ABSTRACT
Background:
Anemia remains a significant public health problem among young children in India despite long-standing supplementary nutrition interventions under the Integrated Child Development Services (ICDS). Balamrutham, a fortified food provided through Anganwadi Centers, aims to improve nutritional and biochemical outcomes; however, evidence of its effectiveness under routine program conditions is limited. This study assessed the burden of anemia and iron deficiency among children attending AWCs and examined the association between Balamrutham consumption and anemia-related biochemical parameters.
Methods:
A community-based cross-sectional mixed-methods study was conducted among 230 children aged 1–6 years attending 23 AWCs in rural Andhra Pradesh. Sociodemographic, feeding, and dietary information were collected using a structured questionnaire. Anthropometric and biochemical assessment, including hemoglobin, serum ferritin, and serum iron was performed. Quantitative data were analyzed using descriptive statistics and logistic regression analysis. Qualitative data on barriers to Balamrutham consumption were collected through in-depth interviews and analyzed thematically.
Results:
Among 230 children, 51 (22.2%) were consuming Balamrutham. The overall prevalence of anemia was 85.1%, with moderate anemia most common (57.8%). Low serum ferritin and low serum iron were observed in 47.0% and 44.8% of participants, respectively. Balamrutham consumption was not significantly associated with hemoglobin, serum ferritin, or serum iron levels. On multivariable logistic regression, younger age (1–3 years) and infrequent non-vegetarian food intake were independently associated with low ferritin levels. Thematic analysis identified five key barriers to Balamrutham utilization: perceived adverse effects, poor child acceptability, parental misconceptions, logistical constraints, and intra-household sharing.
Conclusion:
Despite the availability of fortified supplementary nutrition, inconsistent and inadequate consumption limited its measurable biochemical impact. Enhancing awareness, adherence, and implementation is key to improving ICDS nutrition outcomes.
Keywords: Anemia, Anganwadi centers, food fortification, iron deficiency anemia, preschool children
Introduction
Anemia remains a major global public health problem among young children in India, with about 67% prevalence in children under five, particularly in rural areas.[1,2,3] It is multifactorial, commonly resulting from iron and B12 deficiency, infections, and poor dietary practices.[4] The Integrated Child Development Services (ICDS) program provides fortified supplementary nutrition through Anganwadi Centers to address this burden.[5,6] However, evidence on its effectiveness under routine program conditions remains limited. This study assesses the impact of fortified foods on hemoglobin levels, as well as utilization patterns and barriers to consumption, to inform policymakers on program delivery improvements and strengthen anemia control strategies. The findings are expected to benefit participants by enabling early identification of anemia, improving caregiver awareness regarding optimal feeding practices, and supporting targeted nutritional interventions at the community level.
Materials and Methods
This community-based cross-sectional mixed-methods study was conducted in rural Andhra Pradesh among children aged 1–6 years attending 23 Anganwadi Centers across eight villages. Based on the NFHS-5 prevalence (67.1%), the calculated sample size was 174, which was increased to 230 to account for clustering and non-response.[3]
Simple random sampling was used. Lists of eligible children were obtained from centers, and 10 children per center were randomly selected. Children with chronic illnesses or congenital disorders were excluded. Written informed consent was obtained from parents or guardians, and ethical approval was obtained from the Institutional Ethics Committee before study initiation. Data were collected using a structured questionnaire on sociodemographic characteristics, feeding practices, dietary intake, and WASH indicators. Anthropometry included weight, height, and MUAC using standard equipment. Hemoglobin was measured using a portable hemoglobinometer, and venous samples were analyzed for serum ferritin and serum iron in a laboratory maintaining cold-chain transport. Qualitative data on barriers to supplement use were collected through 20 in-depth interviews (mothers, workers, helpers) and analyzed thematically. Data were analyzed using SPSS version 29. Continuous variables were summarized using mean ± SD and categorical variables using frequencies and percentages. Associations were assessed using Chi-square tests. Variables with P < 0.20 were included in multivariable logistic regression. P < 0.05 was considered statistically significant.
