title: Impact of fortified biscuits on micronutrient deficiencies among primary school children in Bangladesh.
abstract: BACKGROUND
  Micronutrient deficiencies can compromise the development potential of school-aged children, and their later health and productivity as adults. School feeding and school-based fortification approaches have been utilized globally to redress nutritional deficiencies in this age group.
  
  
  OBJECTIVE
  We explored the acceptability and micronutrient impact of a Bangladesh Government supported school-based micronutrient fortification program for children attending rural primary schools in 10 disadvantaged sub-districts.
  
  
  METHODS
  We applied a mixed methods approach. The quantitative component assessed the impact of micronutrient fortification on 351 children aged 6-11 years using a cohort pre-post research design with a control group. The qualitative component explored the acceptability of the intervention using focus group discussions, body mapping and semi-structured interviews with teachers, school-going children and school authorities.
  
  
  RESULTS
  Daily consumption of fortified biscuits by primary school children had a significant positive impact on mean levels of iron, folic acid, vitamin B12, retinol and vitamin D controlling for sex, baseline deficiency status, CRP, and H. pylori. Levels of anemia and vitamin D deficiency were also significantly reduced. Qualitative findings indicated the widespread acceptability of the daily biscuit. Teachers perceived students to be more attentive in class, less tired, and some attributed better school performance to biscuit consumption. Children reported similar improvements in concentration and energy levels.
  
  
  CONCLUSIONS
  This study is among the first in Bangladesh to comprehensively assess a school-based fortification program in terms of its acceptability and impact on micronutrient status of children aged 6-11 years of age. While results strongly support this modality of school feeding, research on the cognitive impacts of micronutrient fortified biscuits will help clarify the case for scaled-up investments in school- based feeding program in Bangladesh and other low and middle income countries.
authors.affiliation: Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.|James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh.|Department of International Health, Georgetown University, Washington DC, United States of America.
authors.forename: Alayne M
authors.initials: AM
authors.lastname: Adams
authors.affiliation: Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Rushdia
authors.initials: R
authors.lastname: Ahmed
authors.affiliation: Institute of Statistical Research and Training, University of Dhaka, Bangladesh.|Centre for Clinical Epidemiology, St. Luke's International University, Tokyo, Japan.
authors.forename: A H M Mahbub
authors.initials: AH
authors.lastname: Latif
authors.affiliation: Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Sabrina
authors.initials: S
authors.lastname: Rasheed
authors.affiliation: Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.|School of Public Health, The University of Queensland, Brisbane, Queensland, Australia.
authors.forename: Sumon K
authors.initials: SK
authors.lastname: Das
authors.affiliation: James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh.
authors.forename: Enamul
authors.initials: E
authors.lastname: Hasib
authors.affiliation: Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Fahmida Dil
authors.initials: FD
authors.lastname: Farzana
authors.affiliation: Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan.
authors.forename: Farzana
authors.initials: F
authors.lastname: Ferdous
authors.affiliation: Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Shahnawaz
authors.initials: S
authors.lastname: Ahmed
authors.affiliation: Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Asg
authors.initials: A
authors.lastname: Faruque
mesh_terms: D000740:Anemia / Q000178:diet therapy; D001459:Bangladesh / Q000453:epidemiology; D002648:Child; D015362:Child Nutrition Disorders / Q000178:diet therapy*; D005260:Female; D005492:Folic Acid / Q000097:blood; D005527:Food, Fortified; D006801:Humans; D007501:Iron / Q000097:blood; D008297:Male; D018977:Micronutrients / Q000172:deficiency*; D014801:Vitamin A / Q000097:blood; D014805:Vitamin B 12 / Q000097:blood; D014807:Vitamin D / Q000097:blood; D014808:Vitamin D Deficiency / Q000178:diet therapy; D014815:Vitamins / Q000097:blood
chemical_list: D018977:Micronutrients; D014815:Vitamins; D014801:Vitamin A; D014807:Vitamin D; D005492:Folic Acid; D007501:Iron; D014805:Vitamin B 12