Effectiveness of Fortified Mid-Day Meal in Reducing Anemia Among School Children in Dhenkanal,Odisha: A Quasi-Experimental Study

Abstract

Background:

Iron-deficiency anemia among school-aged children is widespread in India. The efficacy of micronutrient and iron fortified school-served meals in reducing iron deficiency anemia has been demonstrated in randomized controlled trials in other parts of the globe. The current study evaluates its effectiveness in real-world Indian settings.

Methods:

Mid-day-Meal (MDM) programme provides free lunch to students of grades 1 to 8 in all public-funded Indian schools. An implementation research project fortified MDM of all public schools of 4 out of 8 sub-districts (“blocks”) of Dhenkanal district of Odisha state with fortified rice kernel (FRK). All the schools of the other 4 blocks fortified with micronutrient powders (MNP)—both FRK and MNP containing equal amounts of supplementary iron and other micronutrients. Schools of 4 matched blocks of neighboring nonimplementing Angul district served as control. Cross-sectional representative samples of students were drawn from the 3 arms, before and after intervention (n = 1764 and n = 1640 respectively). Pre-post changes in anemia prevalence and hemoglobin levels were estimated in the sampled children using difference-in-difference analysis after controlling for inter-arm differences in socioeconomic status, and iron and deworming tablet consumptions.

Results:

Factoring in pre-post changes in control and adjusting for potential confounders, the proportion of children without anemia and mean hemoglobin improved by 1.93 (1.38, 2.24, P < .001) times and 0.24 (−0.03, 0.51, P = .083) g/dL in MNP; and 1.63 (1.18, 2.24, P = .002) times and 0.18 (−0.09, 0.45, P = .198) g/dL in FRK arms.

Conclusions:

Fortified MDM could effectively improve anemia status among Indian school-aged children under real-world conditions.

Introduction

Anemia is one of the leading contributors to the preventable global disease burden affecting about 2 billion people (i.e., 30% of the world population) worldwide, ¹ and a very large part of the anemia burden is due to iron deficiency. ^2,3 Thus, iron deficiency anemia (IDA) and anemia are often used interchangeably. The etiologies of IDA mainly comprise poor dietary iron intake in terms of quantity or quality and chronic unreplenished blood loss for any reason. ^{4 -6} Naturally, IDA is widely prevalent in low- and middle-income countries (LMICs), given most of its determinants are associated with poverty. ^{6 -9} Its significant presence in the South Asia region including India has been reported widely. ^6,7

The school-aged children (5–14 years) are vulnerable to IDA, given the high iron requirement at their life stage, ^10,11 its prevalence in this group estimated to be about 48% globally. ¹² Iron deficiency anemia predisposes children to intellectual impairment, poor cognitive development, and weakened immunity leading to increased risk of diseases, therefore, unfavorably impacting lifelong health, education, and productivity prospects of individuals and prosperity of nations at large.

Despite recent economic growth and roll-out of several large food security and poverty alleviation programmes over the last few decades, India still harbors the largest number of people suffering from IDA. ^13,14 In India, among children and adolescents, prevalence of anemia has been reported to be substantial. ^{15 -18}

Weekly Iron and Folic acid Supplementation programme in 2012, National Iron Plus Initiatives in 2013, Intensified National Iron Plus Initiative (Anemia Mukt Bharat) in 2018 are some of the recent policy initiatives of providing iron and folic acid supplementation in the form of tablets and syrups to target subpopulations including children for correcting the IDA scenario in India. ¹⁹ But, these programmes have not succeeded up to the desired level. ¹³ Meanwhile, iron fortification of food items has been found as a feasible, sustainable, and cost-effective strategy to bring about rapid success in controlling IDA in large swathe of the population even in resource-poor settings. ^20,21

Providing free school meals to the pupils attending public schools of India, popularly known as Mid-day-Meal (MDM), is the largest school meal programme in the world, which aims to provide adequate calories and nutrients to the vast majority of Indian children through these meals. ²² The success of fortification of school meal system as a vehicle to prevent various micronutrient deficiencies (MNDs) that also include IDAs in schoolchildren has been demonstrated by multiple efficacy studies across the globe. ^23,24 This appealed to the Indian planners also. In year 2012, fortification of MDM with iron was piloted in Gajapati district, situated in one of the nutritionally vulnerable Indian states, Odisha. The project assessment revealed a significant reduction in anemia in a quick time of less than 3 years (2012–2015) among school children. ²⁵

