The effects of consuming fortified rice with iron and zinc on the nutritional status of women.doc

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MINISTRY OF EDUCATION MINISTRY OF
AND TRAINING HEALTH
INSTITUTE OF NUTRITION
------------------
TRAN VIET NGA
THE EFFECTS OF CONSUMING FORTIFIED
RICE WITH IRON AND ZINC ON THE
NUTRITIONAL STATUS OF WOMEN AT THE
AGE OF 20 TO 49 IN RURAL AREA, THAI BINH
PROVINCE
Major: Nutrition
Code: 9720401
THE ABSTRACT OF THESIS
HA NOI –

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THIS STUDY HAS BEEN COMPLETED IN
THE NATIONAL INSTITUTE OF NUTRITION
Academic advisors:
1. Prof. Dr. Le Danh Tuyen
2. Assoc.Prof.Dr. Pham Van Thuy
Reviewer 1:
Reviewer 2:
Reviewer 3:
The dissertation is defended before the Dissertation Assessment
Council - institutional level at the National Institute of Nutrition.
Time: ....... date .......month .........year 2022.
The dissertation can be found at:
- The National Library
- The library of the National Institute of Nutrition

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LIST OF PUBLISHED STUDIES OF THE
AUTHOR RELATED TO THE
DISSERTATION
1. Tran Viet Nga, Le Danh Tuyen, Pham Van Thuy, Tran Thuy Nga,
Ninh Thi Nhung. Chronic energy malnutrition and several related
factors of women at childbearing age, Vu Thu district, Thai Binh
Province in 2015. Nutrition and Food Jounal, number 6 volum 17,
2021.
2. Tran Viet Nga, Le Danh Tuyen, Pham Van Thuy, Tran Thuy Nga,
Ninh Thi Nhung. The effects of fortified rice with iron and zinc on
anthropometrical status of women at childbearing age in Vu Thu
district, Thai Binh province 2016. Journal of Preventive Medicine,
volume 31, number 9, 2021, page 152-159.

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1
FOREWORDS
Chronic energy deficiency (CED), micronutrient deficiency, especially iron and zinc still remain
public health issues in a number of developing countries, including Viet Nam.
CED, micronutrient deficiency affect to the development of physical, cognitive as well as increase the
morbidity and mortality in women at childbearing age. In Viet Nam, the prevalence of Chronic energy
deficiency among women at childbearing age was 18.5% in 2010, of anemia was 29.2% nationwide, among
that the one of anemia in the Red River area was 23.5%. According to the Nutrion Survey in 2014-2015, the
prevalence of zinc defficiency still remains high.
Food fortification is one of the measures with slow but wide and enduring effects. In 2009, WHO
published different measures and provided evidences for the effective interventions to prevent or mitigate the
deficiency of vitamins and minerals. Therein, fortified rice with iron and other micronutrients is one of the
intervention measures for public health.
Study on the effects of fortified rice with iron and zinc by mixing premix and conventional rice for
daily consumption by women in rural area is a scientific envidence to reduce the chronic energy
malnutrition, anemia, micronutritient deficiency in women at childbearing age with the objectives as below:
1. Evaluate the prevalence of chronic energy deficiency, anemia, iron deficiency, zinc deficiency and
related factors in women at the age of 20 to 49 at Minh Khai commune and Nguyen Xa commune of Vu Thu
district, Thai Binh province.
2. Evaluate the effects of the consumption of fortified rice with iron and zinc after 12 months of
intervention on anthropometrical status of women at the age of 20 to 49.
3. Evaluate the effects of the consumption of fortified rice with iron and zinc after 12 months of
intervention on nutrition status of women at the age of 20 to 49.
Contribution of the study:
With the results of significant improvements of anthropometrical, micronutrient status, the study
contribute to making plan of intervention to improve the nutritional, anemia, micronutrient deficiency for
women at childbearing age living in high risk areas. The outputs of the study are helpful for us to make
recommendations for the draft of National Nutrition Strategy in the period of 2021-2030 and are scientific
foundation for the Government to decide the compulsory regulation of iron and zinc fortification into rice –
supplemented for current effective interventions: fortification of iron and zinc into wheat – one of the less
common food in Viet Nam especially in rural and low income areas.
Content:
The dissertation includes 128 pages as follow: Forewords and Objectives of the study: 3 pages;
Overview: 36 pages; Subjects and Research methods: 22 pages; Results: 35 pages; Discussion: 29 pages;
Conclusions and Recommendations: 3 pages. The dissertation contains 37 tables, 7 figures and 186
references.

