Trial Using Multiple Micronutrient Food Supplement and its Effect on Cognition

23
Original Article
Trial Using Multiple Micronutrient Food Supplement and
its Effect on Cognition
Malavika Vinod Kumar and S. Rajagopalan1
Trustee, Sundar Serendipity Foundation, Chennai, 1Distinguished Fellow, M S Swaminathan Research Foundation,
Chennai, India
ABSTRACT
Objective. To test the efficacy of a multiple micronutrient food supplement (MMFS) on the nutrition status of school children
and its effect on cognition.
Methods. A MMFS was developed containing chelated ferrous sulphate and microencapsulated vitamin A, B2, B6, B12, folic
acid, niacin, calcium pantothenate, vitaminC, vitamin E, lysine and calcium and the efficacy of the MMFS was assessed in 7-
11 year old school children in Chennai, India by a pre-post test design. In the experimental group (N=51), the food in the school
kitchen was cooked with the MMFS for the residential school children for a period of one year. The control group (N=72)
consisted of day scholars who did not eat at the school. Hemoglobin, red blood cell count and hematocrit were measured at
baseline and at the end of the study (after one year). A battery of 7 memory tests (The personal information test, the Mann-
Suiter Visual memory screen for objects, The digit span forward test, The digit span backward test, The delayed response test,
The Benton Visual Retention Test and The Cattells retentivity test), one test for attention and concentration (Letter cancellation
test) and one test for intelligence (Raven’s coloured progressive matrices) were administered to all the children at baseline
and endline.
Results. It was seen that there was a significant (P<0.05) improvement in the experimental group in hemoglobin, hematocrit
and red cell count whereas in the control group there was a statistically significant decline(P<0.05) in hemoglobin and red
cell count. In 5 tests out of the 7 memory tests and in the letter cancellation test for attention, the mean change in scores in
the experimental group is significantly more (P<0.05) than the control group. There was no significant improvement in the
overall intelligence as seen in the Ravens progressive matrices between the experimental and control groups at endline.
Conclusion. The study shows that the MMFS is effective in improving the nutrition status and cognition in children. [Indian
J Pediatr 2008; 75 (7) : 671-678] E-mail: vinodkumar_m_k@hotmail.com.
Key words : Multiple micronutrients; Supplementation through food; Iron; vitamin A; Bcomplex vitamins; Cognition
It has been observed in developing countries that multiple
micronutrient food supplement (MMFS) was developed
micronutrient deficiencies occur in the poorer segment of
which contained vit A, vit B1, vit B2, vit B6, vit B12, niacin,
the population.1, 2 Among micronutrient deficiencies, iron
folic acid, calcium pantothenate, vit C, vit E, Iron, calcium
and iodine deficiencies affect >30 % of the global
and lysine. If used in daily cooking in the family, it would
population.3 However, the approach to combat
supply all these nutrients to the entire family everyday.
micronutrient deficiencies has been to tackle individual
The present study is undertaken to test the hypothesis
micronutrients, for example supply of iron and folic acid
whether the addition of multiple micronutrients during
tablets to pregnant women, vit A drops to children etc. It
cooking improves the nutrient status and cognition in
has been suggested that supplementation with multiple
school children.
micronutrients may be the best possible way to improve
the nutritional status of the malnourished populations.4
MATERIAL AND METHODS
Keeping all these concepts in mind, a multiple
Correspondence and Reprint requests : Malavika Vinodkumar,
In this study, we have tested the stability of the multiple
PhD, Sundar Serendipity Foundation, 6G Century Plaza, 560-562
micronutrient food supplement(MMFS) during storage,
Anna Salai, Teynampet, Chennai-600018, India. Phone: +91-44-
and during cooking. We have then tested the efficacy of
24349230
the MMFS by using it in all the meals cooked for children
[Received January 20, 2007; Accepted May 5, 2008]
in a residential school for a period of one year and tested
Indian Journal of Pediatrics, Volume 75—July, 2008
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24
M. Vinodkumar and S. Rajagopalan
the biochemical parameters like hemoglobin, red cell
(Wockhardt Ltd Mumbai, India), niacin (Lasons India P
count and hematocrit. We have also tested the memory
Ltd, Mumbai, India) and folic acid (Shree Krishna
and cognition in the children to study the effects of
Pharmaceuticals Ltd, Hyderabad) were coated together
improved nutrition on cognition in children.
with glyceryl stearate (Om Corporation, Mumbai, India).