Results
Out of a total of 230 children, 51 (22.2%) were actively receiving Balamrutham, while the remaining 179 (77.8%) were non-recipients. Sociodemographic characteristics did not differ significantly between recipients and non-recipients (all P > 0.05) except age of child with serum ferritin levels; low ferritin was more common among children aged 1–3 years compared to those aged ≥4 years (53.3% vs 39.8%; P = 0.04) [Table 1]. As depicted in Figure 1a, moderate anemia was the predominant category 133 (57.8%), followed by severe 33 (14.3%) and mild anemia 30 (13.0%). Low serum ferritin 108 (47.0%) and low serum iron 103 (44.8%), as illustrated in Figure 1b. Indicators of undernutrition were also substantial, with 55 (23.9%) of children being underweight and 60 (26.1%) stunted [Figure 1c]. On bivariate analysis, Early initiation of complementary feeding (P < 0.001), shorter duration of Anganwadi center food consumption (P = 0.009), interruption of center food intake (P = 0.026), and low intake of green leafy vegetables (P = 0.036) were significantly associated with anemia [Tables 2 and 3]. No significant associations were observed between serum ferritin levels and feeding-related, nutrition, and Anganwadi-related factors (all P > 0.05). In multivariable logistic regression, Children aged 1–3 years had significantly higher odds of low ferritin than those aged ≥4 years (AOR = 1.97, 95% CI: 1.12–3.45; P = 0.018). Consumption of non-vegetarian food only once weekly was also independently associated with low ferritin (AOR = 2.39, 95% CI: 1.26–4.53; P = 0.008). But, Balamrutham supplement intake showed no independent association with ferritin status (AOR = 0.83, 95% CI: 0.42–1.62; P = 0.57) [Table 4]. Multivariable modelling for anemia was not performed due to the small number of non-anemic individuals, which precluded stable model estimation. Thematic analysis of in-depth interviews identified five key barriers to Balamrutham utilization: perceived adverse effects, poor child acceptability, caregiver misconceptions, logistical constraints, and intra-household sharing. Representative quotes and categories for each theme are presented in Table 5.
Table 1.
Sociodemographic characteristics of the study participants according to Balamrutham consumption, serum ferritin and anemia (n=230)
| Variable | Category | Balamarutham | χ² | P | Serum Ferritin | χ² | P | Anemia | χ² | P | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|
|||||||||||
| Not taken (n=179) | Taken (n=51) | Normal (n=122) | Low (n=108) | Present (n=196) | Absent (n=34) | ||||||||
| n (%) | n (%) | n (%) | n (%) | n (%) | n (%) | ||||||||
