AJCN. First published ahead of print September 21, 2011 as doi: 10.3945/ajcn.110.007179.
Micronized ferric pyrophosphate supplied through extruded rice
kernels improves body iron stores in children: a double-blind,
randomized, placebo-controlled midday meal feeding trial in
Indian schoolchildren1–3
Madhari S Radhika, Krishnapillai M Nair, Rachakulla Hari Kumar, Mendu Vishnuvardhana Rao, Punjal Ravinder,
Chitty Gal Reddy, and Ginnela N V Brahmam
ABSTRACT
Background: Micronized ferric pyrophosphate (MFPP) in extruded
rice kernels mixed in a rice-based meal could be an effective strat-
egy for improving iron status of children in India.
Objective: The objective was to determine the impact of MFPP
supplied through extruded rice kernels in a rice-based meal on iron
status of children participating in the midday meal (MDM) scheme
in India.
Design: The sensory characteristics of cooked rice containing
MFPP in extruded rice kernels, in vitro availability, and loss of iron
during cooking from a typical MDM consisting of 125 g rice (dry
weight) containing 19 mg iron [fortified rice (FR); normal rice
mixed with Ultra Rice (extruded kernels containing MFPP of
;3.14-lm mean particle size)] in comparison with unfortified rice
(UFR) were tested. A double-blind, 8-mo, placebo-controlled trial
was conducted in 5–11-y-old schoolchildren (n = 140) who were
randomly assigned to receive either an FR-MDM or an UFR-MDM.
Average consumption amounts of the MDM, height, weight, hemo-
globin, ferritin, and C-reactive protein were measured at baseline and
at 8 mo.
Results: The sensory qualities of cooked FR and UFR were similar.
The in vitro iron availability from FR-MDM (1.3%) was signifi-
cantly (P , 0.05) lower than that from UFR-MDM (3.3%). Pro-
viding FR-MDM to the schoolchildren for 8 mo improved ferritin
significantly (P , 0.001), by 8.2 6 2.10 lg/L. However, the in-
crease in hemoglobin was similar between groups (FR: 0.99 6 0.10
g/dL; UFR: 1.15 6 0.10 g/dL), suggesting that other factors beyond
additional iron intake had a large influence on hemoglobin concen-
tration. The prevalence of iron deficiency decreased significantly
(P , 0.05) in the FR group (33–14%) and increased marginally in
the UFR group (31–37%). The prevalence of anemia and iron de-
ficiency anemia was similar between groups at baseline and at 8 mo.
Conclusion: Regular intake of 19 mg iron/d in MFPP supplied
through extruded rice kernels improves iron stores and reduces iron
deficiency among schoolchildren in India. Am J Clin Nutr doi:
10.3945/ajcn.110.007179.
INTRODUCTION
Anemia is a major micronutrient deficiency disorder of public
health concern in developing countries worldwide, including
India, that affects mostly women of reproductive age and young
Am J Clin Nutr doi: 10.3945/ajcn.110.007179. Printed in USA. Ó 2011 American Society for Nutrition
Copyright (C) 2011 by the American Society for Nutrition
children (1). Large-scale population-based nutrition and health
surveys in India have shown that the prevalence of anemia is
;70–80% among different age, sex, and physiologic groups (2,
3). In young children and adolescents, ID4 even without anemia
impairs cognition, immune status, growth, and development (4,
5). IDA is also high among these vulnerable groups in Asia (6).
The major etiologic factor of anemia is dietary inadequacy of
iron (7). Other important contributory factors are the presence of
high amounts of inhibitors such as phytates and tannins (8) that
limit iron absorption and inadequate intake of dietary promoters
of iron absorption or use such as heme-iron, vitamin C, vitamin
A, riboflavin, folic acid, and vitamin B-12 (9–12).
Fortification of commonly consumed staples with iron is an
effective strategy for reducing ID and IDA, because the requisite
iron can be provided through the diet without altering the pre-
vailing dietary preferences of the population. Technology for
fortification of wheat flour with iron has been developed and
adopted by several flour millers, which benefits the wheat-eating
populations in India (13). However, because rice forms the major
staple in the majority of the population in the southern and eastern
parts of peninsular India, similar technology for fortifying rice is
warranted.