Fortified Rice Kernel and Micronutrient Powders

Buoyed by these results, the Department of School and Mass Education of Government of Odisha, and the World Food Programme India Country Office planned to try out another similar initiative of fortifying MDM with multiple micronutrients including iron in the year 2016. The two strategies adopted for this purpose included fortification of rice and curry, the two basic ingredients of Indian MDM, by fortified rice kernel (FRK) and (micronutrient powders) MNP, respectively.

Efficacy of FRK and MNP has been proved during last two decades. ²⁶ Barring a few exceptions where no change in health outcome has been observed, ²⁷ there are overwhelming evidence in support of FRK ^{28 -32} and MNP ^{33 -40} with regard to improvement of health outcomes, especially IDA.

The FRKs are manufactured by combining rice flour with micronutrients and converting these into rice-like kernels using appropriate extrusion technology, which closely resemble the sheen, transparency, consistency, and flavor of rice. To fortify rice, these FRKs were blended with the government procured MDM rice in a 1:100 ratio. Similarly, the MNP in measured amounts (0.6 gm and 0.8 gm per child in primary and upper primary standards, respectively) was to be added to the cooked and cooled curry dishes served in the MDM. The micronutrient composition in the FRK and MNP was almost similar (based on the review of literature and experience from within India) and both were matched to deliver similar percent of Recommended Dietary Allowances for the micronutrients added. Both modalities, though with proven efficacy under randomized controlled trial (RCT) settings, ^{41 -44} were yet to be tested under real-world conditions in India.

Subsequently, the field-testing of these two strategies was designed as an implementation research project with a rigorous impact assessment component built-in within its framework, so that the results can inform the national and state policies for the suitability and scalability of these strategies under Indian conditions and can also serve as an advocacy tool for the mobilization of state resources for this purpose.

Therefore, we aimed to assess the effectiveness of these two modalities of fortification, which were implemented under real-world conditions, in terms of their ability to reduce anemia among children of school going age.

Methods

Study Design and Setting

The implementation research used a quasi-experimental pre-post non-equivalent group design (NEGD) with a matched control group. Dhenkanal (population: 1192811) is one among the eight socioeconomically less-evolved districts of Odisha, with its key developmental indicators significantly worse than national and state averages, for example, female literacy (Odisha: 64%; Dhenkanal: 71%) and urban–rural population ratio (Odisha: 0.2; Dhenkanal: 0.109). It was chosen for receiving the interventions. Dhenkanal comprises eight sub-districts (sub-district is referred to as “block” in India).

Consequently, all public-funded schools in 4 sub-districts of Dhenkanal were allocated to FRK and MNP arms, respectively. This allocation of sub-districts to arms was done randomly. Normally, all public-funded schools in the state, catering to students from grades 1 to 8, serve MDM (nonfortified) on school days. During the implementation phase of the project, these schools were required to serve fortified MDM—the type of fortification determined by which arm they belonged to—starting from January 2017. On an average 130000 students of Dhenkanal received fortified MDM on every school day once the interventions were implemented.

Schools of four blocks were selected from the neighboring Angul district as controls—a district that did not implement fortification of MDM. The control blocks were matched with those of Dhenkanal through the following key sociodemographic indicators: population, sex ratio, the proportion of 0 to 6 years children, the caste/tribe composition of the population, proportion of literates, and rate of school enrollment—leading to the formation of three arms of the study, FRK, MNP, and control (Figure 1).

Figure 1.

Study design and setting.

Study Sample

Three cross-sectional representative samples of students were drawn from each of the 3 arms, just before the implementation of MDM fortification—the “pretest” sample. Similarly, three samples were again drawn after the intervention was implemented for 17 months—the “posttest” sample. The same schools selected for pretest were revisited for posttest.