| Age group | 1–3 years | 93 (52.0) | 29 (56.9) | 0.38 | 0.53 | 57 (46.7) | 65 (53.3) | 4.17 | 0.04 | 103 (52.5) | 19 (55.8) | 0.13 | 0.72 |
| ≥4 years | 86 (48.0) | 22 (43.1) | 65 (53.3) | 43 (39.8) | 93 (47.5) | 15 (44.2) | |||||||
| Gender | Male | 110 (61.1) | 22 (44.0) | 1.23 | 0.26 | 64 (52.6) | 54 (50.0) | 0.02 | 0.86 | 94 (48.0) | 16 (47.1) | 1.18 | 0.89 |
| Female | 69 (38.9) | 29 (56.0) | 58 (47.4) | 54 (50.0) | 102 (52.0) | 18 (52.9) | |||||||
| Class of enrolment | Anganwadi | 142 (79.3) | 44 (86.3) | 1.18 | 0.75 | 84 (68.9) | 89 (82.4) | 1.45 | 0.69 | 146 (74.5) | 26 (76.5) | 11.10 | 0.19 |
| LKG/UKG/Primary | 37 (20.7) | 7 (13.7) | 38 (31.1) | 19 (17.6) | 50 (25.5) | 8 (23.5) | |||||||
| Father’s education | Below high school | 41 (22.9) | 14 (27.5) | 0.45 | 0.50 | 26 (21.3) | 29 (26.9) | 0.96 | 0.32 | 47 (24.0) | 8 (23.5) | 3.31 | 0.19 |
| High school and above | 138 (77.1) | 37 (72.5) | 96 (78.7) | 79 (73.1) | 149 (76.0) | 26 (76.5) | |||||||
| Mother’s education | Below high school | 33 (18.4) | 10 (19.6) | 0.03 | 0.85 | 24 (19.7) | 19 (17.6) | 0.16 | 0.68 | 38 (19.4) | 5 (14.7) | 5.35 | 0.07 |
| High school and above | 146 (81.6) | 41 (80.4) | 98 (80.3) | 89 (82.4) | 158 (80.6) | 29 (85.3) | |||||||
| Type of family | Joint | 56 (31.3) | 15 (29.4) | 0.06 | 0.79 | 40 (32.8) | 31 (28.7) | 0.44 | 0.50 | 60 (30.6) | 11 (32.4) | 0.55 | 0.76 |
| Nuclear | 123 (68.7) | 36 (70.6) | 82 (67.2) | 77 (71.3) | 136 (69.4) | 23 (67.6) | |||||||
| Number of siblings | 0 | 32 (17.9) | 9 (17.6) | 1.28 | 0.52 | 21 (17.2) | 20 (18.5) | 0.39 | 0.82 | 38 (19.4) | 3 (8.8) | 13.6 | 0.009 |
| 1 | 127 (70.9) | 39 (76.5) | 90 (73.8) | 76 (70.4) | 142 (72.4) | 24 (70.6) | |||||||
| ≥2 | 20 (11.2) | 3 (5.9) | 11 (9.0) | 12 (11.1) | 16 (8.2) | 7 (20.6) | |||||||
| WASH score* | Median (IQR) | 12 (11–14) | 12 (10–14) | U=4415 | 0.71 | 11 (10–12) | 12 (11–13) | U=6013 | 0.24 | 12 (10-14) | 11.5 (10-13) | U=3200 | 0.70 |
| Standard of living | Low | 13 (7.3) | 7 (13.7) | 2.09 | 0.14 | 10 (8.2) | 10 (9.3) | 0.08 | 0.77 | 16 (8.2) | 4 (11.8) | 0.65 | 0.72 |
| Medium | 166 (92.7) | 44 (86.3) | 112 (91.8) | 98 (90.7) | 180 (91.8) | 30 (88.2) | |||||||
Values are expressed as n (%), unless otherwise indicated. WASH score expressed as median (interquartile range). WASH=Water, Sanitation, and Hygiene
Figure 1.
Hematological and anthropometric profile of children aged 1–6 years attending Anganwadi Centers (N = 230) (a) Bar graph showing distribution of study participants by anemia severity, (b) Bar graph showing distribution of study participants by Serrum ferritin and total iron level, (c) Bar graph showing distribution of study participants by stunting and underweight
Table 2.