PATH (Seattle, WA) owns the technology (14) for fortification
of rice using Ultra Rice (Bon Dente International), which consists
of extruded rice kernels made from rice flour fortified with MFPP
1
From the Division of Community Studies (MSR, RHK, CGR, and
GNVB), the Division of Micronutrient Research (KMN and PR), and the
Department of Biostatistics (MVVR), National Institute of Nutrition, Indian
Council of Medical Research, Hyderabad, India.
2
Supported by the Department of Biotechnology, New Delhi, India. The
Program for Appropriate Technology in Health (PATH), Seattle, WA, pro-
vided the Ultra Rice premix.
3
Address correspondence to GNV Brahmam, Division of Community
Studies, Jamai Osmania, Hyderabad – 500 007, Andhra Pradesh, India.
E-mail: gnvbrahmam@yahoo.com.
4
Abbreviations used: CRP, C-reactive protein; FR, fortified rice (normal
rice mixed with Ultra Rice); ID, iron deficiency; IDA, iron deficiency ane-
mia; MDM, midday meal; MFPP, micronized ferric pyrophosphate; NCHS,
National Center for Health Statistics; PATH, Program for Appropriate Tech-
nology in Health; UFR, unfortified rice.
Received October 28, 2010. Accepted for publication August 3, 2011.
doi: 10.3945/ajcn.110.007179.
1 of 9
2 of 9 RADHIKA ET AL
(;3.14-lm mean particle size). The technology is ideally suited
to the needs of the rice-eating population in India, and therefore
assessment of the importance of this technology on its benefi-
ciaries is essential. To date, only a few studies have been pub-
lished that show the efficacy of this technology in improving the
iron status of nonpregnant and nonlactating women in Mexico
and that of infants and young children in Brazil (15, 16). The
efficacy of this technology remains to be tested by a govern-
mental national food security program. Therefore, our primary
objective for this study was to assess the efficacy of nourishment
with MFPP by means of extruded rice kernels mixed in normal
rice (FR) on iron status among primary-school children under an
efficacy-like trial condition, through the national food security
program, the MDM program of the government of India, which
is considered one of the largest food security programs in the
world. We also assessed the sensory quality, in vitro availability,
and loss of iron during cooking of a typical MDM consisting of
FR compared with UFR.
SUBJECTS AND METHODS
Study approvals
The protocol was approved by the Institutional Ethical Com-
mittee of the National Institute of Nutrition and the Human Sub-
ject’s Protection Committee of PATH. Written permission for
carrying out the study was obtained from the Department of District
Education, the school authorities, and the village head of Ranga
Reddy District, Andhra Pradesh, India.
MDM
The MDM consisted of cooked rice equivalent to ;125 g rice
(dry weight) per child per meal along with regular side dishes
provided under the government-implemented MDM program on
all school working days, excluding Sundays and school holi-
days. Rice served in combination with a typical liquid prepa-
ration of pulse, locally called sambar (prepared by combining
dehusked split pigeon peas, tamarind pulp, and vegetables, eg,
bottle gourd, cucumber, brinjal), or a semiliquid preparation of
the same pulse with green leafy vegetables (eg, spinach, ama-
ranth, sorrel), locally called aakukoora pappu. Another variation
in the menu included rice seasoned with tamarind pulp, locally
called pulihora. The main ingredients used on a daily basis were
tomatoes, onions, peanuts, red chilies, salt, and peanut oil. The
rice and side dishes were cooked in wide-mouthed aluminum
vessels covered with a lid, and firewood was used for fuel. A
boiled egg was provided once per week. To avoid monotony and
maintain interest, the 3 meals were prepared and served to the
children in repeated sequence in a typical week during the ac-
ademic year.
Fortification of rice
Rationale for setting the amount of fortification
The Recommended Dietary Allowance of iron for Indian
children in the age group 5–11 y is 28 mg/d (17); their mean
dietary intakes were estimated to be about 10 mg/d (18).
Therefore, for the present study, the deficit of ;18 mg iron was
provided through a single MDM containing 125 g FR, on a dry-
weight basis. The FR was prepared by mixing MFPP-fortified
extruded rice kernels into normal rice just before use in the
kitchen.
