Guava with an institutional supplementary meal improves iron status of preschoolers: a cluster‐randomized controlled trial

The Integrated Child Development Services of India provides Supplementary Nutrition Program (SNP) to preschoolers. Using this platform, the current study examined the impact of diversifying a cereal/pulse–based SNP‐meal with guava on iron status and cognitive development among 24–48 months old children. A three‐arm, nonblinded, cluster‐randomized controlled trial (CTRI/2014/09/004983) included 399 beneficiaries from 28 preschools in 16 villages in Telangana state, India. The villages were randomly assigned to receive 25 g of guava (guava group (GG)), banana (banana group (BG)), or cucumber (cucumber group (CG)) along with a SNP meal for 140 days. Nutrient biomarkers (iron status, plasma vitamin C, vitamin B 12 , and folate), cognitive development, anthropometric indicators (WAZ, HAZ, and WHZ), and morbidity were assessed at baseline and endline. A linear mixed model and a generalized estimating equation were applied to compare changes in outcomes across the groups. All outcome variables were comparable across groups at baseline. The iron to vitamin C molar ratio improved in the GG from 1:1.4 to 1:12 but remained unaltered in control groups. Higher hemoglobin ( P  = 0.002), serum ferritin (SF; P < 0.001), vitamin C ( P  = 0.047), and lower soluble transferrin receptor (sTfR; P < 0.001) causing decreased prevalence of iron deficiency (ID) ( P  = 0.003) were observed in the GG compared with BG and CG. Prevalence of acute respiratory infection (ARI) was lower in the GG ( P  = 0.035) versus controls. No impact was observed on cognitive development or growth. Thus, diversifying a cereal/pulse–based meal with guava increased meal vitamin C content, thereby reducing ID and ARI‐related morbidity. This approach represents a valid and scalable strategy to address ID among young children.