Coated vit C (Amoli organics, Mumbai, India) was used
Process of manufacture of the MMFS
for the study. Vit E oil (Merck Ltd, Bangalore, India)was
When multiple micronutrients are used, they interact
adsorbed in silica and the powdered product was used.
with each other leading to losses in potency. Iron is stable
Calcium pantothenate and lysine were used without any
and best bioavailable in an acidic pH whereas vit A is
coating. All the above micronutrients were added to
unstable and looses its potency in an acidic environment.
calcium carbonate (Ferrous Minerals and chemicals P Ltd,
To prevent such interactions, the micronutrients are
Mumbai)which served as the carrier. The nutrient
microencapsulated to prevent interactions with each
composition of the MMFS is given in Table 1.
other. All ingredients used were of food grade.
The multiple micronutrient food supplement was
Ferrous sulphate is the most bioavailable form of iron.
manufactured in a ribbon blender (RPM 50)
However, it is well known to interact with many vehicles
(Bhuvaneshwari Engineering, Chennai, India). The
of fortification or with other food ingredients during
homogeneity of the supplement’s micronutrient content
cooking by producing discolorations. Therefore, Ferrous
was established at the manufacturing level by assessing
sulphate monohydrate (Heina Pharma, Mumbai, India)
the micronutrient content at different parts of the ribbon
was chelated by us in our laboratory with chelating
blender. It was found out that the product had a uniform
agents and the absorbtion promoter was further added to
and homogenous distribution of all the micronutrients.
enhance the iron absorbtion. Ferrous Sulphate was
Stability during cooking
chelated with malic acid (Thirumalai Chemicals Ltd,
Ranipet, Tamilnadu) and sodium hexameta phosphate
A study was done to test the stability of all the
(Sulux Phosphates, Mumbai). The acidic pH was
micronutrients during cooking. (Table 1) The assays were
maintained by sodium dihydrogen phosphate (Sulux
carried out initially and after subjecting the
Phosphates, Mumbai) which served as an absorbtion
micronutrients to typical Indian cooking conditions after
promotar. The resultant chelated iron complex was white
adding them to an Indian dish- sambar(lentil soup) and
in color. Vit A (Nicholas Piramal, Mumbai, India) which
cooking for 20 minutes. The required aliquotes from the
was supplied microencapsulated in gumaccacia and
lentil soup were taken for the analysis of micronutrients.
sugar was coated with butylated hydroxy anisole (P.D
Six samples were taken before and after cooking.
Fine Chem, Bangalore, India), butylated hydroxy toluene
Stability during storage
(P.D Fine Chem Bangalore, India) and tocopherol (Merck
Ltd, Bangalore, India) to enhance the stability of vit A.
Samples of the MMFS were stored at 30 degrees C,
Thereafter, it was encapsulated in cellulose acetate
humidity 45%, for 12 months. (Table 1) and stability tests
phthalate (GM.Chemicals, Mumbai, India) to protect it
were done once in 3 months.
