The abstract of thesis: 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

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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; 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; 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.

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Nội dung Text: The abstract of thesis: 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

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 – 2022
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
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.
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 2 n: sample size ; Z (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. 548 subjects, divided into 2 communes: Minh Khai and Nguyen Xa, 274 women/commune Stage1: Cross- Sectional study Evaluate CED and anemia Select 350 subjects (BMI > 16,0 - < 25 (kg/cm2), divided into 2 Exclusion: BMI ≤ 16,0 and ≥ 25(kg/cm2); Hb< 80 g/L. 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 Intervention group: 175 women eating Control group: 175 women eating fortified rice daily conventional rice daily Stage 2: T0, T12 evaluate: anthropometrical, Hb, ferritine,TfR, zinc, Intervention study vitamin A Intervention group 163 women Control group: 162 women At T12 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 8,5 µmol/L; Zinc deficiency when zinc concentration in serum
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 Minh khai Nguyen xa Total p Index 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 Minh khai Nguyen xa Total p Index 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  test comparing the mean of two groups. 2 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 ≥ 800.000 đ 1 Income/month 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 No anemia 1 Hemoglobin status 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 ≤ middle 0.023 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 No CED 1 Nutrition status < 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 ≥ middle 0.154 91 (55.8%) 103 (63.6%) school Famer, Worker 128 (78.5%) 131 (80.9%) Occupation Officer, trader, 0.601 35 (21.5%) 31 (19.1%) others < 800.000 đ 8 (4.9%) 16 (9.9%) Income/month 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%) people in 0.165 household > 4 people 67 (41.1%) 79 (48.8%) 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 Intervention Control Index 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 b p < 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 Intervention Control Index 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 b p < 0.001 0.790 Data presented as mean ±SD
7 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 BMI in intervention group is increased higher than control group (p < 0,001). Table 3.8. Effectiveness of treatment on CED status after intervention Intervention Control 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 Intervention Control Index pa 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 b p < 0.001 < 0.001 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 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 Intervention Control 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 Intervention Control 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) (p) Fisher exact test, difference comparation of changing between two groups 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 Intervention Control Index 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 Intervention Control 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) (p) Fisher exact test, difference comparation of changing between two groups 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 Intervention Control 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) (p) Fisher exact test, difference comparation of changing between two groups 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 was statistically significant (p < 0.001). Table 3.15. Effectiveness of treatment intervention on iron-deficiency anemia (IDA) Intervention Control Index p n = 10 n = 11 IDA 0 (0.0%) 7 (63.6%) 0.004 No IDA 10 (100%) 4 (36.4%)
9 ARR% (95%CI) 63.6 (35.2 – 92.0) NNT 1.6 (1.1 – 2.8) (p) Fisher exact test, difference comparation of changing between two groups After 12 months of intervention, the effectiveness of treatment was 63.6% and for every 2 normal 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 Intervention Control Index pa n = 153 n = 151 Before intervention (T0) 10.53 ± 2.65 10.08 ± 2.63 0.139 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 b p < 0.001 0.310 Data presented by average ±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, 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 Intervention Control 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) (p) Fisher exact test, difference comparation of changing between two groups 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 was statistically significant (p < 0.05). Table 3.18. Effectiveness of treatment intervention on zinc deficiency Intervention Control 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 After 12 months of intervention, the effectiveness of treatment was 64.3% and for every 2 normal women who were intervened after 12 months, one woman was not zinc deficiency (NNT2), the difference was statistically significant (p < 0.05).
10 Table 3.19. Changing of vitamin A concentration after intervention Intervention Control Index pa n = 148 n = 147 Before intervention (T0) 1.72 ± 0.55 1.81± 0.65 0.192 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 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, vitamin A concentration of intervention group was increased higher than control group, the difference between 2 groups was statistical significant (p
11 Our results show that, after 12 months Hemoglobin concentration of intervention group was increased higher than control group (p
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 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.