2
Chapter I. OVERVIEW
1.1. Chronic energy deficiency in women at childbearing age
Chronic energy deficiency (CED) is a status affected by many factors. The main factor is the energy
deficiency of intake. Lack of household food security, low awareness, lack of safe water, environment
sanitation and low healthcare services are potential causes of CED.
CED causes different adverse in women at childbearing age such as: increase the susceptibility to
infections, weakens the immune system, and slow recovery. Mother with CED can increase mortality and affect to
nutrition status of the baby. In addition, CED can cause the bad effects to the economic status of households and
nation economy because it reduces labor productivity, causing bad effects to many generations.
1.2. Micronutrient and micronutrient deficiency
Micronutrient deficiency in women at childbearing age is a public health issue in developing
countries including Viet Nam, especilly women in rural area with low intake in term of quality and quantity.
There have been good results in improvement of nutrion status and prevention of micronutrient deficiency
for women but high prevalences of CED and micronutrient defficiency remain important issues of public
health in our country.
1.3. Fortification of iron and zinc into rice to prevent micronutrient deficiency.
According to the definition of WHO/FAO: Food fortification is to fortify micronutrients into food to
improve the nutritional quality of food, improve public health together with minimize the bad effects to
community. Currently, food fortification has been implemented in many countries since the beginning of the
20th
Century. It is one of the most effective interventions worldwide and also a measure recomended by
WHO, WFP, UNICEF, FAO và WB to solve the situation of micronutrient deficiency.
Rice is one of the main food of asian people, including Vietnamese. According to the Survey of the
National Institute of Nutrition in 2010, rice was a main energy intake (66,4%); protein intake 41,4% and
lipid intake 14.9%. Therefore, rice is selected for fortification because of its quality and selection of
consumers. There have been different studies on comunity’s acceptablity of fortified rice.
1.4. Some studies on the effects of food fortification in women
Intervention studies shown that, consumption fortified food (iron, zinc) can improve the anemia,
iron, zinc deficiency in 2 high-risk groups: children and women at childbearing age. With the advantages of
reasonable price, not changing the habit of using food, easy to apply in a big community, food fortification is
considered as middle-term solution for the strategy of prevention for micronutrient deficiency and had been
applied in many countries.
CHAPTER 2. SUBJECTS AND
METHODS 2.1. Subjects, place and time of study
Subjects for evaluation of CED and anemia: women at the age of 20 to 49 and voluntarily
participated in this study. Exclusion criteria: women with pregnancy, lactating less than 12 months, disorder
or unable to interview.
Subjects for intervention: women with BMI >16,0 (kg/cm2
) and < 25 (kg/cm2
), living in studied
communes at least 12 months, volunteer for participation and follow all the study activities.
- Place for study: The cross-sectional descriptive study in Minh Khai commune and Nguyen Xa
commune, Vu Thu district, Thai Binh province. The community intervention study: Minh Khai is
intervention commune and Nguyen Xa is control commune.