form the acidic environment (which is necessary for iron
Dosage of Iron
bioabsorbtion) and coated with a layer of silicone to
provide heat resistance during cooking. The B complex vit
Most of the studies reviewed in literature gave iron in the
B2, B6 (Romeda Chemicals Ltd, Mumbai) and B12
form of ferrous sulphate tablets, ferrous fumerate or other
TABLE 1. Nutrient Composition of the Multiple Micronutrient Food Supplement (MMFS) and Stability of the MMFS During Cooking
and Storage
Ingredient
Nutrient
Nutrient status
Loss in nutrient
Nutrient status
Loss in nutrient
composition
after cooking
after cooking %
after one year
on storage after
for 20 minutes
of storage
one year %
Vitamin A IU/g
1500
1342
10.5
1099
26.7
Vitamin B2 mg/g
1
1
0
1
0
Calcium pantothenate mg/g
1
1
0
1
0
Niacin mg/g
15
15
0
14.94
0.4
Vitamin B6 mg/g
1
1
0
1
0
Folic Acid mcg/gm
100
99.49
0.51
99.5
0.5
Vitamin B12 mcg/gm
1
1
0
1
0
Vitamin E IU/g
30
29.93
0.23
29.9
0.33
Vitamin C mg/g
30
26.6
11.3
22.30
25.6
Iron mg/g
10
10
0
9.97
0.3
Lysine mg/g
250
241.9
3.24
249.56
0.18
Calcium %
15.63
15.63
0
15.63
0
672
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Trial Using Multiple Micronutrient Food Supplement and its Effect on Cognition in Children
hematinics for periods ranging from 2 months to a year.5-
(experimental group) were informed about the use of the
13 The present study is different in that the experimental
MMFS in the cooking of all the meals in the schools,
group children received 10 mg of elemental iron every
periodic deworming and the periodic blood tests. The
day through the multiple micro nutrient food supplement
parents/legal guardians of the day scholars (control
for a period of one year. The iron was in a chelated form
group) were informed about the periodic deworming and
with the biopromotor added. Chelated iron compounds
the periodic blood tests. All the parents/legal guardians
have a much higher bioavailability than inorganic iron
were informed that blood tests would be done in all the
compounds.
children for assessment of anemia and the children with
severe anemia (Hb less than 8g/dl) would be treated for
Bioefficacy Study
the anemia immediately therapeutically. These children
Subjects
were excluded from the study. All the children who were
anemic at the end of the study were treated with ferrous
The Research Design was a pre- post test design with
sulphate tablets with 60mg elemental iron for 3 months.
experimental(N=51) and control (N=72) groups. It was a
randomized controlled trial. The children residing in the
Study Procedure
residential school constituted the experimental group. The
The MMFS was used in all the meals cooked for the
children who lived in communities nearby and attended
children in the experimental group for a period of one
the day school constituted the control group. There was
year. There was no intervention in the control group
no intervention in the children belonging to the control
except for deworming. Deworming was done in both
group except deworming. The school where this study
experimental and control children by giving a tablet of
was conducted was chosen randomly from a list of
albendazole 400 mgs at baseline, after 6 months of
schools that had residential school children and also
intervention and after one year of intervention (end of
admitted day scholars from communities around the
study).Deworming was done to ensure that there are no
school.
worms which compete for the micronutrients and ensures
A survey was conducted on different schools prior to
the intestinal tract is clear for bioabsorbtion of the
randomization and the schools were chosen where there
micronutrients as in other studies.15, 16
were minimum instances of outside cooked food
The MMFS was supplied to the school every month
(unfortified) served to the children and where there were
and the continuous use of the MMFS in all the meals
minimum intervening holidays when the children would
prepared everyday was monitored. The dosage of the
go home and cause a disruption in the study. From this
MMFS was one gram per child per day. Since, the number
list of schools, one school was randomly chosen to
of children was known the MMFS was weighed and
conduct the study.
packed in packets which had to be cut and added to the
Sample size calculation
meals cooked for the day. The MMFS was used in all the
food preparations. It was dissolved in water and added to
In our earlier study studies14 we had observed an increase
liquid food preparations in the final stages of cooking. It
of about 0.5 g/dL in hemoglobin and a standard deviation
was sprinkled as such on solid food preparations. The
of about 0.9. If we assume similar increase in the mean
MMFS did not change the color or taste of any food
and if alpha is assumed to be 0.05 and power assumed to
preparation. It was observed that generally there was no
be 80%, then the sample size required for the
wastage of food prepared in the residential school. All the
experimental group would be 50 children in the
food prepared is consumed.
experimental group and 50 children in the control group.
