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

Abstract

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 SNPmeal 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.

The Effects of Nutritional Interventions on the Cognitive Development of Preschool-Age Children: A Systematic Review

“…In summary, 50% of trials were conducted in developed countries [55][56][57][58][59][60] and 50% in low and middleincome countries (LMICs) [61][62][63][64][65][66]. Four experimental studies were conducted in rural areas with low socioeconomic status [61,62,64,66], and six studies in urban areas with high socioeconomic status [55][56][57][58][59][60]. The earliest trial was completed in 2004 [58] and the latest in 2020 [65].…”

“…Six studies had an overall low risk of bias [55,56,59,60,65,66] and six had a moderate risk of bias [57,58,[61][62][63][64] as indicated in Table 3. Five studies did not record methods of handling withdrawal [57,58,[61][62][63] and two studies [57,64] reported moderate differences between study groups at baseline.…”

“…Supplement-based interventions were adopted in five out of twelve studies. These interventions included guava supplementation [62], DHA tablets [59], iron supplementation [58], B vitamin sachets [55], and iodized salt [61]. Multiple-micronutrient (MMN) food fortification interventions were implemented in three studies.…”

“…A diverse range of standardized cognitive tests were used to assess outcomes in multiple cognitive domains, including learning abilities, verbal reasoning, intellectual functioning, information processing speed, vocabulary, word reasoning, speed and accuracy of discrimination, fine and gross motor skills, coding, symbol search, and working memory. Half of the studies administered the Wechsler Pre-school and Primary Scale of Intelligence (WPPSI) test [55][56][57]60,61,63], two experimental studies administered the 9-Hole Peg Test (9-HPT) [56,57], and two studies administered the Mullen Scale of Early Learning (MSEL) [59,62]. Table 2 includes a detailed description of cognitive tests used in each trial, cognitive domains assessed, and effects on cognitive outcomes of preschool-aged children.…”

“…Five RCTs measured the effect of supplement-based interventions on children's cognition. Three trials failed to find a significant impact on cognition: the B vitamin [55], iodized salt [59], and guava [62] supplementation interventions. Guava is a fruit high in several vitamins and minerals and is also rich in lycopene, a carotenoid phytonutrient known for its antioxidant effect [67].…”