3
- Time of study: The cross-sectional descriptive study: from October 2015 to December 2015. The
intervention study was conducted for 12 months from March 2016 to March 2017. Data analysis and thesis
completion was conducted from March 2018 to December 2021.
2.2. Sample size:
Sample of cross-sectional descriptive study:
Z 2
(1-α/2) p (1 – p)
n =
d2
n: sample size ; Z 2
(1-α/2) = 1.96 (Confidence interval CI 95%); p: prevalence of CED 37.7%; anemia: 26.3%;
d: absolute bias 0.0406 (4.06%). Therefore, the numbers of sample are 548 in total and 274 for each commune.
Sample of intervention study:
2δ2
(Z1-α/2 + Z1-β/2 )2
Using this formulation: n =
(µ0 - µa)2
n: sample size;: error number (type 1: 5%). (Z1-a/2 =1.96); β: error number (type 2: 10%), (Z1-β/2
= 1.28); µ0 - µa: difference of means; δ: standard deviation of means.
Anthropometry sample size n =142 subjects/group; Hb: 89 subjects/group; ferritin: 23 subjects/group;
Transferrin Receptor: 47 subjects/group; Zinc: 47 subjects/group; vitamin A: 37 subjects/group. Estimated
exclusion: 20%, so sample size for each group: 175 subjects. Total number of samples: 350 subjects.
Number for intake study: 60 subjects/group, total is 140 subjects.
2.3. Design of study
- Cross-sectional descriptive study: to evaluate the nutritional, anemia status and related factors.
- Community intervention study with a control group: to evaluate the effectiveness of fortified rice
with iron, zinc on anthropometrical, hemoglobin, ferritin, zinc, vitamin A of women at the age of 20 to 49.
Selection of subjects: Selected 175 women from intervention commune using Random and Rank
functions of Microsoft Excel from 265 women. Then those women were paired with 175 women (selected
from 267 women) in control group based on nutritional and anemia status, making sure their similarity in
weight, BMI, hemoglobin.
Stage1: Cross-
Sectional study
548 subjects, divided into 2 communes: Minh Khai and Nguyen Xa, 274
women/commune
Evaluate CED and anemia
Exclusion: BMI ≤ 16,0 and ≥ 25(kg/cm2
); Hb< 80 g/L.
Select 350 subjects (BMI > 16,0 - < 25 (kg/cm2
), divided into 2
groups.
Minh Khai commune: 265 women, Nguyen Xa commune: 267 women. The selection of
paired women are based on nutritional and anemia status
At T0
Stage 2:
Intervention study
At T12
Intervention group: 175 women eating Control group: 175 women eating
fortified rice daily conventional rice daily
T0, T12 evaluate: anthropometrical, Hb, ferritine,TfR, zinc,
vitamin A
Intervention group 163 women Control group: 162 women
Excluded: 12 women (6.9%) Excluded: 13 women (7.4%)

4
Flow chart of study
2.4. Criteria and variation:
General information: Age, occupation, education, household’s economic status, monthly income,
health status in last month (diarrhea, acute infection diseases…), number of household’s member, number of
children…
Nutritional status: Chronic energy deficiency with BMI <18,5 (kg/cm2
).
Hematological index: anemia with Hb < 120 g/L. iron depletion with ferritin < 15 µg/L; iron
deficiency when sTfR > 8,5 µmol/L; Zinc deficiency when zinc concentration in serum <10,1mol/L;
Vitamin A deficiency when vitamin A concentration in serum < 0,7 μmol/L.
Intake survey: Use the method of asking to record the servings of the last 24 hours, determine the
nutritional value of the diet using the Vietnamese Food Composition Table (National Institute of Nutrition -
Ministry of Health, 2016).
2.5. Conduct intervention study
Albendazole (400 mg) was provided for all women 3 days prior to the study.
All selected women are re-surveyed for anthropometry status and intake, re-tested for Hb, zinc in
serum, ferritin, sTfE, Vitamin A in serum at T0 and T12.
For Control group: all the selected women in Nguyen Xa commune were health checked and tested
for above criteria at T0 and T12 as intervention group.
For intervention group: Exchange the iron and zinc fortified rice for all family member used. The
use of fortified rice is accepted by all subjects. Each project coordinator is responsible for hamlet (from 10 to
15 households). The rice exchange is carried out monthly at the same place in commune (no extra money for
exchange between conventional rice and fortified rice). In addition, the coordinator received all the
comments during using fortified rice and report to the Director of project.
2.6. Data analysis:
Data analysis using SPSS 20.0 software. Using logistic regression method to analyze related factors.
Using multivariable logistic regression to control for confounding factors. Calculate odds ratio OR (Odds
Ratio) and 95% confidence interval to assess the relationship between factors with lack of energy capacity
and anemia.
Applied statistical tests: Kolmogorov-Smirnov test; Chi- square test (2
- test) or Fisher exact test;
Paired t-test, independent t-test; Test Mann Whitney U Test, Wilcoxon test to compare the medians between
two groups of the same and different time points.
To evaluate the effects of the intervention, using the following indexes: ARR (absolute risk
reduction): NNT: (the number of patients you need to treat to prevent one additional bad outcome).
2.7. Research ethics
The study was approved by the Ethical Review Board in Biomedical Research of the National
Institute of Nutrition according to Decision No 470/VDD-QLKH dated 14 July 2015.

