Community-level fortification of a food supplement for pre-school aged children in India

Background. Children participating in the Integrated Child Development Service (ICDS) supplementary nutrition program in India have high rates of iron deficiency and vitamin A deficiency. ICDS previously relied heavily on micronutrient-fortified food supplements that were either imported or factory-produced domestically---these supplements are now increasingly produced at the community-level and not fortified.; Objective. (1) To assess the efficacy and feasibility of an iron, vitamin A, and folic acid fortified premix added at the community-level to prepared khichdi (a preparation of rice and lentils). We measured the efficacy in terms of increasing iron and vitamin A stores and decreasing the prevalence of iron deficiency, anemia, and vitamin A deficiency. (2) To determine the relation between nutritional status, dietary intake and health status in children aged 36 to 66 months who are enrolled in ICDS. We measured nutritional status through the indicators of weight-for-height z-score, hemoglobin concentration and serum retinol concentration.; Design. This cluster randomized, double-blind, controlled trial was initiated in thirty Anganwadi centers in the South 24 Parganas district of West Bengal state in India. Village based ICDS centers were randomly assigned to receive either a fortified premix or a non-fortified premix. Enrolled children, 36--66 month old (n=516), received the assigned premix for 24 weeks. At 0 and 24 weeks, blood was drawn by venipuncture for the analysis of hemoglobin, serum ferritin, serum retinol, and c-reactive protein. A survey (incorporating demographic, economic and health data), anthropometric measurements, and a 24-hour dietary recall were collected at 0 and 24 weeks, and focus group discussions were held at the end of the intervention.; Results. The change in hemoglobin concentration of anemic children was significantly different between children who received fortified khichdi and children who received non-fortified khichdi after 24 weeks of intervention (p<0.001). Prevalence rates of anemia, iron deficiency, and iron deficiency anemia were significantly lower after 24 weeks in the fortified group compared to the non-fortified group (p<0.001). There was no significant change in serum retinol concentration. Focus group discussions and monitoring records indicate that the fortified khichdi is stable, is feasible in its production and distribution and is acceptable to community workers, parents and children. Furthermore, it may be the most cost-effective means of addressing micronutrient deficiencies among program participants. Nutritional status among enrolled children was poor with dietary intake and health status explaining 1.9% of the variability in weight-for-height (p<0.005), 2.8% of the variability in hemoglobin and none of the variability in serum retinol.; Conclusion. A micronutrient fortified premix added to ICDS supplementary food at the community-level is effective in increasing iron stores and in reducing the prevalence of iron deficiency and anemia. The fortification is feasible to implement and is a cost-effective and acceptable method of providing necessary micronutrients to pre-school aged children. Nutritional status of pre-school aged children participating in ICDS was poor and should be a cause of concern in India.