Production of MFPP-fortified extruded rice kernels
The extruded kernels were produced by a cold-extrusion
process. The MFPP and other stabilizing ingredients were added
to the rice flour and then a dough was prepared and extruded in
a pasta-manufacturing machine by using die with rice-shaped
inserts by a contract manufacturer under an agreement with
Camil Alimentos SA (Sao Paulo, Brazil). The extruded rice
premix contained 9.6 mg Fe/g as MFPP with a mean particle size
of ;3.14 lm (AKSELL Quı́mica). The other constituents in the
premix were soybean oil, sodium alginate citric acid, sodium
tetra polyphosphate, butylated hydroxyl anisole, butylated hy-
droxyl toluene, and calcium chloride. All constituents used were
in conformity with Codex Alimentarius standards. The formu-
lation, production, and supply of the extruded rice kernels were
coordinated by PATH and transported to the study headquarters
as a single consignment of 60 kg, sufficient for the entire study
duration.
Fortification
Every 2 weeks, 100 kg rice supplied for the MDM to the school
through the public distribution system of the government of
Andhra Pradesh, India, was obtained and divided into 2 equal
portions. One portion was blended with the extruded rice premix
and the other was used as UFR. The process of blending the rice
with the premix was done through manual mixing in 50-kg
batches outside rice mills or normal packaging facilities, for the
sole purpose of use in the school study. The premix (0.8 kg) was
mixed with normal rice (49.2 kg), ie, a dilution of 1:61.5, so as to
provide 15 mg iron per 100 g FR (ie, 18.8 mg iron per 125 g FR),
on a dry-weight basis. Briefly, the rice was formed into a cone or
pile. The cone was flattened and divided into 4 equal segments
and formed into 4 separate piles. The premix was similarly di-
vided into 4 equal parts. Each part of the premix was added to
each pile of the rice and mixed thoroughly. The diagonally
opposite piles were combined and mixed again. This process was
repeated 3 times to ensure uniform mixing. The FR and UFR
were packed in color-coded, 10-kg, high-density polyethylene
bags and supplied to the school for MDM preparation.
Sensory evaluation
The sensory evaluation in terms of color, appearance, texture,
odor, taste, and overall acceptability was determined in cooked
rice by using a 5-point (5, very good; 4, good; 3, fair; 2, bad; 1,
very bad) hedonic scale (19) on 2 consecutive days. The panel
consisted of 132 children (56 boys, 76 girls) aged 8–11 y from
one of the government primary schools, situated in Keesara,
a rural village of Keesara Mandal, Ranga Reddy District, Andhra
Pradesh, India, which is located 30 km from our study head-
quarters, the National Institute of Nutrition. The children were
randomly allocated to 2 groups (n = 66, 28 boys and 38 girls in
each group) and blinded to the study procedures. The study was
conducted at 1200 h under uniform lighting conditions and each
child was seated separately while participating in the study. The
investigators explained to the children how to evaluate the food
samples and record results on a pretested sensory evaluation
 RCT OF MFPP-FORTIFIED EXTRUDED RICE IN CHILDREN
sheet prepared in the local language. Both types of coded rice
were washed in potable drinking water and cooked separately in
the school kitchen. Only plain, cooked rice was served without
any side dishes for testing the sensory qualities. On the first day,
one group of children received 1 of the 2 types of rice and the
second group received the other type of rice to test the sensory
qualities. On the second day, the study was repeated on the same
children by interchanging the type of rice given to each group.
The children were allowed to consume the side dishes only after
they had completed the sensory evaluation of the cooked rice.
Study site for the intervention study
The intervention study was carried out in an adjacent govern-
ment primary school in the same village of Keesara, where the
MDM program is in operation for children in the age group 5–11 y.
Study design
The study was a double-blind, randomized, placebo-controlled
feeding trial conducted in a primary school, in children in the age
group 5–11 y.
Sample size
Assuming an overall mean increment in hemoglobin of 0.56
g/dL with an SD of 1.04 g/dL (based on a pilot study), 95% CI,
significance of 0.05 (2-tailed), 80% power of estimate, and 20%
attrition, the sample size calculated was 70 children per group.
Screening
Informed written assent from children and consent from their
parents were obtained for screening. The school had 230 children
(85 boys and 145 girls) aged 5–14 y, who were screened for
inclusion in the study. The criteria for inclusion were age 5–11 y;
hemoglobin 7 g/dL; weight for age, height for age, and/or
weight for height of at least the median minus 3 SD of NCHS
reference values, and regular participation in MDM. Height,
weight, and hemoglobin were measured in 228 children. A total
of 146 children (56 boys and 90 girls) were eligible for inclusion
in the intervention study. Eighty-four children (29 boys and 55
girls) were excluded from the study: 2 children with age .12 y;
4 with severe anemia (hemoglobin ,7 g/dL); 3 with weight for
age, height for age, and/or weight for height less than the me-
dian minus 3 SD of NCHS reference values; 10 not participating
in the MDM program; and 65 participating irregularly in the
MDM program. The severely anemic and the severely un-
dernourished children received medical treatment as appropriate.