5
Chapter III. STUDY RESULTS
3.1. Nutritional, anemia status and other related factor of women from 20-49 of ages.
Table 3.1. Chronic energy deficiency by commune
Index
Minh khai Nguyen xa Total p
n= 274 n= 274 n = 548
Obesity 1 (0.4) 1(0.4) 2 (0.4)
Normal 216 (78.8) 218 (79.6) 434 (79.2)
CED 57 (20.8) 55 (20.1) 112 (20.4)
0.933
CED level 1 37 (13.5) 40 (14.6) 77 (14.1)
CED level 2 12 (4.4) 9 (3.3) 21(3.8)
CED level 3 8 (2.9) 6 (2.2) 14 (2.6)
Data presented by n (%). p as2
test comparing the mean of two groups.
Prevalence of CED was 20.4%. The difference between the two groups was not statistically significant (p > 0.05).
Table 3.2. Anemia status by commune
Index
Minh khai Nguyen xa Total p
n= 274 n= 274 n = 548
No anemia 217 (79.2) 214 (78.1) 431 (78.6)
Light
45 (16.4) 51 (18.6) 96 (17.6) 0.662
anemia
Anemia 12 (4.4) 9 (3.3) 21 (3.8)
Data presented by n (%). p as2
test comparing the mean of two groups.
Prevalence of anemia in 2 communes: 21.4%, no cases of heavy anemia. The difference between the
two communes was not statistically significant (p > 0.05).
Table 3.3. Multivariable logistic regression model predicts some factors related to CED
Risk factors β OR 95% CI p
Income/month
≥ 800.000 đ 1
0.001
< 800.000 đ 0.99 2.69 1.50 – 4.82
Number of ≤ 2 children 1
0.004
children > 2 children 1.41 4.09 1.56 – 10.73
Diarrhea in last No 1
< 0.001
month Yes 1.04 2.82 1.71 – 4.65
Hemoglobin status
No anemia 1
0.001
Anemia 0.86 2.36 1.40 – 3.96
The results showed that: Income per month, number of children, diarrhea in last month, and
hemoglobin status are related to CED status (p < 0.05).
Table 3.4. Multivariable logistic regression model predicts some factors related to Anemia
Risk factors β OR 95% CI p
≥ high school 1
Education 0.023
≤ middle
0.52 1.69 1.08 – 2.64
school
Officer, trader, 1
Occupation others 0.011
Famer, Worker 0.84 2.32 1.21 – 4.43
Diarrhea in last No 1
0.018
month Yes 1.18 3.24 1.22 – 8.60
Nutrition status
No CED 1
< 0.001
CED 1.53 4.61 2.87 – 7.40

