 1.7%, respectively. On the other hand, 55.6% were anemic and 11.3% had vitamin A deficiency. Deficiency in two or more micronutrient was found in 79.4% of the children. Parameters associated significantly with anemia were selenium deficiency (OR 2.80 95% CI 1.63-4.80, p=0.0002) and serum retinol<1.05 micromol/L (OR 1.83, 95% CI 1.10-3.05, p=0.021). Magnesium deficiency (OR 3.09 95% CI 1.36-7.03) was found to be a risk factor for zinc deficiency and vice versa. The results indicate that micronutrient deficiencies are prevalent among preschool children in Vietnam. In addition, the results also demonstrate a strong relationship between selenium deficiency and anemia. Clearly, sustainable strategies are urgently required to overcome the problems in the country.

Relationship of low serum selenium to anemia among primary school children living in rural Vietnam.

A cross-sectional study of 292 primary school children was conducted in rural Vietnam to investigate the relationship among micronutrient deficiencies, and other risk factors for anemia. Serum levels of iron, copper, zinc, selenium and magnesium were determined by inductively coupled plasma mass spectrometry and that of retinol by high performance liquid chromatography. Hemoglobin concentration in whole blood was measured by the cyanmethemoglobin method. The incidence of low serum zinc, selenium, magnesium, and copper in the children was 91.4, 75.6, 59.5, and 8.6%, respectively. Forty-five percent of the children were anemic and 11.3% suffered from vitamin A deficiency. A parameter significant associated with anemia was low serum selenium and vice versa (OR 1.85, 95% CI 1.06-3.24, p<0.05). Other factors associated with anemia were serum retinol <1.05 micromol/L (OR 2.05, 95% CI 1.25-3.36, p<0.01), and age in years (OR 1.59, 95% CI 1.16-2.18, p<0.01). The study showed that low selenium is associated with anemia among school children in Vietnam. Interventions are required to gain insight into the potential role of selenium on prevention and control of anemia.

Serum levels of trace elements and iron-deficiency anemia in adult Vietnamese.

This study was aimed at assessing the serum levels of vitamin A, copper, zinc, selenium, and iron among adult Vietnamese with and without iron-deficiency anemia. Blood was collected from adult Vietnamese living in the midland of northern Vietnam. One hundred twenty-three subjects in the age range 20-60 yr were included in the study. Anemia, where the concentration of hemoglobin in whole blood is less than 120 g/L in females and 130 g/L in males, was found in 30% (37/123) of the study population. The levels of vitamin Aand selenium in the sera of anemic subjects (n = 37) were significantly lower than that in nonanemic group (n = 86). On the other hand, no significant differences were observed in the concentrations of copper and zinc between the two groups. This study was the first to show serum levels of trace elements in adult Vietnamese, providing useful baseline information for further studies.

The use of NaFeEDTA-fortified fish sauce is an effective tool for controlling iron deficiency in women of childbearing age in rural Vietnam.

One cost-effective strategy for controlling iron deficiency is the fortification of staple foods or condiments with iron. We evaluated the effectiveness of fortifying fish sauce with NaFeEDTA for improving iron status in women of childbearing age in Vietnam in a double-blind intervention with randomization by village. All families in the selected villages were supplied with fish sauce that was either unfortified (Group C, 10 villages) or fortified with NaFeEDTA [9 mmol (500 mg) Fe/L, Group F, 11 villages] for 18 mo. The effect of fortification was assessed in the 576 women (n = 288/group) by measuring hemoglobin and serum ferritin (SF) at 6, 12, and 18 mo. Analysis of the group x time interaction using a repeated-measures test for each response demonstrated a significant effect of fortification on hemoglobin (P = 0.039) and log SF (P < 0.0001) in Group F with no significant changes in Group C. The prevalence of iron deficiency (SF < 12 microg/L) decreased from 22.3 to 4.0% and the prevalence of anemia (hemoglobin < 120 g/L) from 24.7 to 8.5% in Group F with no significant changes in Group C. NaFeEDTA fortification of fish sauce is an effective method for reducing the prevalence of iron deficiency in women in Vietnam.

Milk fortified with iron or iron supplementation to improve nutritional status of pregnant women: an intervention trial from rural Vietnam.

Anemia is still the major nutritional problem among pregnant women in Southeast Asia. The objective of this study was to measure hemoglobin status and reduction of underweight in a group of pregnant women who received iron-fortified or nonfortified milk, and another group who received iron supplements (tablets) or placebo. The 44 women in the iron-fortified milk group received 15 mg of iron per day per 400 ml of milk, and 41 women received placebo. The 40 women in the iron supplement group received 60 mg of iron per day, and 43 women received nonfortified milk. During this intervention trial, all women were supervised from the 14th to the 18th week of gestation until delivery. Blood was sampled at 0, 5, 10, and 16 weeks of intervention. After the 16th week of intervention, the changes in hemoglobin (deltaHb) concentrations in both treatment groups (the iron-fortified milk and the iron tablet groups) were not significantly different (deltaHb: -0.5+/-0.9 and -0.3+/-0.9 g/L, respectively), but the changes were significantly greater in the nonfortified milk and placebo groups (deltaHb: -1.2+/-0.9 and -1.1+/-0.8 g/L, respectively; p < .01). The change in transferrin saturation (deltaTS) in the iron-fortified milk group (deltaTS: 3.4+/-12.9%) was greater than that in the placebo and nonfortified milk groups (deltaTS: -10.1+/-9.8% and -11.6+/-10.7 %, respectively) (p < .01). The weight gain of the subjects during intervention did not differ significantly in the fortified and nonfortified milk groups (delta weight: 5.0+/-2.0 and 5.8+/-2.1 kg, respectively), but was higher than in the iron tablet group (delta weight: 4.6+/-3.1 kg; p < .05) and the placebo group (delta weight: 3.8+/-2.5 kg; p < .001). Iron supplementation and fortification were seen to be effective in promoting weight gain in pregnant Vietnamese women. For women who are underweight, the administration of iron-fortified milk has additional benefits to those of supplementation, most likely due to additional energy and nutrient inputs.

