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

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 grade 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.