Earlier studies had shown an increase of about 11 points
Nutritional status
in intelligence tests like the Ravens progressive matrices
Nutritional status was assessed by estimation of
with a standard deviation of about 20. If alpha is assumed
hemoglobin, hematocrit and red blood cell count.
to be 0.05 and power assumed to be 80%, then the sample
Hemoglobin estimation was carried out before the start of
size required for the experimental group would be 50
the study, six months after the commencement and one
children in the experimental group and 50 children in the
year after commencement (end) of the study. The
control group.
hematocrit and red blood cell count were done before the
The study was approved by the Institutional Ethics
study began (base line) and at the end of one year of the
committee also referred to as the Institutional Review
study (end).
Board of Sundar Serendipity Foundation and the Doctoral
Blood collection, storage and laboratory analysis
committee of M.S.Swaminathan Research Foundation.
Informed written consent was obtained from the School
2 ml of venous blood was drawn from each child. The
Director and informed oral consent was obtained from the
blood was transferred into vials which had EDTA as
parents/legal guardians of all the children. The parents/
anticoagulant. The tests for hemoglobin, hematocrit and
legal guardians of the children in the residential school
red cell counts were carried out in the sample within a
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26
M. Vinodkumar and S. Rajagopalan
few hours of blood collection. The blood samples were
which shows that it is a homogenous and comparable
transferred to the laboratory within 2 hours of collection
group of children.
at the school. Hemoglobin was estimated by
There were no children in both the experimental and
cyanamethemoglobin method.17 Hematocrit was
control groups whose hemoglobin was more than 12 g/
estimated by centrifuging blood in wintrobe tubes.17 Red
dl. Therefore, this study has no non-anemic controls.
blood cell count was done by counting the cells using the
neubauer counting chamber.17 Hemoglobin was done in
Description of the memory tests
duplicate for all the samples. In hematocrit and RBC
count estimations, in 10% of the samples the test was done
Personal information: This test is a measure of remote
twice for validation.
memory which constitutes recall of past events of
personal life. This is adopted from Wechsler memory
Statistics
scale18 and PGI memory scale.19
Statistical analysis was done using SPSS 11.0 (SPSS Inc.,
Digit span: This subtest is taken from Wechsler memory
Chicago IL, USA) and Microsoft Excel 2000 (Microsoft
scale.18 This comprises of span for digits forward and
Corp., Seattle WA, USA). Repeat measures Analysis of
backward. The maximum number of digits used in the
variance was done to compare the effects of group*time
series is limited to 9. This test is a measure of attention
for hemoglobin, hematocrit, Red blood cell count and all
and concentration.
the cognitive tests. Students t test was done to analyze
the effects between groups and paired students t tests was
Delayed response learning : This subtest is taken from
done to analyze the effects within groups.
Wechsler memory scale.18 This essentially requires the
ability to delay the previous response in order to arrive at
Tests for Memory, Concentration and IQ
a final solution. This measures delayed memory span.
Iron deficiency anemia is one of the important causes of
There are 4 sets of fairly simple arithmetical problems.
lowered concentration abilities and impaired memory
Each problem consists of 2 parts presented one after the
skills. The present study involves giving a battery of
other. In the first part a simple arithmetical problem is
memory tests and concentration tests to see if there is an
given, the child solves it and keeps the result in mind and
improvement in these memory and concentration abilities
then solves the second part of the problem 10 seconds
when anemia is reduced through the nutritive
later incorporating the result from the previous part.
intervention.
Mann-Suiter Visual memory screen for objects
To test the memory in children we used the Children’s
(picture recall test): This is designed to assess the ability
memory test developed by NIMHANS (National institute
to revisualise pictures of common objects presented in
of mental health and neurological sciences, Bangalore,
groups. There are 4 cards. On the first card there are 2
India). Though the NIMHANS memory test had verbal
pictures and it was exposed for 2 seconds. The second
and nonverbal components, the children we were dealing
card has 3 pictures and it was exposed for 3 seconds, the
with are rural children who studied in the regional
3rd card had 4 pictures and the 4th card had 5 pictures
language and not in English. The verbal component of the
and it was exposed for 4 seconds and 5 seconds
NIMHANS memory test was in English. We therefore,
respectively. The child was expected to recall the pictures
chose to give the children only the nonverbal component
in the same sequence. This test measures short term
of the test where English language was not a barrier. This
visual memory.20
was possible because each test was individually scored.