Feeding-related characteristics of the study participants based on ferritin and anemia status (n=230)
| Variable | Category | Serum Ferritin | χ² (df) | P | Anemia | χ² (df) | P | ||
|---|---|---|---|---|---|---|---|---|---|
|
|
|
||||||||
| Normal (n=122) | Low (n=108) | Present (n=196) | Absent (n=34) | ||||||
| n (%) | n (%) | n (%) | n (%) | ||||||
| Albendazole consumption | Yes | 109 (89.3) | 91 (84.3) | 1.31 (1) | 0.25 | 168 (85.7) | 32 (94.1) | 1.84 (1) | 0.40 |
| No | 13 (10.7) | 17 (15.7) | 28 (14.3) | 2 (5.9) | |||||
| IFA intake under WIFS | Yes | 87 (71.3) | 70 (64.8) | 0.84 (1) | 0.35 | 134 (68.4) | 22 (64.7) | 0.77 (1) | 0.68 |
| No | 35 (28.7) | 38 (35.2) | 62 (31.6) | 12 (35.3) | |||||
| Exclusively breastfed | Yes | 116 (95.1) | 103 (95.4) | 0.14 (1) | 0.70 | 185 (94.4) | 33 (97.1) | 0.44 (1) | 0.80 |
| No | 6 (4.9) | 5 (4.6) | 11 (5.6) | 1 (2.9) | |||||
| Complementary feeding initiation | Before 1 year | 112 (91.8) | 100 (92.6) | 0.92 (2) | 0.62 | 29 (14.8) | 5 (14.7) | 0.18 (1) | 0.91 |
| At 1 year | 8 (6.6) | 4 (3.7) | 167 (85.2) | 29 (85.3) | |||||
| After 1 year | 3 (2.5) | 3 (2.8) | 180 (91.8) | 32 (94.1) | 38.6 (2) | <0.001 | |||
| Prelacteal feed given | Yes | 20 (16.4) | 14 (13.0) | 0.53 (1) | 0.46 | 11 (5.6) | 1 (2.9) | ||
| No | 102 (83.6) | 94 (87.0) | 5 (2.9) | 1 (2.9) | |||||
| Meals per day | 1 | 10 (8.2) | 5 (4.6) | 5.73 (3) | 0.12 | 13 (6.6) | 2 (5.9) | 1.72 (3) | 0.94 |
| 2 | 20 (16.4) | 29 (26.9) | 42 (21.4) | 7 (20.6) | |||||
| 3 | 86 (70.5) | 72 (66.7) | 134 (68.4) | 25 (73.5) | |||||
| ≥4 | 6 (4.9) | 2 (1.9) | 7 (3.6) | 0 (0.0) | |||||
| Fixed meal schedule | Yes | 28 (23.0) | 30 (27.8) | 0.78 (1) | 0.37 | 47 (24.0) | 11 (32.4) | 1.65 (1) | 0.44 |
| No | 94 (77.0) | 78 (72.2) | 149 (76.0) | 23 (67.6) | |||||
Values are expressed as n (%). IFA- Iron and Folic Acid; WIFS-Weekly Iron and Folic Acid Supplementation
Table 3.
Nutrition- and Anganwadi food–related characteristics of the study participants according to ferritin and status (n=230)
| Variable | Category | Serum Ferritin | χ² (df) | P | Anemia | χ² (df) | P | ||
|---|---|---|---|---|---|---|---|---|---|
|
|
|
||||||||
| Normal (n=122) | Low (n=108) | Present (n=196) | Absent (n=34) | ||||||
| n (%) | n (%) | n (%) | n (%) | ||||||
| Duration of AWC food consumption | <1 year | 20 (18.5) | 17 (13.9) | 1.11 (2) | 0.57 | 33 (16.8) | 4 (11.8) | 9.53 (1) | 0.009 |