6
The results showed that: educations, occupation, diarrhea in last month, CED are related to anemia
(p < 0.05).
3.2. Effectiveness of intervention by changing the Anthropometry
Table 3.5. Some general characteristics before the intervention
Characteristics Variable Intervention Control p
group group
< 35 120 (73.6%) 104 (64.2%)
Age 0.066
≥ 35 43 (26.4%) 58 (35.8%)
≤ high school 72 (42.2%) 59 (36.4%)
Education 0.154
≥ middle
91 (55.8%) 103 (63.6%)
school
Famer, Worker 128 (78.5%) 131 (80.9%)
Occupation 0.601
Officer, trader,
35 (21.5%) 31 (19.1%)
others
Income/month
< 800.000 đ 8 (4.9%) 16 (9.9%)
0.087
≥ 800.000 đ 155 (95.1%) 146 (91.1%)
Number of ≤ 2 children 136 (83.4%) 140 (86.4%)
0.452
children > 2 children 27 (16.6%) 22 (13.6%)
Number of ≤ 4 people 96 (58.9%) 83 (51.2%)
0.165
people in
> 4 people 67 (41.1%) 79 (48.8%)
household
Data presented by n (%)
The difference in general characteristics between the two groups was not statistically significant (p > 0.05).
Table 3.6. Change in weight after the intervention
Index
Intervention Control
pa
n=163 n=162
Before intervention
47.68 ± 5.01 47.65 ± 4.43 0.946
(T0)
After 12 months
49.10 ± 4.65 47.68 ± 4.27 0.004
(T12)
Difference T12 – T0 1.41 ± 1.72 0.03 ± 1.57 < 0.001
pb
< 0.001 0.811
Data presented as mean ±SD
pa
from the t-test comparing the mean of two groups at the same time.
pb
from the paired t-test comparing the mean of the same group before and after the intervention.
After 12 months of intervention, average of weight in intervention group is increased higher than
control group (p < 0.001).
Table 3.7. Changing in BMI after intervention
Index Intervention Control pa
n=163 n=162
Before intervention
20.43 ± 1.80 20.33 ± 1.63 0.589
(T0)
After 12 months
21.03 ± 1.63 20.35 ± 1.64 < 0.001
(T12)
Difference T12 – T0 0.45 ± 0.72 0.02 ± 0.68 < 0.001
pb < 0.001 0.790

7
pa
pb
from the paired t-test comparing the mean of the same group before and after the intervention.
After 12 months of intervention, average of BMI in intervention group is increased higher than
control group (p < 0,001).
Table 3.8. Effectiveness of treatment on CED status after intervention
Index
p
n = 22 n = 21
CED 5 (22.7%) 14 (66.7%)
0.004
No CED 17 (77.3%) 7 (33.3%)
ARR% (95%CI) 43.9 (17.2 – 70.6)
NNT 2.3 (1.4 – 5.8)
(ARR) absolute risk reduction after 12 months of intervention
After 12 months of intervention, 43.9% subjects have been treated to be no more CED and 1 in every
2 subjects be intervened will be no more CED (NNT2), (p < 0.05).
3.3. Effectiveness of intervention by changing biochemical index
Table 3.9. Changing of Hb concentration after intervention
n = 153 n = 151
Before intervention
127.0 ± 12.24 128.2 ± 11.87 0.946
(T0)
After 12 months (T12) 133.5 ± 8.72 128.7 ± 11.92 0.004
Difference T12 – T0 6.47 ± 9.85 0.46 ± 12.61 < 0.001
pb < 0.001 < 0.001
pa
pb
from the paired t-test comparing the mean of the same group before and after the intervention
After 12 months of intervention, average of Hb concentration of intervention group is increased
higher than control group; the difference between two groups is statistically significant (p < 0,001).
Table 3.10. Effectiveness of preventive intervention on Anemia
Index
p
n = 117 n = 121
Anemia 0 (0.0%) 16 (13.2%)
< 0.001
No Anemia 117 (100%) 105 (86.8%)
ARR% (95%CI) 13.2 (7.2 – 19.3)
NNT 7.6 (5.2 – 13.9)
(p) Fisher exact test, difference comparation of changing between two groups
After 12 months of intervention, the effects of preventive intervention was 13.2% and for every 8
normal women who were intervened after 12 months, one woman was not anemic (NNT8), the difference
was statistically significant (p < 0.05).
Table 3.11. Effectiveness of treatment intervention on Anemia
Index
p
n = 36 n = 30
Anemia 0 (0.0%) 16 (53.3%)
< 0,001
No Anemia 36 (100%) 14 (46.7%)
ARR% (95%CI) 53.3 (35.5 – 71.2)