Benton Visual Retention Test (BVRT) : This test is
The individual scoring also helps us find out in which
designed to assess visual perception, Visual memory and
aspects of memory does improvement take place when
visuo-constructive abilities. There are 10 cards. Each card
iron and other micronutrients are given.
is exposed for 10 seconds and the child is asked to
In both the experimental and control groups, a battery
reproduce the design from memory. This test measures
of tests developed and standardized on Indian children to
the visuo spatial perception, visual and verbal
suit Indian conditions by NIMHANS to assess memory
conceptualization and immediate memory span.21
and concentration was administered. The children in both
the experimental and control groups were also
Cattells retentivity test
administered the Ravens Children’s Progressive Matrices,
It consists of complex and unfamiliar designs of irregular
a test to assess the IQ of these children and a letter
geometric figures which cannot elicit any verbal
cancellation test to assess concentration. These tests were
associations. On a card 10 geometrical figures are
administered before the start of the study (base line) and
presented for 30 seconds, after a 2 minute pause and from
after one year of nutrient intervention. The results of the
the second card the child has to recognize the geometrical
Ravens Children’s Progressive Matrices at base line
figures which he has already seen in the first card. This
showed that there was no significant difference in the IQ
measures the visual recall for irregular geometrical
of the children in the experimental and control group
674
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Trial Using Multiple Micronutrient Food Supplement and its Effect on Cognition in Children
designs and delayed memory span.22
TABLE 2. Baseline Characteristics of the Experimental and
Control Groups*
Letter cancellation test
Baseline Characteristics
Experimental group
Control group
This test is a measure of concentration.23 The children are
given the test which has many alphabets typed out in
rows and the children are instructed to score out the A’s
Age in years (Mean ± SD)
9.35 ± 1.12
9.03 ± 1.1
Height in cms (Mean ± SD)
120.94 ± 10.02
124.16 ± 8.5
and E’s within a period of 2 minutes. If the child has
Weight in Kg (Mean ± SD)
20.37 ± 4.49
21.8 ± 4.42
omitted to score a letter or if she has scored a letter which
Male
12
28
is not A or E, it is considered as a wrong. If the child has
Female
39
44
correctly struck out an A or E it is considered as right. The
Intelligence test-Ravens
final score is obtained by subtracting the total of wrongs
Children’s Progressive
Matrices
from the totals of rights.
(Mean Scores ± SD)
28.88 ± 30.9
32.26 ± 29.49
Ravens coloured progressive matrices
Socio economic status
Monthly Family income
This is an IQ test to measure intelligence in children.24
In Rupees (Mean ± SD)
1670 ± 447
1730 ± 400
The same tests were administered before the intervention
*No Significance (P<0.05) between the experimental and control
program and repeated after one year of nutritive
groups in all the above baseline characteristics.
intervention.
hence can be compared for cognitive outcomes. These
Scoring for cognitive studies
results are presented in Table 2.
Based on the age of the child the raw score is converted to
Dietary assessment of the households of a sub-sample
the percentile score, as per the standardization done by
of control group(N=25 ) showed that there were no
NIMHANS on Indian children. Therefore, age matching
significant differences in the nutrient intake of both the
between the experimental and control group is taken care
experimental and control groups. The dietary
of in the scoring itself. The score obtained at the end of the
consumption was calculated by assessing the details of
study is subtracted from the initial score to get the change
food consumed in the past 3 days in the subsample of the
in score. The comparison is made between the experiment
control group households and in the residential school
and control with regard to the change in scores to offset
which constituted the experimental group.
the increment due to familiarity in the retest.