The calculation of sample size considered 80% power, 5% level of significance testing, prevalence of anemia to be 75% among the students, and 10% to 15% expected improvement in the intervention arms. ^33,34,45 A sample design effect of 2 was factored in to adjust for the clustered nature of the sample. The calculated sample size came to 584 students for each arm for each round.

A two-stage stratified clustered sampling procedure using probability proportionate to size in the first stage and simple random method in the second stage was employed. The two stages included sampling of schools and then students from schools. The schools belonged to three strata—primary (grade 1-5), upper primary (grade 6-8), and primary plus upper primary (grade 1-8) schools—the three types of schools in Dhenkanal district that serve MDM to their students. From each stratum, nine, five, and four schools were sampled in each arm representing their proportion in the universe of schools. The students were selected from the sampled schools stratified by their grade and gender. The details of the sample are presented in Table 1. However, because of unanticipated interruptions due to inclement weather (storm and rains), an unintentional reduction in the posttest sample of the control arm was encountered—four schools in that arm could not be visited during the posttest phase leading to a reduction of 122 students in that subsample.

Table 1.

Sample Size of the Schoolchildren at Pre-and Posttest Across the Intervention and Control Arms.

Types of schools	FRK		MNP		Control
	Pre (n 597)	Post (n 599)	Pre (n 578)	Post (n 574)	Pre (n 589)	Post (n 467)
Primary	221	227	245	243	259	151
Primary plus upper primary	275	292	232	243	261	293
Upper primary	101	80	101	88	69	23

Abbreviations: FRK, fortified rice kernel; MNP, micronutrient powders.

Data and Blood Specimen Collection

Five milliliters of blood specimens, each during both pre-and post-intervention were also collected from the sampled students and tested in the biochemistry laboratory of the All India Institute of Medical Sciences, Bhubaneswar, an autonomous government medical college of national importance. Pretested structured questionnaires in Odia (translated from English) were administered to the sampled students and their parents.

The student–parent questionnaire measured sociodemographic (age, sex, religion, caste—a major stratifying axis of the Indian society, and parental education) and economic attributes (25 key-assets, cooking fuel and toilet practices) of households of sampled children. Consumption of other school-provided micronutrient supplements and medicine that is iron folic acid (IFA) and deworming tablets, which could potentially influence the principal outcome of the study if not balanced across the arms, were also recorded. These supplements were provided throughout the study period through the usual school health system. A standard of living index (SLI) was created using the inverse probability weights of assets and other possessions. ⁴⁶

The hemoglobin levels were estimated using cyanmethemoglobin method. Hemoglobin measures were treated as continuous variables. Anemia status (Yes/No) was identified among children with a hemoglobin concentration of <11.5 g/dL for children aged <11 years and <12 g/dL for children >11 years. ³

Statistical Analyses

Descriptive

We analyzed the distribution of sex, religion, caste, education, SLI, and all other relevant covariates for pretest as well as posttest samples stratified by arms. The statistical significance of the distribution differentials was tested using the chi-square test for categorical and analysis of variance (ANOVA) for quantitative variables.

Analytical

We employed difference-in-difference (DiD) analysis, which is frequently used in quasi-experimental study to compare the changes in outcomes over time between a population enrolled in an intervention (the intervention arm) and a population that is not (the control arm). The DiD method used multilevel linear regression to assess the change in hemoglobin (mg/dL), and multilevel log-binomial regression to examine anemia status (rather “no anemia” status) while accounting for the clustered (whereby children are clustered within schools) nature of the data, as equated below:

Equation for multilevel linear regression

${\mathit{Y}}_{\mathit{i}\mathit{j}}={\mathit{\beta }}_{\mathbf{0}}+{\mathit{\beta }}_{\mathbf{1}}{\mathit{X}}_{\mathbf{1}}+{\mathit{\beta }}_{\mathbf{2}}{\mathit{X}}_{\mathbf{2}}+{\mathit{\beta }}_{\mathbf{3}}{\mathit{X}}_{\mathit{i}\mathit{j}}+{\mathit{\mu }}_{\mathbf{0}\mathit{j}}+{\mathit{\epsilon }}_{\mathit{i}\mathit{j}}$