8
NNT 1.9 (1.4 – 2.8)
After 12 months of intervention, the effects of treatment intervention is 53.3% and every 2 normal
women who were intervened after 12 months, one woman was not anemic (NNT2), the difference was
statistically significant (p < 0.05).
Table 3.12. Changing of ferritin after intervention
Index Intervention Control pe
n = 148 n = 147
Before intervention
62.1 (35.5 – 102.9) 73.4 (44.3 – 101.4) 0.422
(T0)*
After 12 months (T12)* 79.2 (46.2 – 109.5) 63.1 (32.5 – 102.5) 0.055
Difference T12 – T0 10.2 (-4.9 – 27.6) -2.6 (-24.3 – 20.8) 0.002
pd
< 0.001 0.723
*Data presented by mean.
(pe
): Mann- Whitney U test: mean comparison between two groups
(pf
): Wilcoxon test: mean comparison in one group at 2 times of before and after intervention
After 12 months, ferritin concentration of intervention group was increased higher than control
group; the difference between 2 groups was statistical significant (p < 0.05).
Table 3.13. Effectiveness of prevention intervention on iron depletion
Index
p
n = 134 n = 134
Iron depletion 0 (0,0%) 10 (7.5%)
0.002
No iron depletion 134 (100%) 124 (92.5%)
ARR% (95%CI) 7.5 (3.0 – 11.9)
NNT 13.4 (8.4 – 33.2)
After 12 months of intervention, the effectiveness of preventive intervention is 7,5% and for every
13 normal women who are intervened after 12 months, one woman is not iron depletion (NNT13), the
difference was statistically significant (p < 0.05).
Table 3.14. Effectiveness of treatment intervention on iron depletion
Index
p
n = 14 n = 13
Iron depletion 0 (0.0%) 9 (69.2%)
< 0.001
No iron depletion 14 (100%) 4 (30.8%)
ARR% (95%CI) 69.2 (44.1 – 94.3)
NNT 1.4 (1.1 – 2.3)
After 12 months of intervention, the effectiveness of treatment was 69.2% and for every 1 normal
woman who was intervened after 12 months, one woman was not iron depletion (NNT1), the difference
Table 3.15. Effectiveness of treatment intervention on iron-deficiency anemia (IDA)
Index
IDA
No IDA
p
n = 10 n = 11
0 (0.0%) 7 (63.6%)
0.004
10 (100%) 4 (36.4%)

9
ARR% (95%CI) 63.6 (35.2 – 92.0)
NNT 1.6 (1.1 – 2.8)
women who were intervened after 12 months, one woman was not IDA (NNT2), the difference was
statistically significant (p < 0.01).
Table 3.16. Changing of zinc concentration after intervention
n = 153 n = 151
Before intervention
10.53 ± 2.65 10.08 ± 2.63 0.139
(T0)
After 12 months (T12) 12.06 ± 2.16 9.89 ± 2.14 < 0.001
Difference T12 – T0 1.53 ± 1.61 - 0.19 ± 2.33 < 0.001
pb
< 0.001 0.310
Data presented by average ±SD.
pa
pb
After 12 months, average of zinc concentration in serum of intervention group is increased higher
than control group; the difference between two groups is statistical significant (p < 0,001).
Table 3.17. Effectiveness of prevention intervention on zinc deficiency
Index
p
n = 75 n = 67
Zinc deficiency 0 (0%) 26 (38.8%)
< 0.001
No zinc deficiency 75 (100%) 41 (61.2%)
ARR% (95%CI) 38.8 (27.1 – 50.5)
NNT 2.6 (2.0 – 3.7)
After 12 months of intervention, the effectiveness of prevention was 38.8% and for every 3 normal
women who were intervened after 12 months, one woman was not zinc deficiency (NNT3), the difference
Table 3.18. Effectiveness of treatment intervention on zinc deficiency
Index
p
n = 78 n = 84
Zinc deficiency 13 (16.7%) 68 (81.0%)
< 0.001
No zinc deficiency 65 (83.3%) 16 (19.0%)
ARR% (95%CI) 64.3 (52.5 – 76.1)
NNT 1.6 (1.3 – 1.9)
(p) Chi-Squared test, difference comparation of changing between two groups
women who were intervened after 12 months, one woman was not zinc deficiency (NNT2), the difference

