Developing a formula for fortifying common foods with micronutrients for 7-10 year old students according to the 2016 World Health Organization guidelines and evaluating the effectiveness - 1

Trn Khanh Van

THANK YOU

From the bottom of my heart , I am deeply grateful to my parents who gave birth to me , nurtured my passion for learning and supported me throughout my life.

I would like to sincerely thank my supervisors, Associate Professor Dr. Nguyen Xuan Hiep and Associate Professor Dr. Tran Thuy Nga, for their dedicated encouragement and guidance during the process of completing this thesis.

I would like to express my deep gratitude to Professor Le Danh Tuyen, Director of the Institute of Nutrition; a teacher , a brother , a colleague who has fostered my determination , trained my discipline , created conditions for me to grow up , be steadfast in my career , and in a special period, the process of completing this thesis.

My heartfelt thanks go to my husband and two sons , who have always opened their arms and given me energy , who have brought me more “work” and “trouble” but with the dear meaning of love and life , giving me the flavor of life , faith and motivation to complete this thesis.

Finally, I would like to sincerely thank my colleagues at the Training Center , Planning Department, Micronutrients Department , Organization and Administration Department , Institute of Nutrition , Thai Nguyen Provincial Preventive Medicine Center , Phu Binh District Medical Center , Thai Nguyen, who are always enthusiastic in helping me , not hesitating to give me more of their precious time and skills so that I can complete my research and thesis report.

INDEX

ACKNOWLEDGEMENTS iv

LIST OF ABBREVIATIONS viii

CHART LIST xi

PROBLEM STATEMENT 1

Chapter I. OVERVIEW 4

1.1. MICRONUTRIENTS 4

1.1.1. History of micronutrients 4

1.1.2. Characteristics of school age and the role of nutrition for this age group 5

1.1.3. Micronutrient deficiency in school-age children 6

1.1.3.1. In the world 6

1.1.3.2. In Vietnam 8

1.1.4. Some risk factors for micronutrient deficiency in school-age children

Road 11

1.1.5. Methods for assessing community micronutrient status (vitamin A, anemia, iron, zinc) of school-age students 14

1.1.5.1. Assessment of vitamin A deficiency 14

1.1.5.2. Assessment of anemia 14

1.1.5.3. Assessment of iron deficiency 15

1.1.5.4. Assessment of zinc deficiency 15

1.2. FORTIFICATION OF MICRONUTRIENTS IN FOOD 17

1.2.1. History of food fortification with micronutrients 17

1.2.2. Methods of fortifying micronutrients in food 18

1.2.3. Effect of food fortification on micronutrient status 20

1.2.3.1. For vitamin A status 20

1.2.3.2. For iron status 22

1.2.3.3. For zinc status 25

1.2.3.4. For multiple micronutrient status 26

1.2.4. Cost effectiveness 27

1.2.5. Methods of fortifying milk with micronutrients 29

1.2.6. Sensory evaluation of fortified foods 32

*Some limitations of studies on VCDD fortification in milk 33

Chapter II. RESEARCH OBJECTS AND METHODS 34

2.1. Research subjects, locations and materials 34

2.1.1. Research subjects 34

2.1.1.1. Subjects evaluating the effectiveness of interventions on nutritional anthropometric status 34

2.1.1.2. Subjects evaluating the effectiveness of interventions on micronutrient status 35

2.1.1.3. Subjects of sensory evaluation of taste of milk fortified with micronutrients 35

2.1.2.Research location and time 36

2.1.3. Research material 37

2.1.3.1. Milk used for research 37

2.1.3.2. Equipment 38

2.2. Research methods 39

2.2.1. Formula for fortifying milk with micronutrients 39

2.2.2. Evaluation of intervention effectiveness of fortified milk

Nourish 40

2.2.2.1. Research methods 40

2.2.2.2. Sample size 40

2.2.3. Sampling method 43

2.2.4. Distribution of research products 45

2.2.5. Monitoring and supervision 46

2.2.6. Data collection methods and evaluation criteria 47

2.2.7. Data processing and analysis 52

2.2.8. Measures to control errors 53

2.2.9. Ethics in research 53

Chapter III. RESEARCH RESULTS 54

3.1. Some demographic characteristics of students participating in the study 54

3.2. Formula for enhancing micronutrients 57

3.3. Sensory properties of fortified milk 61

3.4. Research on evaluating the effectiveness of fortified milk with micronutrients 63

3.4.1. Nutritional status of primary school students before intervention 63

3.4.2. The effectiveness of using fortified milk on anthropometric indicators of primary school students 65

3.4.3. Intervention effectiveness on changes in micronutrient indices of primary school students at risk of stunting 72

Table 3.21. Changes in serum vitamin A concentration (μmol/L) after intervention 72

Chapter IV. DISCUSSION 85

4.1. Developing a formula to fortify milk with micronutrients for school-age children 85

4.2. Some characteristics of the diet and nutritional status of students before the intervention 93

4.3. The effectiveness of using fortified milk on changes in anthropometric indexes 95

4.4. The effectiveness of using fortified milk on micronutrient status in students at risk of stunting and malnutrition 102

4.4.1. Effect on vitamin A status 102

4.4.2. Effectiveness for anemia 104

4.4.5. Effect on zinc status 109

CONCLUSION 112

1. Formula for fortifying milk with micronutrients for primary school students aged 7-10 years old has been developed 112

2. The effectiveness of using fortified fresh milk and fortified sterilized milk on anthropometric indicators 112

3. Intervention effectiveness on micronutrient status 113

RECOMMENDATION 115

REFERENCES 116

LIST OF ABBREVIATIONS

BMI/T: BMI by age

CC/T: Height by age

CDC: Centers for Disease and Prevention Control (US Centers for Disease Control)

CN/T: Weight by age

DALY: Disability-Adjusted Life-Year

GDP: Gross Domestic Products

Hb: Hemoglobin

IVACG: International Vitamin A Nutrition Consultative Group – International Vitamin A Nutrition Consultative Group

IZiNCG : International Zinc Nutrition Consultative Group - International Zinc Nutrition Consultative Group

NCDDKN: Recommended nutritional needs SDD: Malnutrition

VAD-TLS: Subclinical vitamin A deficiency

VAD-GH: Marginal Vitamin A deficiency VCDD: Micronutrients

YNSKCĐ: Public health significance

WHO: World Health Organization