1

$\left(\mathit{i}=\mathbf{1},\mathbf{2},\dots \dots ,\mathit{n}\right);{\mathit{\mu }}_{\mathbf{0}\mathit{j}}\sim \mathit{N}{\left(\mathbf{0},{\mathit{\sigma }}_{\mathit{u}}\right)}^{\mathbf{2}};\mathit{e}\_\mathit{i}\mathit{j}\sim (\mathbf{0},\mathit{\sigma }\_\left(\mathit{e}\right){)}^{\mathbf{2}}$

where ${\mathit{\beta }}_{\mathbf{0}}$ and ${\mathit{\beta }}_{\mathbf{1}}$ , ${\mathit{\beta }}_{\mathbf{2}}$ ,… ${\mathit{\beta }}_{\mathit{k}}$ are fixed regression coefficients. ${\mathit{\mu }}_{\mathbf{0}\mathit{j}}$ is multilevel residual for the intercept and $e_{\mathit{i}\mathit{j}}$ is multilevel residuals for the model. ${\mathit{\sigma }}_{\mathit{u}}^{\mathbf{2}}$ and ${\mathit{\sigma }}_{\mathit{e}}^{\mathbf{2}}$ are random parameters to be estimated along with the (fixed) regression coefficients.

${\mathit{\beta }}_{\mathbf{3}}$ denotes the coefficient for interaction between phase and intervention, representing the DiD estimate in terms of mean difference in hemoglobin (gm/dL)—which is post minus pre differences of mean hemoglobin in the intervention arm(s), accounting for similar differences in the control arm.

Equation for multilevel log-binomial regression

$\mathit{log}{\mathit{\gamma }}_{\mathit{i}\mathit{j}}={\mathit{\beta }}_{\mathbf{0}\mathit{j}}+{\mathit{\beta }}_{\mathbf{1}}{\mathit{X}}_{\mathbf{1}}+{\mathit{\beta }}_{\mathbf{2}}{\mathit{X}}_{\mathbf{2}}+{\mathit{\beta }}_{\mathbf{3}}{\mathit{X}}_{\mathit{i}\mathit{j}}$

2

where i = arm and j = phase (Pretest and Posttest). logγ denote log of predicted probability of the outcome, X denotes the explanatory variable, ${\mathit{\beta }}_{\mathbf{0}}$ denotes the intercept,

${\mathit{\beta }}_{\mathbf{1}}$ & ${\mathit{\beta }}_{\mathbf{2}}$ denote the effect of the principal explanatory variables,

${\mathit{\beta }}_{\mathbf{3}}$ denotes the coefficient for interaction between phase and intervention, representing the DiD estimate in terms of prevalence ratio—which is the post to pre ratio of probability of being nonanemic in the intervention arm(s), accounting for similar ratios in the control arm.

Further, the potential confounding covariates were controlled for in both sets of models to derive the adjusted DiD estimators—the principal statistic of our impact assessment.

Sensitivity Analyses

Four out of the sampled 18 schools could not be accessed during the posttest phase in the control arm due to unavoidable circumstances (mentioned above), which led to the reduction of the posttest control sample by 122 school children as compared to pretest sample. Whether this reduction led to biased results was tested using a sensitivity analysis, whereby children from these 4 schools were also dropped from the pretest control sample and the entire DiD analyses were reconducted.

Research Ethics Approval

Ethics approval was received from the Institutional Ethics Review Board of Indian Institute of Public Health, Bhubaneswar (IIPHB-IEC-2016-012) and State Research and Ethics Committee, Govt. of Odisha (218/SHRMU). Written informed consent (translated into the local language) was obtained from all parents and plain language statements distributed. No material benefits were offered to encourage participation. Any subjects found to be suffering from malnutrition or infections were referred to the health facilities. Identities of all participants were secured using deidentifying identity numbers and the decode keys were maintained by the principal investigator.