Efficacy Study-Biochemical Parameters: There was a
In earlier studies in India,25 it was seen that there were
significant (P<0.05) improvement in the experimental
increment in scores in arithmetic and digit span subtests
group in hemoglobin, hematocrit and red cell count
in the placebo group also. In a Thailand study,26all the
whereas in the control group there was a statistically
children improved their scores at follow-up regardless of
significant decline(P<0.05) in hemoglobin and red cell
their iron status. It can be reasoned out that there is
count. (Table 3)
always a familiarity element when a retest is given and
this familiarity leads to improvement in scores in the
Cognitive study
control also. To offset this improvement in scores due to
We find that out of the 7 memory tests administered, in 5
familiarity, the endline score is subtracted from baseline
of the tests, namely the Benton Visual Retention Test, the
score and the change in scores is taken to consider
Cattells retentivity test, Mann-Suiter Visual memory
whether there is an improvement of the experimental
screen for objects (picture recall test), Delayed Response
group over the control.
Learning test and the digit forward test , the mean change
in scores in the experimental group is significantly
RESULTS
more(P<0.05) than the control group. Only in the personal
information test and the digit backward test, the change
in scores in the experimental group is not statistically
Baseline characteristics of the experimental and control
significant. In the letter cancellation test which is a
groups
measure of attention and concentration too the mean
The experimental and control groups of children were
change in score in the experimental group is significantly
similar in age, intelligence, nutrient intake and socio-
more than (P<0.05) the control. There are no significant
economic status. Analysis of the results of the intelligence
differences with respect to the intelligence test-the
tests showed that there was no statistical difference
Raven’s coloured progressive matrices in the
between the experimental and control groups with
experimental and control group. This is understandable as
reference to the baseline scores of the Ravens progressive
there usually will not be an improvement in the overall
matrices showing that the experimental and control
intelligence but only in certain specific areas of memory
groups were comparable to intelligence at baseline and
which is measured by the memory tests. (Table 4)
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M. Vinodkumar and S. Rajagopalan
TABLE 3. Biochemical Status of the Experimental and Control Groups over a Period of One Year
Experimental group n=51
Control group n=72
Base
Endline
Base
Endline
line
after one year
line
after one year
Hemoglobin gms/dl*
9.98 ± 0.75a
10.23 ± 0.60 a
10.43 ± 0.83b
10.13 ± 0.74 b
(9.77 - 10.19)
(10.07 - 10.4)
(10.23 - 10.63)
(9.95 -10.31)
Hematocrit l/l*
0.2872 ± 0.018a
0.3000 ± 0.021 a
0.3062 ± 0.022
0.3013 ± 0.023
(0.2823 - 0.2922)
(0.2941 - 0.3059)
(0.3010 - 0.3115)
(0.2958 -0.3069)
Red blood cells million/cmm
3.24 ± 0.22 a
3.43 ± 0.27a
3.62 ± 0.49 b
3.47 ± 0.28 b
(3.18 - 3.30)
(3.35 - 3.50)
(3.5 -3.74)
(3.4 -3.53)
a: significant improvement(P<0.05) from baseline to endpoint
b: significant decrease(P<0.05) from baseline to endpoint
Data given as mean+-SD
* ANOVA repeat measures Significant (P<0.05) group*time
95% Confidence interval for mean with lower bound and upper bound values given in brackets
TABLE 4. Results Cognition: Change in Scores
Name of the test
Test measures
Experiment n=51
Control
mean
n=72 mean
Benton Visual Retention Test (BVRT)*
memory
13.73 ± 4.52a
3.61 ± 2.14a
Cattells retentivity test*
memory
6.28 ± 3.11a
-0.83 ± 2.82a
Mann-Suiter Visual memory screen for objects (picture recall test)*
memory
15.29 ± 3.83a
5.62 ± 2.21 a
Delayed Response Learning test*
memory
14.51 ± 3.67 a
5.49 ± 2.19 a
Personal Information test
memory
20.59 ± 6.75
15.35 ± 3.49
Digit Forward test*
memory
3.14 ± 2.20a
-2.11 ± 1.76 a
Digit Backward test
memory
0.39 ± 3.12
-0.85 ± 3.03
Letter cancellation test*
Attention and concentration
11.78 ± 1.34 a
5.50 ± 1.06 a
Ravens coloured progressive matrices
intelligence
11.58 ±2.88
11.08 ± 2.53
a: significant improvement of the experimental group (P<0.05) over the control.