| 6–12 months | 27 (25.0) | 29 (23.8) | 54 (27.6) | 2 (5.9) | |||||
| >1 year | 61 (56.5) | 76 (62.3) | 109 (55.6) | 28 (82.3) | |||||
| Days of AWC food consumed | >4 days/week | 25 (23.1) | 26 (21.3) | 0.11 (1) | 0.73 | 46 (23.5) | 5 (14.7) | 1.42 (1) | 0.49 |
| ≤4 days/week | 83 (76.9) | 96 (78.7) | 150 (76.5) | 29 (85.3) | |||||
| Ever stopped AWC food consumption | Yes | 21 (19.4) | 25 (20.5) | 0.03 (1) | 0.84 | 45 (23.0) | 1 (2.9) | 7.26 (1) | 0.02 |
| No | 87 (80.6) | 97 (79.5) | 151 (77.0) | 33 (97.1) | |||||
| Green leafy vegetable consumption | Once a week | 26 (24.1) | 31 (25.4) | 1.04 (2) | 0.59 | 54 (27.6) | 3 (8.8) | 10.3 (2) | 0.03 |
| 2–4 times/week | 72 (66.7) | 84 (68.9) | 125 (63.8) | 31 (91.2) | |||||
| Daily | 10 (9.3) | 7 (5.7) | 17 (8.6) | 0 (0.0) | |||||
| Pulses consumption | Once a week | 7 (6.5) | 10 (8.2) | 1.50 (2) | 0.47 | 16 (8.2) | 1 (2.9) | 6.81 (2) | 0.14 |
| 2–4 times/week | 86 (79.6) | 101 (82.8) | 154 (78.6) | 33 (97.1) | |||||
| Daily | 15 (13.9) | 11 (9.0) | 26 (13.3) | 0 (0.0) | |||||
| Fruits consumption | Once a week | 10 (9.3) | 6 (4.9) | 4.64 (2) | 0.09 | 15 (7.7) | 1 (2.9) | 8.01 (2) | 0.09 |
| 2–4 times/week | 53 (49.1) | 49 (40.2) | 92 (46.9) | 10 (29.4) | |||||
| Daily | 45 (41.7) | 67 (54.9) | 89 (45.4) | 23 (67.6) | |||||
| Milk consumption | Once a week | 4 (3.7) | 3 (2.5) | 0.36 (2) | 0.83 | 6 (3.1) | 1 (2.9) | 5.53 (2) | 0.24 |
| 2–4 times/week | 17 (15.7) | 21 (17.2) | 33 (16.8) | 5 (14.7) | |||||
| Daily | 87 (80.6) | 98 (80.3) | 157 (80.1) | 28 (82.4) | |||||
| Egg consumption | Once a week | 6 (5.6) | 5 (4.1) | 0.30 (2) | 0.85 | 11 (5.6) | 0 (0.0) | 7.97 (2) | 0.09 |
| 2–4 times/week | 37 (34.3) | 44 (36.1) | 73 (37.2) | 8 (23.5) | |||||
| Daily | 65 (60.2) | 73 (59.8) | 112 (57.1) | 26 (76.5) | |||||
| Non-vegetarian food consumption | Once a week | 84 (77.8) | 78 (63.9) | 5.64 (2) | 0.06 | 139 (70.9) | 23 (67.6) | 0.94 (2) | 0.92 |
| 2–4 times/week | 22 (20.4) | 42 (34.4) | 54 (27.6) | 10 (29.4) | |||||
| Daily | 2 (1.9) | 2 (1.6) | 3 (1.5) | 1 (2.9) | |||||
| Packaged food consumption | Once a week | 70 (64.8) | 76 (62.3) | 0.59 (2) | 0.74 | 122 (62.2) | 24 (70.6) | 3.53 (2) | 0.47 |
| 2–4 times/week | 32 (29.6) | 41 (33.6) | 64 (32.7) | 9 (26.5) | |||||
| Daily | 6 (5.6) | 5 (4.1) | 10 (5.1) | 1 (2.9) | |||||
Associations were assessed using the Chi-square test. P<0.05 is considered statistically significant
Table 4.