Random assignment of study participants
Informed written assent from children and consent from their
parents were obtained for participation in the study. The children
who met the inclusion criteria were stratified according to age
group and sex, ensuring that an even number existed in each of
the age/sex strata. The children (n = 140, 54 boys and 86 girls)
were randomly allocated to 2 groups (n = 70, 27 boys and 43
girls in each group) to receive the rice containing MFPP-fortified
extruded kernels (FR group) or the unfortified rice (UFR group)
in the MDM each day. In this process a total of 6 unmatched
children were excluded. Individual color-coded photo identity
3 of 9
cards were prepared and distributed to the children. All of the
participating children were dewormed with 100 mg mebenda-
zole (Mebex; Cipla Limited) twice daily for 3 d, 1 wk before
initiating the feeding trial.
The study group randomization and the process of fortification
and coding of rice were completed by a scientist not involved in
the study, to ensure the double-blinding of the study. The codes
were kept secure, and the decoding was completed after the
analysis of data.
Preparation and serving of the MDM
During the intervention period, the 2 types of coded rice were
weighed separately (at 125 g per child) depending on the day’s
attendance of children and cooked in 2 similar-looking coded
vessels in the school kitchen by the MDM cooks, using the
recipes mentioned above. The side dishes were cooked com-
monly for both groups. The meal was served ad libitum to the
children with local serving spatulas in stainless steel serving
plates along with potable water. The group assignment of the
children was identified by using the color-coded photo identity
cards, and the children consumed their respective meals in 2
different large halls. Care was taken to ensure that the children
did not share their meal or exchange their plates with other
participants. The entire process of cooking, serving, and con-
sumption was directly monitored by the project’s field staff each
day. Unannounced study site visits by the research investigators
were also conducted to monitor compliance.
Estimation of meal intakes
Institutional diet survey by weighing method (20) was performed
at baseline and at 8 mo, on 2 consecutive days with different menus
(pulihora on day 1 and rice with sambar and boiled egg on day 2).
Individual intake of MDM was measured on the same days among
a subsample of 24 randomly selected children belonging to dif-
ferent age and sex strata (12 from each of the study group). The
edible portions of all foods were weighed before and after prep-
aration by using a mechanical column weighing scale with an
accuracy of 50 g (Seca 710) and at the time of consumption by
using an electronic kitchen scale with an accuracy of 1 g (Soehnle
Vera). Visible leftovers in the serving dishes and on individual
plates were weighed and recorded. The data on nutrient intake
from MDM were derived from Indian food composition tables
(21) with the use of an in-house computer program.
Data collection
The study period was from 1 July 2007 to 15 April 2008. The
baseline and final measurements (at 8 mo) were done for height
and weight and for biochemical estimation of hemoglobin, fer-
ritin, and CRP. The FR and UFR samples (uncooked and cooked)
were collected in duplicates from the school kitchen, twice
monthly on random days, for estimation of the iron content.
Anthropometric measurements
The height and weight of the children were measured by using
an anthropometer rod with an accuracy of 1 mm (AP-BGC) and
a compact, digital, personal weighing scale of 100 g accuracy
(Seca 813), respectively (22). The nutritional status of each child
4 of 9 RADHIKA ET AL
was determined according to SD classification (23) using NCHS
reference values (24).
Biochemical analysis
Two milliliters of blood from the antecubital vein was
collected in heparinized evacuated tubes. Hemoglobin was es-
timated on the same day of blood collection by the cyanme-
themoglobin method (25) and the plasma was separated and
divided into aliquots and stored at 270°C until analysis for
ferritin and CRP. An indigenous sandwich ELISA developed
against human liver ferritin and previously validated against
recombinant human ferritin (WHO International Reference
Material 94/572; National Institute for Biological Standards and
Control, United Kingdom) with an assay sensitivity of 2 ng/mL
(26) was used to measure ferritin concentrations. CRP was es-
timated by a commercial ELISA kit (Abazyme, LLC) according
to the manufacturer’s instructions (27), and a value 0.8 mg/L
was considered to be an elevated CRP value.