Community mobilization and social marketing to promote weekly iron-folic acid supplementation: a new approach toward controlling anemia among women of reproductive age in Vietnam.

Community-based social marketing and mobilization increased knowledge and participation in preventive weekly iron-folic acid supplementation among women of reproductive age in Vietnam. Rates of buying and taking the weekly supplement containing 60 mg elemental iron and 3.5 mg folic acid among non-pregnant women of reproductive age was between 55% and 92%. Free distribution to pregnant women of the weekly supplement containing 120 mg iron and 3.5 mg folic acid covered almost all pregnant women during the project. In developing countries where community women's groups and health networks are strong, preventive supplementation can be successfully promoted to encourage active participation in the prevention and control of iron-deficiency anemia.

Community mobilization and social marketing to promote weekly iron-folic acid supplementation in women of reproductive age in Vietnam: impact on anemia and iron status.

The community mobilization and social marketing program promoting a preventive approach of weekly iron-folic acid supplementation in women of reproductive age improved iron status of non-pregnant women in Vietnam. Three to six months of weekly pre-pregnancy supplementation and regular weekly intake of supplements during pregnancy allowed women to achieve good iron and hemoglobin status during the two first trimesters of pregnancy. In the third trimester, iron deficiency and anemia were notably present but low birth weight prevalence was low. This demonstrates the effectiveness and safety of the preventive approach as implemented here to prevent and control iron deficiency and anemia in women of reproductive age before and during pregnancy.

Regular consumption of NaFeEDTA-fortified fish sauce improves iron status and reduces the prevalence of anemia in anemic Vietnamese women.

BACKGROUND: Fish sauce is consumed daily by a large proportion of the Vietnamese population and could therefore be a potentially useful food vehicle for iron-fortification programs. OBJECTIVE: We evaluated the efficacy of iron-fortified fish sauce in improving the iron status of anemic women. DESIGN: In a randomized, double-masked study of 152 anemic (hemoglobin concentration of 81-119 g/L) women, a meal based on noodles or rice was served 6 d/wk with 10 mL fish sauce containing either 10 mg Fe as NaFeEDTA (iron-fortified group) or no added iron (control group). Concentrations of hemoglobin, serum ferritin (SF), and serum transferrin receptor (TfR) were measured at baseline and after 3 and 6 mo. RESULTS: After 6 mo, hemoglobin and SF concentrations were higher and TfR concentrations were lower in the iron-fortified group than in the control group [hemoglobin: 116.3 +/- 8.7 ( +/- SD) compared with 107.6 +/- 11.0 g/L (P < 0.0001); SF: 30.9 (95% CI: 23.4, 40.6) compared with 14.6 (11.3, 19.0) micro g/L (P = 0.0002); TfR: 7.2 (6.4, 7.9) compared with 9.0 (8.1, 9.9) mg/L (P = 0.002)]. The prevalence of iron deficiency (SF < 12 micro g/L or TfR > 8.5 mg/L) and iron deficiency anemia (iron deficiency with hemoglobin < 120 g/L) was lower in the iron-fortified group than in the control group [32.8% compared with 62.5% (P = 0.0005) and 20.3% compared with 58.3% (P < 0.0001), respectively]. CONCLUSIONS: Regular consumption of iron-fortified fish sauce significantly reduced the prevalence of iron deficiency anemia in Vietnamese women during the 6-mo intervention. Fortifying fish sauce with iron by using a water-soluble, highly bioavailable compound (NaFeEDTA) is a promising strategy for combating iron deficiency anemia in Vietnam.

Control of vitamin A deficiency in Vietnam: achievements and future orientation.

Vitamin A deficiency is one of the major nutritional deficiencies in Vietnam. The first survey, conducted in 1985-1988 showed that the prevalence of severe xerophthalmia was seven times higher than the cutoff point established by the World Health Organization (WHO) to define vitamin A deficiency as a public health problem. The result of this survey strongly convinced the government to launch a program to control vitamin A deficiency, which started in 1988. The program strategies included nutrition education, universal distribution of high-dose vitamin A capsules to children aged 6 to 36 months in combination with national immunization days, and promotion of production and consumption of vitamin A-rich foods at the family level. The implementation network was set up based on the existing preventive health structure at all administrative levels. Organizations such as the women's union and other social sectors have participated actively in the program. Surveys conducted in 1994 and 1998 showed that the prevalence of clinical xerophthalmia was significantly lower than that identified in the baseline survey and below the WHO criteria for a public health problem. The achievements of our program have demonstrated that an effective vitamin A supplementation program can be implemented successfully by the preventive health network with active community participation. In the coming years, it will be important for our program to develop approaches other than vitamin A supplementation in order to maintain the past achievements.