Univariate and multivariable logistic regression analysis for factors associated with low ferritin levels among children aged 1–6 years (n=230)
| Variable | Category | Crude OR (95% CI) | P | Adjusted OR (95% CI) | P |
|---|---|---|---|---|---|
| Age category | ≥4 years (Ref) | 1.00 | — | 1.00 | — |
| 1–3 years | 1.72 (1.02–2.91) | 0.04 | 1.97 (1.12–3.45) | 0.02 | |
| Meals per day | 3 meals/day (Ref) | 1.00 | — | 1.00 | — |
| 1 meal/day | 0.59 (0.19–1.80) | 0.35 | 0.47 (0.14–1.54) | 0.21 | |
| 2 meals/day | 1.71 (0.89–3.27) | 0.11 | 1.55 (0.78–3.06) | 0.21 | |
| ≥4 meals/day | 0.20 (0.02–1.67) | 0.14 | 0.17 (0.02–1.52) | 0.11 | |
| Pulse consumption | 2–4 times/week (Ref) | 1.00 | — | 1.00 | — |
| Once/week | 0.60 (0.20–1.82) | 0.36 | 0.60 (0.20–1.82) | 0.36 | |
| Daily | 1.44 (0.61–3.40) | 0.41 | 1.44 (0.61–3.40) | 0.41 | |
| Non-vegetarian food consumption | 2–4 times/week (Ref) | 1.00 | — | 1.00 | — |
| Once/week | 2.06 (1.13–3.75) | 0.02 | 2.39 (1.26–4.53) | 0.01 | |
| Daily | 1.91 (0.25–14.49) | 0.53 | 2.98 (0.36–24.60) | 0.31 | |
| Receiving fortified foods | Yes (Ref) | 1.00 | — | 1.00 | — |
| No | 0.90 (0.48–1.68) | 0.74 | 0.83 (0.42–1.62) | 0.58 |
Outcome variable: Low ferritin. Reference outcome: Normal ferritin
Table 5.
Thematic analysis of barriers to taking Balamrutham among children
| Themes | categories | Quotes | Participant Type |
|---|---|---|---|
| Adverse effects and Suitability concerns | Gastrointestinal discomfort | “Motions and stomach aches happen, so I will stop to give balamrutham.” | Mother |
| Respiratory/cold-related fears | “Who takes over the 100-gram balamurutham that time it will happen [loose motions].” | AWW | |
| “Parents of children who suffered pneumonia were worried about balamrutham.” | Anganwadi Helper | ||
| Perceived lack of suitability | “The child was 3 years old; we used balamrutham, but it did not suit her child.” | Mother | |
| Child Acceptance and Habituation Issues | Initial refusal/dislike | “Child does not eat balamrutham, so we give one spoon with butter slowly.” | Mother |
| “If the child didn’t like it, we tell them physical growth will not be good.” | AWW | ||
| Taste or texture issues | “Children will eat whatever they are given; initially, the food is slippery.” | AWW | |
| Difficulty establishing habituation | “We used it many times, but it did not suit the child; she could not eat it.” | Mother | |
| Dependence on recipe modifications | “They give balamrutham only as dosa or biscuits so that the child eats.” | AWW | |
| Parental Misconceptions and Low Awareness | Quality doubts (“free=low quality”) | “Not all the ones that come free are of good quality.” | Mother |
| Sugar-related fears | “In balamrutham, have sugar so decrease the sugar level.” | Mother | |
| “Parents think sugar in it will make children sick.” | AWW | ||
| Poor understanding of nutritional value | “Mothers do not know the value of it; they give it away for free.” | AWW | |
| Confusion in preparation | “They do not know how to give it—first spoon, then mix with water, and so on.” | AWW | |
| Practical and Logistical Constraints | Preparation burden | “Mothers are just lazy and don’t put them in.” | AWW |
| Other foods take effort. still they do not prepare balamrutham regularly.” | |||
| Supply irregularities | “Sometimes they didn’t send first week; when Anganwadi receives, they distribute.” | AWW | |
| Storage concerns | “If kept outside without closing, ants will come.” | Mother | |
| Packet damage during transport | “Sometimes packets come damaged; we return them.” | AWW | |
| Household Sharing and Inadequate Child Intake | Sharing with siblings | “Two children eat balamrutham.” | Mother |
| “Parents give the packet to both children even if only one is eligible.” | AWW | ||
| Sharing with elders | “Family members also eat balamrutham.” | Mother | |
| “If the child does not eat, elders will eat it.” | Mother | ||
| Insufficient quantity when shared | “It is sufficient only if used for one child.” | Mother |
Discussion