In children aged 5–11 y, anemia (mild to moderate) was de-
fined as a hemoglobin concentration between 7 and 11.5 g/dL, ID
was defined as ferritin ,15 lg/L, and IDA was defined as he-
moglobin between 7 and 11.5 g/dL and ferritin ,15 lg/L (6).
Iron content and iron retention
The iron content in the extruded rice premix, FR, and UFR was
estimated. The iron content was analyzed in triplicate by the
bathophenanthroline method in mineral solution after microwave
digestion (28).
In vitro availability of iron
In vitro iron availability from cooked FR and UFR rice along
with the side dish sambar was estimated. For this estimation, the
food samples were lyophilized and subjected to gastric digestion
with pepsin at pH 2 followed by intestinal phases of digestion with
pancreatin and bile salts at pH 6.8 (29, 30), and the amount of iron
dialyzed was estimated by the bathophenanthroline method (28).
Statistical analysis
Data were entered into Microsoft Excel 2003 (Microsoft
Corporation) and analyzed with SPSS for Windows (version 15.0,
2006; SPSS Inc) to assess the impact of intervention on iron status
of children. Descriptive statistics were computed to analyze the
central tendencies and dispersions. The geometric mean and CI
for ferritin were also computed, as the values were not normally
distributed. The effect of time and treatment was assessed for all
outcome variables. The difference in the mean values for an-
thropometric measurements, hemoglobin, and CRP within
a study group was tested by means of the paired t test and be-
tween study groups with the independent Student’s t test. Be-
cause the ferritin values were not normally distributed, the
nonparametric test (Wilcoxon signed rank test) was used to test
the differences between baseline and postintervention (at 8 mo)
values within study groups. The difference in mean ferritin be-
tween groups was tested with the nonparametric Wilcoxon
Mann-Whitney U test. Efficacy analysis for hemoglobin and
ferritin was also performed after exclusion of the data on chil-
dren with elevated CRP values at baseline, at 8 mo, or at both
time points. Proportions were tested with the proportion t test.
The difference in mean sensory scores between the 2 types of
rice was tested by means of the independent Student’s t test.
In addition, 3 different types of linear regression analysis were
performed to evaluate the efficacy of intervention on hemoglobin
and ferritin concentrations (31). In the first method, ie, the ab-
solute change analysis, a linear regression model was constructed
considering the change in hemoglobin and ferritin as an outcome
variable and the intervention group as an independent variable. In
the second method, the ANCOVA model, the postintervention
hemoglobin and ferritin values were considered to be the outcome
variable, the corresponding baseline value as covariate, and the
intervention group as the independent variable. In the third
method, the residual change model, analysis was carried out in 2
steps. In step 1, regression analysis was performed considering
postintervention hemoglobin and ferritin values as the outcome
variable and the corresponding baseline values as the independent
variable to generate nonstandardized predicted residual values. In
step 2, the difference between the actual postintervention value
and the predicted residual value was considered as the outcome
variable and the intervention group as the independent variable.
Differences were considered significant at P , 0.05.
RESULTS
Characteristics of rice containing MFPP extruded rice
kernels
The mean scores for the sensory attributes tested for both the
cooked FR and the cooked UFR were .4.0 on a 5-point scale
and were similar (Table 1). The overall acceptability of FR and
UFR was 86% and 97%, respectively.
In vitro iron availability from the FR-MDM was 1.3% and that
from the UFR-MDM was 3.3%.
The mean (6SD) iron content (on a dry-weight basis) of the
uncooked and cooked FR was 19.2 6 0.44 mg/100 g and 19.0 6
0.39 mg/100 g, respectively, and that of the UFR samples was 2.0 6
0.25 mg/100 g and 1.8 6 0.16 mg/100 g, respectively. Minimal
variation in iron concentrations in both uncooked and cooked FR
and UFR samples was observed over the duration of the study.
Compliance
Of the 140 children recruited, 128 completed the study (Figure
1). Seven children from the FR group and 5 from the UFR group
left the school during the study period because of migration of
their families. During the intervention period of 8 mo (244 d),
TABLE 1
Sensory evaluation scores for the cooked FR and UFR1
Sensory attribute FR group (n = 66) UFR group (n = 66)
Appearance 4.2 6 0.95 4.4 6 0.88
Color 4.1 6 0.95 4.3 6 0.88
Texture 4.2 6 0.83 4.4 6 0.69
Odor 4.1 6 1.13 4.3 6 0.86
Taste 4.1 6 1.21 4.4 6 0.74
Overall acceptability 4.1 6 1.09 4.4 6 0.79
1
All values are means 6 SDs. Sensory attributes were rated on
a 5-point hedonic scoring scale (1 = very bad, 5 = very good). Values in
the same row were not significantly different by independent Student’s t test.
