Double Fortified Salt Delivered Through the Public Distribution System Reduced Risk of Iron Deficiency but Not of Anemia or Iron Deficiency Anemia in Uttar Pradesh, India

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Abstract Objectives Double fortified salt (DFS) with iodine and iron is efficacious in improving anemia, but evidence of effectiveness in large-scale programs is limited. We evaluated a program delivering double fortified salt (DFS) over 12 mo in five districts through the public distribution system in Uttar Pradesh, India on iron status and anemia. Methods Only two (Etawah and Auraiya) of the five intervention districts met the evaluability threshold of 50% DFS utilization chosen as an a priori criterion for endline inclusion. We present findings on cross-sectional survey data collected from 6388 non-pregnant women of reproductive age (WRA) in Etawah and Auraiya, and their two matched adjacent boundary comparison districts. We used generalized linear models that accounted for clustering, with log link function for risk ratio (RR) and identity link function for mean difference, adjusting for matched pairs. Models were adjusted for WRA age, education of WRA and household head, religion and housing. Ferritin levels were inflammation adjusted using the BRINDA regression equation. Results There was no difference in anemia and iron deficiency anemia (IDA) prevalence or in mean hemoglobin concentration between WRA in intervention and comparison districts. However, we observed a 15% lower risk of being iron deficient in intervention areas (RR = 0.85: 95% CI, 0.75–0.98). Additionally, WRA in intervention districts who reported regular use of DFS had 23% lower risk of being iron deficient (RR = 0.77: 95% CI, 0.66–0.93), and those reporting partial use had 20% lower risk (RR = 0.80: 95% CI, 0.66–0.99). There was no difference among non-users (RR = 0.98: 95% CI, 0.88–1.22). Conclusions DFS was effective in reducing risk of iron deficiency, but not anemia or IDA, among WRA. This modest effectiveness may have been in part due to supply chain interruptions over the course of the implementation period (slow start and earlier than planned cessation). We observed a dose responsive effect, with greater risk reductions among regular and partial users than among non-users. To maximize this potential and perhaps extend impacts to anemia or IDA, the program will require: 1) longer duration of exposure, 2) investments in addressing barriers to coverage and utilization, and 3) complementary efforts to address other causes of anemia in this context. Funding Sources Bill & Melinda Gates Foundation.