Results

Except for age, the distributions of demographic characteristics across the arms and across the 2 time-points were marginally different (Table 2). The control arm had a relatively higher proportion of affluent households (P < .05). The average IFA receipt by the students, however, showed wider variations across groups and rounds. Notable was the fluctuation in receipt between the 2 time-points—the FRK arm saw 11% points decline whereas the MNP arm experienced 30% points increase. The control arm had the lowest but similar IFA reception in both rounds (Pre: 59%, Post: 65%) (Table 2).

Table 2.

Sociodemographic, and IFA and MDM Consumption Status at Pre-and Posttest Across the Intervention and Control Arms.

	Pre						Post
	FRK		MNP		Control		FRK		MNP		Control
	(n 597)		(n 578)		(n 589)		(n 599)		(n 574)		(n 467)
	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD
Age (years)	9.80	2.40	9.70	2.30	9.70	2.30	9.30	2.30	9.60	2.40	9.70	2.40
	N	%	n	%	N	%	n	%	n	%	n	%
Sex
Male	294	49.25	291	50.35	293	49.75	302	50.42	283	49.30	221	47.32
Female	303	50.75	287	49.65	296	50.25	297	49.58	291	50.70	246	52.68
Quintiles of SLI
Poorest	105	17.59	122	21.11	126	21.39	117	19.53	108	18.82	113	24.20
Poor	109	18.26	118	20.42	134	22.75	94	15.69	130	22.65	95	20.34
Middle	86	14.41	120	20.76	138	23.43	114	19.03	141	24.56	72	15.42
Rich	127	21.27	128	22.15	110	18. 68	134	22.37	101	17.60	100	21.41
Richest	170	28.48	90	15.57	81	13.75	140	23.37	94	16.38	87	18.63
Caste of the household
General	47	7.87	94	16.26	120	20.41	107	19.74	93	16.20	199	42.80
Scheduled caste	228	38.19	131	22.66	158	26.87	148	27.31	189	32.93	93	20.00
Scheduled tribe	69	11.56	89	15.40	96	16.33	75	13.84	85	14.81	92	19.78
Other Backward Class	241	40.37	264	45.67	205	34.86	206	38.01	207	36.06	81	17.42
None of them	12	2.01	0	0.00	9	1.53	6	1.11	0	0.00	0	0.00
Children consumed MDM for 6 days
No	61	10.22	42	7.27	28	4.75	21	3.51	11	1.92	17	3.64
Yes	536	89.78	536	92.73	561	95.25	578	96.49	563	98.08	450	96.36
Children consumed IFA tablets in school
No	45	7.54	176	30.45	236	40.07	108	18.03	6	1.05	136	29.12
Yes	541	90.62	389	67.30	337	57.22	470	78.46	561	97.74	255	54.60
Don’t know	11	1.84	13	2.25	16	2.72	21	3.51	7	1.22	76	16.27

Abbreviations: FRK, fortified rice kernel; IFA, iron and folic acid; MDM, mid-day-meal; MNP, micronutrient powders; SD, standard deviation; SLI, standard of living index.

The mean hemoglobin was maximum in the control arm children (10.38), followed by FRK (10.27) and MNP (10.12) arms in the pretest. However, in the posttest, the average of hemoglobin was highest in MNP and FRK (11.01) followed by control (10.96) arms. Similarly, before the intervention started, the proportion of children without anemia in the control arm was 25.8%, while the FRK and MNP arms were trailing with corresponding figures of 17.5% and 14.2%, respectively. After the intervention, the nonanemic children across the FRK, MNP, and control arms were 28.2%, 28.1%, and 26.4%, respectively (Table 3).

Table 3.

Mean Hemoglobin (gm/dL) Level and Anemia Status of Sampled Schoolchildren at Pre-and Posttest Across the Intervention and Control Arms.

	FRK				MNP				Control
	Pre (n 595)		Post (n 592)		Pre (n 578)		Post (n 555)		Pre (n 581)		Post (n 459)
	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD
Hemoglobin	10.26	1.31	11.01	1.19	10.12	1.48	11.02	1.31	10.38	2.28	10.96	1.27
	n	%	n	%	n	%	n	%	n	%	n	%
Children with no anemia	104	17.50	167	28.20	82	14.20	156	28.10	147	25.30	121	26.40

Abbreviations: FRK, fortified rice kernel; MNP, micronutrient powders; SD, standard deviation.