FR, fortified rice [normal rice mixed with Ultra Rice]; UFR, unfortified rice.
 RCT OF MFPP-FORTIFIED EXTRUDED RICE IN CHILDREN
FIGURE 1. Flowchart showing details at each stage of the study. FR, fortified rice (normal rice mixed with Ultra Rice); MDM, midday meal; NCHS,
National Center for Health Statistics; UFR, unfortified rice.
there were a total of 166 effective feeding days after excluding
Sundays (35 d), school holidays (35 d), and days when MDM
was not prepared because of meetings of the teaching staff (8 d).
The mean (6SD) number of feeding days was 138 6 23.78 in
the FR group and 133 6 29.33 in the UFR group.
Meal intakes
The intake based on the institutional diet survey and individual
intake from MDM were similar; the intake of rice was ;110 g
and 111 g per child per meal (on a dry-weight basis) and that of
iron was ;2 mg and 21 mg (of which 19 mg were from MFPP)
per child per meal in the UFR and FR groups, respectively. The
meal intakes were comparable at baseline and at 8 mo, within
and between the groups.
Characteristics of the study group
The mean (6SD) age (7.7 6 1.50 y) and the sex-wide dis-
tribution of children were similar in both the groups. The mean
5 of 9
heights and weights were comparable during the study period.
The mean CRP values and the proportion of children with ele-
vated CRP values (CRP 0.8 mg/L) remained similar between
and within groups both at baseline and at 8 mo (Table 2).
Impact on hemoglobin and ferritin
The mean hemoglobin and ferritin concentrations among chil-
dren were comparable between the 2 study groups at baseline. After
8 mo, the mean increase in hemoglobin values in the FR and the
UFR groups was ;1 g/dL. There was a significant (P , 0.001)
difference in the change in mean ferritin concentrations between
groups, with an increase of 8.2 6 2.10 lg/L in the FR group and
a decrease of 3.0 6 1.70 lg/L in the UFR group (Table 2). Similar
changes in hemoglobin and ferritin concentrations were also ob-
served when the data on children with elevated CRP values were
excluded from each group (Figure 2).
To assess the impact of intervention, the change in hemoglobin
and ferritin values were analyzed by the 3 different methods of
regression (Table 3). In the FR group, the increase in ferritin
6 of 9 RADHIKA ET AL
TABLE 2
Nutritional status, iron status, and CRP concentrations in children in the UFR and FR groups at baseline and at 8 mo1
UFR group (n: 65) FR group (n: 63)

Variable Baseline 8-mo Baseline 8-mo

Nutritional status
Height (cm) 121.6 6 11.102 126.3 6 10.95 120.8 6 10.04 125.4 6 9.94
Weight (kg) 19.8 6 4.67 22.8 6 5.77 19.8 6 4.43 22.6 6 5.50
Underweight (%) 30.8 26.2 25.6 19.0
Stunting (%) 12.3 10.8 15.2 14.3
Wasting (%) 22.4 21.5 12.1 12.7
Iron status
Hemoglobin (g/dL) 11.4 6 1.00a 12.5 6 1.01b 11.5 6 1.09a 12.5 6 1.05b
Ferritin (lg/L) 24.4 6 15.30a 21.4 6 13.8a 24.7 6 15.30a 32.9 6 22.03b,4
Ferritin (lg/L)3 20.0 (17.88, 22.13)a 16.3 (14.12, 18.49)a 24.7 (17.43, 21.73)a 32.9 (20.02, 28.31)b,4
CRP
(mg/L) 0.21 6 0.29 0.20 6 0.29 0.24 6 0.32 0.21 6 0.29
0.8 mg/L (%) 7.7 7.7 11.1 7.9
1
All values were comparable at baseline. CRP, C-reactive protein; FR, fortified rice (normal rice mixed with Ultra
Rice); UFR, unfortified rice. Values in the same row with different superscript letters were significantly different from
respective baseline values by paired t test for hemoglobin and Wilcoxon signed rank test for ferritin values: P , 0.001.
2
Mean 6 SD (all such values).
3
Values are geometric means; 95% CIs in parentheses.