This study evaluated the burden of anemia and associated nutritional parameters among children aged 1–6 years attending Anganwadi Centers (AWCs) in rural Andhra Pradesh, and assessed the real-world impact of Balamrutham—a fortified supplementary food distributed under the Integrated Child Development Services (ICDS) scheme. An overall anemia prevalence of 85.1% was recorded—considerably higher than the national estimate of approximately 67% among under-five children from NFHS-5.[1,2] A systematic review by Jeevan et al.[4] confirmed that anemia rates among Indian children remain disproportionately concentrated in rural settings. The high prevalence observed in this study reinforces the need for periodic community-level screening at AWCs, as routine hemoglobin assessment can enable early identification and management. Moderate anemia was the dominant severity category at 57.8%, followed by mild and severe forms—a pattern reported consistently across community-based pediatric studies in India and other low and middle-income countries.[2,5] Low serum ferritin and low serum iron were recorded in nearly half of the study population, confirming iron deficiency as a major concern. These proportions are consistent with prior studies.[6,7] The prevalence of underweight and stunting further illustrates the multidimensional character of nutritional deprivation in this cohort, where concurrent deficits in energy, protein, and micronutrients simultaneously impair linear growth and hematopoiesis.[8]
Despite its micronutrient-enriched formulation, Balamrutham consumption showed no statistically significant association with hemoglobin, serum ferritin, or serum iron levels, and multivariable regression confirmed the absence of an independent effect on ferritin status (AOR 0.83, 95% CI: 0.42–1.62; P = 0.57). These results remain consistent with programmed evaluations of ICDS supplementary nutrition under routine delivery conditions, where biochemically adequate formulations have repeatedly failed to produce measurable improvements in iron status.[9,10] A 2025 systematic review and network meta-analysis of randomized controlled trials on nutrition-specific interventions concluded that food fortification strategies yield meaningful biochemical benefits only when dosing is consistent and delivery is actively supervised.[11] A large-scale effectiveness trial in Bihar reported meaningful decreases in anemia among children aged 6–18 months when home fortification was delivered with implementation support.[12,13,14] What distinguishes the present study from these prior evaluations is its explicit documentation of the mechanisms through which delivery failed under routine conditions like household sharing, dose dilution through recipe modification, and early discontinuation due to perceived adverse effects -providing a level of explanatory depth.
Children aged 1–3 years had nearly twice the odds of low ferritin compared to those aged four years and above (AOR 1.97, 95% CI: 1.12–3.45; P = 0.018), even after adjustment for dietary and programmed-related factors. This is physiologically expected due to rapid somatic growth and disproportionately high iron requirements. A recent narrative review on the multifactorial aetiology of anemia in India notes that the shift from breast milk toward predominantly cereal-based diets creates a critical window of iron depletion risk.[15] A large observational study examining predictors of anemia in Uttar Pradesh similarly identified younger age and inadequate complementary feeding quality as key determinants of poor iron status.[16] Dietary quality was a significant determinant of iron status. Children consuming non-vegetarian food only once weekly had significantly higher odds of low ferritin compared to those with more frequent intake (AOR 2.39, 95% CI: 1.26–4.53; P = 0.008), confirming the critical role of haem iron in maintaining adequate iron stores. Previous research demonstrated that predominantly vegetarian diets, combined with the inhibitory effect of phytate-rich staple cereals on non-haem iron absorption, substantially elevate iron deficiency risk.[17] At the bivariate level, infrequent consumption of green leafy vegetables was significantly associated with anemia (P = 0.036). Beyond their non-haem iron content, green leafy vegetables provide folate and ascorbic acid, which support erythropoiesis and enhance iron absorption. A multilevel analysis of dietary diversity and anemia among children aged 6–23 months across sub-Saharan Africa demonstrated that regular vegetable inclusion independently reduces anemia severity.