Home Fortification of Complementary Foods Reduces Anemia and Diarrhea among Children Aged 6-18 Months in Bihar, India: A Large-Scale Effectiveness Trial

J Nutr. 2021 Jul 1;151(7):1983-1992. doi: 10.1093/jn/nxab065.


Background: Home fortification of complementary foods with multiple micronutrient powders (MNPs) is recommended to reduce child anemia in resource-poor settings. However, evidence of program effectiveness in India to guide policies and programs is lacking.

Objectives: We implemented a large-scale intervention of MNPs in Bihar, India. The primary outcome was MNP consumption and change in hemoglobin concentration among children aged 6-18 mo between baseline and endline (12 mo). Secondary outcomes were change in child weight and length and infant and young child feeding (IYCF) practices (initiation, diversity, and feeding frequency). Ad hoc analyses included changes in anemia; stunting; underweight; wasting; and reported diarrhea, fever, and hospitalization.

Methods: We conducted a cluster-randomized, effectiveness trial in >4000 children within the context of ongoing health and nutrition programs implemented by CARE, India. Seventy health subcenters were randomly assigned to receive either MNPs with IYCF counseling (intervention) or IYCF counseling only (control). We used an adjusted difference-in-difference approach using repeat cross-sectional surveys at baseline and endline to evaluate impact.

Results: At baseline, 75% of intervention and 69% of control children were anemic and 33% were stunted. By endline, 70% of intervention households reported their child had ever consumed MNPs, and of those, 64% had consumed MNPs in the past month. Relative to control, hemoglobin concentration increased (0.22 g/dL; 95% CI: 0.00, 0.44 g/dL) and anemia declined by 7.1 percentage points (pp) (95% CI: -13.5, -0.7 pp). There was no impact on anthropometry nor IYCF practices. However, there was a decline of 8.0 pp (95% CI: -14.9, -1.1 pp) in stunting among children aged 12-18 mo. Diarrhea prevalence in the past 2 wk was reduced by 4.0 pp (95% CI: -7.6, -0.4 pp).

Conclusions: Home fortification of complementary foods within a government-run program in Bihar had moderate compliance and caused modest improvements in hemoglobin and reductions in anemia and diarrhea prevalence.

Keywords: India; anemia; children; hemoglobin; multiple micronutrient powders.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anemia* / epidemiology
  • Anemia* / prevention & control
  • Cross-Sectional Studies
  • Diarrhea / epidemiology
  • Diarrhea / prevention & control
  • Dietary Supplements
  • Humans
  • Infant
  • Infant Nutritional Physiological Phenomena
  • Micronutrients*


  • Micronutrients