4
Significantly different from the UFR group at 8 mo by Wilcoxon Mann-Whitney U test for ferritin values, P , 0.001.

concentrations was significant (P , 0.001), whereas the change observed even after exclusion of the data on children with ele-
in hemoglobin in both the groups was not different by any of the vated CRP concentrations.
3 regression methods.

Changes in prevalence of anemia, ID, and IDA
The prevalence of anemia, ID, and IDA was similar between
the 2 groups at baseline. Over a period of 8 mo, the prevalence of
ID decreased significantly (P , 0.05) from 33% to 14% in the
FR group, whereas it increased marginally in UFR group (from
31% to 37%). Prevalence of anemia decreased significantly
(P , 0.01) in the 2 groups; however, the difference was not
significant between groups. No significant effects of time or
treatment were observed on changes in prevalence of anemia
within and between groups (Figure 3). Similar changes were
DISCUSSION
We have observed in the present study that consumption of
MFPP-fortified extruded rice kernels mixed with normal rice
close to meal preparation for a period of 8 mo through MDM
significantly improved body iron stores and reduced ID among
primary-school children. A significant increase of similar mag-
nitude in the mean hemoglobin concentrations with a consequent
significant decrease in prevalence of anemia was observed in both
the FR and UFR groups. However, despite a clear improvement in
body iron stores in the FR group, any additional impact of in-
tervention on hemoglobin status or on the prevalence of anemia

FIGURE 2. Mean (6SE) changes from baseline in hemoglobin and ferritin concentrations in the FR [fortified rice (normal rice mixed with Ultra Rice] and
UFR (unfortified rice) groups after exclusion of cases with C-reactive protein 0.8 mg/L (n = 52 in the FR group, n = 56 in the UFR group). Bars with
different superscript letters indicate significant differences between groups by the Wilcoxon Mann-Whitney U test: P , 0.001. Hb, hemoglobin.
 RCT OF MFPP-FORTIFIED EXTRUDED RICE IN CHILDREN
TABLE 3
Effect of intervention on hemoglobin and ferritin status evaluated with
different methods of regression analysis
Method of regression analysis Regression coefficient SE
Hemoglobin
Absolute change 20.162 0.145
Analysis of covariance 20.105 0.133
Residual change 20.104 0.132
Ferritin
Absolute change 11.21 2.689
Analysis of covariance 11.31 2.593
Residual change 11.30 2.582
and IDA was obscured by the improvement of these variables in
the UFR group as well. These observations indicate that other
factors beyond additional iron intake had a large influence on the
hemoglobin concentration. Similar results were also observed in
other iron intervention trials that used low-dose iron supplements
in East African children (32) or iron-fortified rice in Mexican
women (15) or Indian children (33). The reasons for these
findings are not clear but could be the result of regular con-
sumption of MDM, thereby improving overall food intakes in
both the groups as a result of supervised meals. Although par-
asitic load was not measured in this study, it is likely that
deworming all of the children before intervention could have
contributed to the improvement in hemoglobin status and thereby
the reduced anemia prevalence in both groups. Moreover, studies
in rural Indian schoolchildren of similar age have indicated a high
prevalence of hookworm infections (34), and a worm load of
approximately 1000 eggs/g feces has been reported among the
majority of the rural populations (35). The association between
intensity of hookworm infection and anemia is well documented
(36), and reducing intestinal parasitic load has been shown to be
beneficial in improving iron status of populations in endemic
areas (37).
It is also clear from this study that consumption of MFPP-
fortified extruded rice kernels in a rice-based meal was more
efficacious in improving body iron stores and ID and less ef-
fective in reducing IDA or improving hemoglobin status. This
7 of 9
could be because of poor upregulation of the absorption of the
small-particle-size MFPP as indicated by Moretti et al (38). The
other reasons could be that only a small percentage of the par-
P value ticipating children had IDA; concurrent inadequacies of other
micronutrients existed, particularly vitamin C, vitamin A, ribo-
0.267
flavin, folic acid, and vitamin B-12, limiting the absorption and
0.431 utilization of iron for hemoglobin synthesis (9–12); inadequate
0.432 duration of intervention; or a combination of these factors. Long-
term follow-up studies would be required to evaluate the effects
,0.001 of the fortification of rice with iron on hemoglobin status, IDA
,0.001 among children, or both. Regular consumption of MDM resulting
,0.001 from supervised meals, thereby improving overall food intake or
deworming all the children before intervention are plausible
possible factors contributing to the improvement in hemoglobin
status and thereby reduced anemia prevalence in the UFR group
and to that of a similar magnitude in the FR group.
