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.

The British journal of nutrition

Oct 2012

DOI: 10.1017/S0007114511006945

Citations:44

Influential Citations:1

Interventional (Human) Studies

Enhanced Details

Methods

Randomised, double-masked, placebo-controlled trial in five primary schools in Quang Nam province, Vietnam; school children aged 6–9 years; 403 eligible and randomised into FB, C, and SUP groups; dewormed at baseline; anthropometric and biochemical measures taken at baseline and after 6 months.

Intervention

FB: five fortified biscuits per day (~30 g per serving) for 6 months; each serving provides 8.8 mg iron and multiple micronutrients; consumed during the morning break (09:00–09:30 h), five days/week under supervision; energy ~627 kJ/serving. SUP: weekly ferrous fumarate tablets (30 mg if body weight <20 kg; 40 mg if weight ≥20 kg) taken once per week for 6 months, with daily non-fortified biscuits.

Results

Both FB and SUP improved iron status versus control after 6 months. FB led to a lower anemia prevalence (1.0% vs 10.4% in control) and higher Hb (129 g/L vs 126 g/L in control); SUP had intermediate Hb (128 g/L) and anemia prevalence (7.4%) and also improved iron stores. PF was higher and TfR lower in FB (PF 36.9 mg/L; TfR 5.7 mg/L) and SUP (PF 46.0 mg/L; TfR 5.5 mg/L) than in control (PF 34.4 mg/L; TfR 5.9 mg/L); body iron higher in FB (5.6 mg/kg) and SUP (6.1 mg/kg) than control (4.2 mg/kg). After 6 months, iron deficiency prevalence was lower in FB and SUP vs control; IDA was 0.0% in FB, 5.2% in control, 2.1% in SUP. Vitamin A deficiency at baseline modulated effects: among vitamin A-deficient children, Hb increased more with FB than with control or SUP; end-point Hb higher by ~8.0 g/L (FB vs control) and ~7.1 g/L (FB vs SUP) in this subgroup (P<0.005). FB also yielded higher weight-for-height z-scores than SUP (P=0.009). Compliance was high (~95%). Conclusions: multi-micronutrient-fortified biscuits effectively reduce anaemia and improve iron status in Vietnamese school children; weekly iron supplementation also improves iron status and is a viable alternative when fortification is not feasible; addressing other nutrient deficiencies (notably vitamin A) can enhance Hb responses.

Limitations

Attrition and incomplete end-point data: 403 randomised but only 381 followed for 6 months and 297 at end-point with 290 blood samples; many parents refused venous blood drawing; inflammation markers were not measured, which could influence ferritin interpretation; study conducted in controlled school settings, which may limit generalizability; potential confounding from deworming and other micronutrient deficiencies; results may not fully translate to real-world mass interventions.

Abstract

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. show less