* ANOVA repeat measures significant (P<0.05) group*time
Data given as mean ± standard error of mean (SEM )
DISCUSSIONS
iron supplementation programmes may be beneficial and
There is strong evidence that among school aged children,
have immediate effects.
initially lower scores on tests of cognition or school
Anemia causes poor attentiveness, poor memory and
achievement due to iron deficiency anemia can be
poor academic performance in school age children. These
improved and in some cases reversed after iron
children are often disruptive, irritable, restless and show
treatment.25,26 One reason for this evidence is a large
behavioral abnormalities like lack of attention, fatigue,
number of placebo controlled trials, which are able to pick
insecurity and reduced learning ability. Poor attention
up treatment effects. Another reason might be the
span, memory and concentration as well as concept
increased sensitivity of the tests used. It could also be that
acquisition leading to poor school performance have been
the effects of iron deficiency in school aged children are
attributed to anemia during this phase of critical learning.
more transitory than in infants and are thus more
Restoration of hemoglobin levels to normal by hematinic
responsive to the effects of iron treatment. Most of the
supplementation, (only iron and iron and folic acid)
studies 25,26 showed significant improvement in cognitive
resulted in significant improvements in over all IQ stores
function or educational achievement of the children who
as well as in tests involving specific abilities of attention
received iron supplements compared to those who
and concentration in 4-6 year old and 6-15 year old
received the placebo.
children. 8,27
These results are in contrast with those obtained in
We find that when the MMFS is used in cooking for a
infants where the benefits of treatment are rarely
period of one year, it results in significant improvement in
observed. The adverse effects on cognitive and
the hemoglobin, hematocrit and red cell count status of
educational test performance due to iron deficiency
the children in the experimental group where as there is
anemia in preschool and school aged children appear
a significant decrease in hemoglobin and red cell count
more transitory in nature than the effects on development
and a nonsignificant change in hematocrit of the control
on infants and imply that treatment of iron deficiency
group of children. When the cognitive tests are
anemia in preschool and school aged children through
administered, we find that in 5 memory tests out of 7 tests
676
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Trial Using Multiple Micronutrient Food Supplement and its Effect on Cognition in Children
administered, and in the letter cancellation test which
In conclusion the multiple micronutrients in the
measures attention and concentration, we find that the
MMFS has significantly (P<0.05)improved the
change in scores in the experimental group is significantly
hemoglobin, hematocrit and red cell count and
higher(P<0.05) than the control. Thus the improvement in
concurrently improved the scores of cognitive tests in the
iron has resulted in concomitant increase in the cognitive
experimental group where the MMFS was used , thus
parameters in the experimental group of children.
establishing the efficacy of the MMFS in combating
multiple micronutrient deficiencies. This study has been
Improvement in the cognitive parameters when
done in a residential school and the delivery of multiple
anemia was tackled by iron supplementations has been
micronutrients through supplementation during cooking
demonstrated by other workers.8, 13, 25, 26, 28-31
has been found useful. Studies need to be further
All the above studies have given iron as ferrous
undertaken to test the acceptability of this method of
sulphate tablets or other hematinics for a period ranging
multiple micronutrient delivery by the community and to
from 2-8 months. The present study is different in that the
test whether this improves nutritional status and
iron source is 10 mg of chelated iron given per day ,for a
cognition in children in community settings.
year, through the multiple micronutrient food
Acknowledgements
supplement, which was added to the food during
cooking.
We wish to acknowledgement the funding received from Sundar
Serendipity Foundation than enabled us to conduct the study. We
The iron sources used in earlier studies were usually
also acknowledge with thanks the guidance given by Professor
inorganic compounds like ferrous sulphate , ferrous
M.S.Swaminathan , Chairman, MS Swaminathan Research
fumerate etc.6-9 Since the Indian diet is high in phytates
Foundation who guided and supported us throughout the study.
which inhibit iron absorbtion, it was felt that the iron
source has to be bioavailable despite the presence of
phytates and one way of doing this is to use highly
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