The presence of subclinical infection, acute or chronic in-
flammation, or both has been associated with increased serum
ferritin concentrations (39), impaired iron utilization (40), or
both. This may not be the cause in the present study because, even
after excluding the data of children with higher-than-normal CRP
values (an indicator of subclinical infection/inflammation), the
effect of intervention remained significant on ferritin concen-
tration and ID. These results suggest the plausibility of the ob-
served impact to be attributed to the consumption of rice
containing MFPP-fortified extruded rice kernels.
We have shown in this study that MFPP-fortified extruded rice
kernels mixed with normal rice has indistinguishable sensory
qualities compared with unfortified rice in the cooked form as
evaluated among schoolchildren participating in the MDM
program. We have observed that the relative in vitro availability
of iron from FR-MDM was 3 times lower than from UFR-MDM.
However, translating this result into available iron would mean
that children in the FR group would have absorbed ;0.27 mg
iron/d, whereas those in UFR group would have obtained only
;0.07 mg iron/d through MDM. Therefore, despite lower bio-
availability, providing 21 mg iron in FR through a single MDM
is expected to meet approximately one-third (0.273 mg) of the
daily requirements of 0.8 mg for 5–11-y-old children and has

FIGURE 3. Changes in prevalence of anemia, iron deficiency, and iron deficiency anemia in the FR [fortified rice (normal rice mixed with Ultra Rice)] and
UFR (unfortified rice) groups. Values are proportions (n = 63 in the FR group, n = 65 in the UFR group). Bars with different superscript letters indicate
significant differences between groups by the proportion t test: P , 0.01 for iron deficiency only. 1The proportion is significantly different from its respective
baseline value by proportion t test: P , 0.01 for anemia, P , 0.05 for iron deficiency.
8 of 9 RADHIKA ET AL
been efficacious in significantly improving their body iron stores
and reducing ID. Similar observations related to iron absorption
were elucidated in recent studies that used rice fortified with
ferric pyrophosphate (15, 16, 33). Our study is limited in that the
total dietary intake of iron from other sources apart from MDM
was not determined during the intervention period.
In view of these results, further studies are needed to show the
technical feasibility of this approach as a food-fortification
strategy on a large scale. Also, community-based intervention
studies are needed to assess the impact among other vulnerable
population groups such as preschool children, adolescent girls,
pregnant women, and lactating mothers. Use of this technology
through targeted programs such as supplementary feeding pro-
grams and other food security programs of national governments
could be considered to test the effectiveness of this strategy. Large-
scale, community-based effectiveness trials are warranted to
confirm the findings of the present efficacy trial and the potential
effectiveness of this technology with multiple micronutrients.
Simultaneously, there is a need to develop an appropriate tech-
nology for mixing or blending the MFPP-fortified extruded rice
kernels with normal rice and distributing the mixture through fair
price shops in India.
We gratefully acknowledge the financial assistance provided by Department
of Biotechnology (DBT), Government of India. We also thank PATH USA for
providing Ultra Rice premix for the use in the study. We also gratefully acknowl-
edge the help and cooperation extended by PATH India. We are grateful to K
Venkaiah for helping in coding the rice samples, enabling fortification process
and study group randomization; B Pothuraju, C Saibabu, SPV Prasad, JS
Acharya, B Arumugham, M Srinivas, A Rajesh Naik, D Balamani, D Sarala,
and N Anil Kumar for technical assistance; and P Swathi Chitra, K Nalini, P
Lakshmi Kalyani, V Chandra Babu, and M Goud for assistance in the field. We
also thank the principal, teachers, and cooks of the primary school and the par-
ticipating children and their parents who invested their valuable time and effort
in the study.
The authors’ responsibilities were as follows—GNVB and KMN: con-
ceived, supervised, and provided overall guidance for the study; MSR,
RHK, and CGR: participated in and supervised the field implementation
and coordinated with the collaborating division/department; MVVR: carried
out the statistical analysis; PR: carried out all the laboratory support; MSR:
wrote the manuscript; and GNVB and KMN: provided critical revision. All of
the authors contributed to the study design, implementation, data analysis, and
interpretation of results and to the editing and approval of the final manuscript.
None of the authors had a potential conflict of interest related to this study.
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