10
Table 3.19. Changing of vitamin A concentration after intervention
n = 148 n = 147
Before intervention
1.72 ± 0.55 1.81± 0.65 0.192
(T0)
After 12 months (T12) 1.81 ± 0.74 1.72 ± 0.67 0.300
Difference T12 – T0 0.09 ± 0.62 - 0.08 ± 0.76 0.030
pb 0,070 0,186
Data presented by average ±SD.
pa
pb
After 12 months of intervention, vitamin A concentration of intervention group was increased higher
than control group, the difference between 2 groups was statistical significant (p<0.05).
CHAPTER IV. DISCUSSION
4.1. Status of nutrition, anemia and some related factors of women at the age of 20 to 49 in Minh Khai
and Nguyen Xa commune, Vu Thu district, Thai Binh province
This study shown that the prevalence of CED was 20.4% which was still a public health issue. CED
directly affects to human health, reduces working capability leading to affect to household emconomy and
increase risk of malnutrition of baby when pregnancy or lactating. When using the multivariable logistic
regression model to predict the CED status, this study shows that low income, number of children, diarrhea
in the last month, anemia are related to higher risk of CED than other group, the difference was statistic
significant. (p<0.05).
Addition to CED, anemia also bad affects to health, physical and knowledge status of women at
childbearing age. In our study, prevalence of anemia in 2 communes was 21.4%, which is a middle level of
public health significant. Result of using multivariable logistic regression model shows that women with low
education (lower than middle school), with occupation is famer, worker, diarrhea in the last month has higher
risk of anemia than other group, the difference is statistic significant (p<0.05).
In addition, we realize that there is a tight correlation between CED and anemia status. CED is the
result of the low intake energy for a long time. With less daily food, the low energy intake can cause the
body lack of no energy bearing nutrients, including the nutrients that contribute to blood production
especially iron.
4.2. Effectiveness of intervention on Anthropometry index
The result shows that women eating fortified rice with iron and zinc as daily intake recommendation
has significal changing on BMI, effectiveness of prevention and treatment of CED status after 12 months of
intervention. This improvement can be explained that eating fortified rice with iron and zinc can strengthen
the metabolism so health status can be improved. So the women of intervention group with better BMI index
reduce the CED status. This can assure that eating of fortified rice can improve the nutrition status of women
at childbearing age.
4.3. Effectiveness of intervention on micronutrient changing
4.3.1. Effectiveness of intervention on improvement of anemia and iron deficiency

11
Our results show that, after 12 months Hemoglobin concentration of intervention group was
increased higher than control group (p<0.001). Effectiveness of prevention was 13.2% of anemia (p<0.05)
and effectiveness of treatment was 55.3% anemia (p<0.05). Comparing to other studies on fortified rice such
as study of Gulshan Are in Bangladesh, our results show the better effectiveness. Its result is also better than
study on iron/folic weekly supplement by Tran Thi Hong Van but lower than iron/folic daily supplement by
Truong Hong Son.
Iron supplement is one of current approaches for prevention of iron-deficiency anemia in many
countries especially poor and developing countries. Ferritin in serum is one of the indexes for measure the
iron storage because ferritin concentration is related to total of stored iron in bone marrow and histocyte. Our
study shows that after 12 months of intervention, serum ferritin of intervention group was increased higher
than control group. Effectiveness of prevention and treatment of iron depletion are statistic significant
(p<0.05). Effectiveness of treatment on iron-deficiency anemia reduction is statistic significant (p<0.05).
Anemia in women at childbearing age is almost caused by iron-deficiency, so using fortified rice with iron
and zinc can help to improve Hb and ferritin concentration significally, especially at the group of women
with iron depletion because less iron causing higher iron absorption into blood so status of iron-deficiency
anemia get worse and worse.
4.3.2. Effectiveness of zinc deficiency status improvement
After 12 months, zinc concentration of intervention group is increased higher than control group
(p<0.001). Effectiveness of prevention was reduced of 38.8% and treatment was reduced of 64.3% subjects
to zinc deficiency. These results are higher than study of Gulshan Ara in Bangladesh event it was studied in
high risk group but the zinc concentration was not improved. Our results is lower than results of Siwaporn
Pinkaew studying on rice fortified with iron, zinc and vitamin A in Thailand, it can be explained that the
fortified zinc content (9mg/g rice) was higher than our study (2mg/g of rice).
4.3.3. Effectiveness of vitamin A improvement
The results after 12 months of intervention show that, vitamin A concentration of intervention group
was increased higher than control group. Furthermore, the study provides the scientific evidences on using
fortified rice with iron and zinc increases vitamin A level and reduces prevalence of vitamin A deficiency.
Our result is higher than study of Truong Hong Son 2012. In this study, even we do not fortify with vitamin
A but concentration of vitamin A after 12 months of intervention is still improved. This can be explained that
the fortification of iron and zinc can help to easier absorption of vitamin A.
Intervention by fortification helps to improve the status of anemia, iron deficiency, important
micronutrients such as zinc and vitamin A. Therefore, iron and zinc fortification into rice is really necessary
for subjects of farmer, worker as in our study this rate of subjects is 78.5%-80.9%. This group eating rices
every day to get the energy for working and they have less concern on products with micronutrients.
4.4. Some disadvantages of dissertation
Our study did not control the acute and chronic infection so these factors can affect to results of
study. In addition, fortified rice will be closely controlled by competent authority, Premix rice should be
imported from Philippine so the price of fortified rice will be higher than conventional rice.

