Vitamin C-Rich Guava Consumed with Mungbean Dal Reduces Anemia and Increases Hemoglobin but not Iron Stores: A Randomized Controlled Trial of Food-to-Food Fortification in Indian Children

Background: Adding vitamin C-rich fruit to staples containing iron could be an effective strategy to improve iron bioavailability and thereby reduce iron-deficiency anemia in children. Objectives: We aimed to assess the effect of consuming a mungbean-based meal with or without guava fruit on body iron stores, hemo- globin concentration, and anemia of children as part of a school feeding program. Methods: We conducted a 7-mo randomized, controlled trial with 6- to 10-y-old school children (n = 200; 46% anemic, 71% iron-deficient) from a rural community in Haryana, North India. Children were assigned to 2 treatment groups to daily receive either a meal of mungbean dal only (3.0 mg iron; vitamin C:iron molar ratio--0.5:1), or mungbean dal with fresh guava (3.2 mg iron;--170 mg vitamin C; molar ratio--18:1). Meals were served every school day under supervision. The primary outcome was body iron stores, whereas concentrations of hemoglobin and other iron indicators were secondary outcomes. Results: Daily consumption of mungbean dal along with guava did not result in an overall improvement of body iron stores [mean treatment effect: 0.65 mg/kg body weight; 95% confidence interval (CI):- 0.34, 1.63; P = 0.197]. However, compared with children who consumed mungbean dal only, children in the guava group showed a larger increase in hemoglobin concentration (3.7 g/L; 95% CI: 1.6, 5.6; P = 0.001), and a larger drop in the prevalence of anemia (-51%; 95% CIs:- 74,- 10; P = 0.022) and iron-deficiency anemia (-56%, 95% CI:- 83, 13; P = 0.087). These effects were more pronounced in children who were iron deficient at study start. Conclusions: Addition of guava to a mungbean-based meal containing a moderate amount of iron increased hemoglobin and reduced anemia but did not provide enough additional absorbed iron to also increase body iron stores. Food-to-food fortification by inclusion of vitamin C-rich fruits in iron-containing school meals may help alleviate the burden of anemia in children. Trial registration number: This trial was registered at https://clinicaltrials.gov/ct2/show/NCT01191463.