The covariate-adjusted model estimated an increase of 1.63 (95% confidence interval: 1.18, 2.24, P = .002) and 1.93 (1.38, 2.24, P < .001) times in the prevalence of nonanemic conditions among children in the posttest as compared to the pretest in FRK and MNP arms respectively, after factoring in corresponding changes in the control arm. The increase in average hemoglobin in both the intervention arms was 0.18 (−0.09, 0.45, P = .198) and 0.24 (−0.03, 0.51, P = .083) mg/dL, respectively, again, after factoring in changes in average hemoglobin in the control arm—the improvement in average hemoglobin being not statistically significant (Table 4).

Table 4.

Comparison of Post and Pre-Anemia Status and Hemoglobin Level of Sampled Schoolchildren in 2 Intervention Arms.

	FRK		MNP
	Prevalence ratio of anemia	Difference in mean hemoglobin	Prevalence ratio of anemia	Difference in mean hemoglobin
Post-pre difference	1.6 (1.29, 1.99, P < .001)	0.75 (0.61, 0.90, P < .001)	1.98 (1.29, 1.99, P < .001)	0.9 (0.74, 1.06, P < .001)
Difference-in-difference (Post-pre difference after accounting for differences in the control arm)	1.57 (1.16, 2.11, P = .003)	0.17 (−0.03, 0.43, P = 0.186)	1.93 (1.41, 2.64, P < .001)	0.32 (0.06, 0.58, P = .013)
Covariate-adjusted difference-in-difference (after accounting for differences in the control arm)	1.63 (1.18, 2.24, P = .002)	0.18 (−0.09, 0.45, P = .198)	1.93 (1.38, 2.24, P < .001)	0.24 (−0.03, 0.51, P = .083)
Covariate-adjusted difference-in-difference in MNP (after accounting for differences in FRK)			1.25 (0.87, 1.78, P = .21)	0.09 (−0.13, 0.33, P = .404)

Abbreviations: FRK, fortified rice kernel; MNP, micronutrient powders.

In the sensitivity analysis, the covariate adjusted and control-adjusted prevalence ratios for FRK and MNP were 1.60 (1.15, 2.22, P < .001) and 1.87 (1.32, 2.64, P < .001) respectively, signifying very little changes from the original estimates. Similarly, the pre-post differences in mean hemoglobin (Hb), in the sensitivity analysis were close to the original estimates and also not statistically significant (Supplementary Table S1).

Discussion

This study, to the best of our knowledge, is the first of its kind in India to test the real-world effectiveness of 2 different modalities of fortification of food with micronutrients via a school-based free lunch program. Our study showed that the provision of MDM fortification—either by FRK or MNP—had a significant and positive impact on lowering the prevalence of anemia among school children. These 2 modalities also had an impact, but to a lesser extent, on increasing the average hemoglobin of the recipients. However, it is on expected lines, because such nutritional interventions are most likely to exert a greater influence on deficiency status than on averages. There was a marginally greater decline seen in the anemia prevalence in the MNP intervention arm as compared to the FRK arm, albeit this between-arm difference in impact was statistically not significant.

The study has few limitations. First, since the MNP arm also had an improved average IFA tablet reception than that of the FRK arm in the intervention period, one might argue that this could have marginally influenced the larger improvement of anemia in the MNP arm; however, as these IFA differentials were accounted for in the estimation models, the MNP versus FRK difference was largely independent of variance in IFA reception. Second, the control arm had less anemia than the 2 intervention arms in the preimplementation phase, perhaps due to greater affluence that was observed in that arm. But, such disparities are commonplace in quasi-experimental implementation research, especially when very large units like entire district or sub-districts that are likely to have different mixes of both diseased and nondiseased individuals (in this case anemic and nonanemic) to start with, are chosen as targets of intervention. Moreover, the difference-in-difference estimation method that was employed for this impact assessment is particularly meant to account for such baseline discrepancies across arms while estimating the impact. ⁴⁷ The DiD estimator illustrated that there was much larger improvement of anemia status in the fortified-MDM arms as compared to the small secular improvements in the control group. Third, the reduction of the size of the control arm sample in the posttest phase due to unavoidable operational reasons can be considered as a limitation. However, a sensitivity analysis was carried out dropping those same schools from the pretest phase, the results of which showed only marginal changes from the original estimates.