12
CONCLUSION
1. Anthropometrical, anemic status and some related factors
- Eva rage of height is 152.7± 4.4 cm; Weight is 46.5 ± 5.3 kg; BMI 19.9 ± 2.0 kg/m2
; Hb
concentration 127.9 ± 10.4 g/L; CED 20.4%; Anemia: 21.4%.
- Result of using multivariable logistic regression model shows that the factors as monthly income,
number of children, diarrhea in last month, anemic status of studied subjects are related to CED status
(p<0.05); The factors as education, occupation, diarrhea in last month, CED status of studied subjects are
related to anemic status (p<0.05).
2. The effects of eating iron, zinc fortified rice on the changing of anthropometrical index
- After 12 months, weight, BMI of intervention group is increased higher than control group (p<0.05).
- Effectiveness of CED prevention is 4.3% (p>0.05) and effectiveness of CED treatment is 43.9% (p<0.05).
3. The effects of using fortified rice with iron, zinc after 12 month of intervention on the micronutrient
status of the women at the age of 20 to 49
- The improvement of average hemoglobin concentration of the intervention group was higher than of
the control group (p < 0.05). The effectiveness of preventing anemia was 13.2% (p < 0.001). The
effectiveness of supporting the treatment of anemia was 53.3% (p < 0.001).
- The improvement of ferritin concentration of the intervention group was higher than of the control
group (p > 0.05). The effectiveness of preventing iron deficiency is 7.5% (p < 0.01) and the effectiveness of
supporting treatment of iron deficiency is 69.2% (p < 0.001).
- The improvement of median sTfR concentration of the intervention group was higher than of the
control group (p > 0.05). The effectiveness of prevention was 2.9% and the effectiveness of treatment
support was 33.6% (p > 0.05).
- The improvement of average zinc concentration of the intervention group was higher than of the
control group (p < 0.01). The effectiveness of zinc deficiency prevention was 38.8% and the supportive
effect of zinc deficiency was 64.3% (p < 0.001).
- The improvement of average vitamin A concentration of the intervention group was higher than of
the control group (p < 0.05). The effectiveness of vitamin A deficiency prevention was 1.4% and the
supportive effect of vitamin A deficiency was 40% (p > 0.05).
RECOMMENDATIONS
1. The study on iron and zinc fortification into rice shows the effectiveness on the community and it
can be used as an important measure to reduce the prevalence of CED, anemia, iron deficiency, zinc
deficiency of women at the age of 20 to 49. This measure should be expanded for other areas with similar
conditions.
2. Attention should be paid on communication, education and awareness raising for people of using
nutritional food, diversification of household serving, self-cultivation and using the available food supply.
3. Step by step, the Government should consider of compulsory regulation for rice fortification with
iron and zinc. In addition, the Government should have a plan to encourage; support businesses in food
fortification by tax reduction, technology transfer the premix to facilitate the industry to approach the supply.

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