[18] These associations indicate that Balamrutham supplementation alone cannot compensate for a diet deficient in bioavailable iron, highlighting the need for dietary counselling. The qualitative component explains the limited biochemical impact observed. Five barrier themes were identified: perceived adverse effects, poor child acceptability, parental misconceptions, logistical constraints, and intra-household sharing. Caregivers frequently attributed gastrointestinal discomfort to Balamrutham and discontinued its use as a response documented in community-based nutritional behavior change studies in similar settings.[19] Poor child acceptance due to taste and texture aversion prompted recipe modifications that likely reduced nutrient density and undermined dose consistency. Parental misconceptions-including doubts about government-supplied food quality and fears about sugar content-reflect gaps in health literacy and institutional trust that have been similarly described in qualitative studies on anemia awareness in South India.[20] The widespread practice of intra-household sharing wherein Balamrutham intended for the eligible child was consumed by siblings or adult family members, substantially reduced the effective dose reaching the intended beneficiary, a phenomenon documented in food-insecure households across low- and middle-income countries.[21] These barriers are addressable through targeted programmed redesign, behavior change communication, and improved supply chain management. For AWC workers, counselling visits should specifically address misconceptions about adverse effects and nutritional value, while programmed supervisors should implement simple tracking mechanisms to monitor sharing and actual intake at the household level. This study’s mixed-methods design, combining biochemical outcomes with anthropometric, dietary, and qualitative data across 23 AWCs, offers a more comprehensive evaluation of real-world programmed effectiveness. This study captured the programmed as experienced by beneficiaries—revealing that the critical bottleneck lies not in the supplement’s formulation but in its delivery, acceptability, and household utilization.
Limitations
The cross-sectional design precludes the establishment of causal relationships between supplement consumption and biochemical outcomes. The sample, restricted to rural Anganwadi Centers in a single geographic area, limits generalizability. Dietary intake data were caregiver-reported and may be subject to recall bias. Future studies should employ longitudinal designs with systematic adherence monitoring to more accurately capture the dose-response relationship between fortified food consumption and iron status outcomes.
Author contributions
Study conception and design: AG, VD, RA
Data collection: AG, RGL, BSR, AS, BK, BE
Laboratory analysis and biochemical validation: AG, VD, NG
Analysis and interpretation of results: AG, KE, RA, VD
Draft manuscript preparation: AG, KE, RGL
Critical revision of manuscript: AG, VD, RA, NG
All authors reviewed the results and approved the final version of the manuscript.
Ethics approval
The study was approved by the Institutional Ethics Committee, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India (Date: 11.06.2025; Number: AIIMS/MG/IEC/2025-26/322). Written informed consent was obtained from all participants parents/caregivers prior to inclusion of child in the study.
Prior presentation/publication
This work has not been previously presented, published as an abstract, posted as a pre-print, or submitted as a thesis.
Declaration of generative AI use
During the preparation of this work, we used ChatGPT (OpenAI) to assist with language refinement. After using this tool, we reviewed and edited the content and take full responsibility for the publication.
Conflicts of interest
There are no conflicts of interest.
Acknowledgements
The authors express their sincere gratitude to AIIMS, Mangalagiri, for providing administrative and infrastructural support necessary to conduct this study. We gratefully acknowledge the Department of Biochemistry for technical expertise and laboratory support. We thank the Integrated Child Development Services (ICDS) authorities for granting permission and facilitating field implementation. We sincerely appreciate the Anganwadi teachers, helpers, nursing officers, and Centre for Rural Health staff for their assistance. Finally, we thank the parents and children who participated in the study.
Funding Statement
Nil.
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