The main strengths of the study include its study design, which is pre-post non-equivalent group design (NEGD) with a matched control group, the covariate adjustment of the difference-in-difference estimation process and most importantly, assessment of impact after the interventions were implemented in real-world conditions. In addition to the strong study design, many potential confounders decided a priori from the existing literature and as suggested by experts, were measured, which were then accounted for in the impact estimation process. Therefore, the estimates of impact are unlikely to be substantially biased, if at all, by unmeasured confounding, which is often considered a major weakness of quasi-experimental design. ⁴⁸ Most importantly, the intervention could be carried out and its impact could be achieved with minimal investment of additional resources—mimicking the normally prevailing conditions of the public school system of India. On the contrary, an RCT design, which is usually regarded as the “gold standard” of intervention research, would have carried out the experiment under ideal conditions employing extra resources, thereby compromising the translational potential of the intervention. ⁴⁹ Moreover, RCTs have already demonstrated the proof of efficacy for such meal fortification from various parts of the world. ^{33,40,50 -52} What this current study adds to the body of evidence is the all-important proof of its effectiveness under real-word conditions and more importantly, in locations where such interventions are needed most.

The policy implication of this evaluation is that the fortification of school meals with micronutrients should be taken up on a larger scale for roll-out in all the districts of Odisha. Out of the 2 modalities—MNP and FRK, the one to be preferred for this large-scale roll-out may depend on the context of individual districts, the operational feasibility, and the economic efficiency of each fortification technique. ⁵³ The 2 above-stated aspects, operational feasibility and cost efficiency, are, however, beyond the scope of this article. Efforts are on for publication of those relevant findings in the public domain shortly for facilitating decision-making. Meanwhile, other Indian states with comparable socioeconomic and demographic profiles may also choose to replicate and scale-up the MDM fortification initiatives to safeguard many of their school-aged children from anemia and other MNDs.

It would be worth mentioning at this juncture that despite the substantial impact of fortified MDM, we found that anemia remained highly endemic among school children of Dhenkanal (Table 3). This may be due to the reason that fortified MDM was only provided for 17 months to the school children of the district, implying longer exposure could have delivered more children from anemia, which future studies might reveal. However, this is the situation across India, which despite implementation of various anti-anemia measures for decades and remarkable economic growth (and therefore presumably matching dietary improvements) has not been able to control anemia substantially in its population. ⁵⁴ Therefore, the country would need bundling of many proven effective anti-anemia strategies together and ensure their effective delivery to the population. The fortification of school meal may be one of the main such programmes as our results have demonstrated doubling of “no anemia” children after fortification in this anemia-endemic population. Also, school meal fortification can reach a large young anemia-vulnerable population in this country and other similar LMICs within a very short period of time and without much investment of additional resources.

To conclude, capitalizing on the robust quasi-experimental design using sound pre- and post-cross-sectional survey method with identifiable treatment and comparison groups while accounting for potential confounders, our findings add important information to the body of evidence that micronutrient fortification of school meal could be an effective approach to address anemia among the school-aged children in Odisha and other states of India.

Supplemental Material

Supplemental Material, sj-docx-1-fnb-10.1177_03795721231172253 - Effectiveness of Fortified Mid-Day Meal in Reducing Anemia Among School Children in Dhenkanal, Odisha: A Quasi-Experimental Study

Supplemental Material, sj-docx-1-fnb-10.1177_03795721231172253 for Effectiveness of Fortified Mid-Day Meal in Reducing Anemia Among School Children in Dhenkanal, Odisha: A Quasi-Experimental Study by Mrinal Kar Mohapatra, Ashirbad Pradhan, Divya Tiwari, Shariqua Yunus, Binod Kumar Patro, Binod Kumar Behera, Suchanda Sahu, Vikas Bhatia, Shreeporna Bhattacharya, Pradnya Paithankar and Ambarish Dutta in Food and Nutrition Bulletin