Addressing micronutrient deficiency: Sustaining the initiatives

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Moti Lal Jain1, Neetu Purohit2, Sudeep Sharma3
1. Project Director, Institute of Health Management Research (IIHMR) University, Jaipur, India

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2. Associate Professor, Institute of Health Management Research (IIHMR) University, Jaipur, India
3. Project Officer, Institute of Health Management Research (IIHMR) University, Jaipur, India

Abstract
Objective: The objective of this paper is to inform about the implementation and success of an innovative pilot

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project for addressing the high prevalence of micronutrient deficiency in Rajasthan, India.

Design: The paper is based on the secondary information collected during the implementation phase of the project.
The project was implemented in two blocks of Udaipur district in Rajasthan, India to provide facility of flour

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fortification at the level of small chakkis (local grinding mills) where anyone could get their wheat grinded and
fortified with Iron, Folic Acid and Vitamin B-12 at no additional cost.

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Setting: A census of available small chakkis in the blocks was done. In total, 397 chakkis were identified in both
blocks. The identified chakkis were categorized according to their daily grinding and those which were grinding
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wheat up to 100 kg and above daily, were made partners in this initiative. In total, 200 chakkis were engaged in both
blocks.

Subject: The subject for the study included both grinding mill owners and the rural population residing in the study
area.
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Results: From February 2013 till January 2015, the average production by 200 chakkis was 340 MT per month
which means approximately 38,000 individuals have consumed micronutrient added wheat flour.
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Conclusion: The acceptance for flour fortification has increased exponentially within a short period of 15 months, it
can be assumed that the acceptance will grow further if dedicated efforts are made which is possible only if the
awareness generation activities started during the intervention is sustained.
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Keywords: Micronutrients, Malnutrition, Fortification, Sustainability

______________________________________________________________________________
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Introduction

Micronutrient malnutrition continues to be a problem of unacceptable proportions in developing

countries. Globally, more than 2 billion persons suffer from micronutrient deficiencies, most of
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them are from developing countries [1]. Data from the National Nutrition Monitoring Bureau
(NNMB) over the last three decades have consistently shown that more than 70 percent of pre-

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 school children in India consume less than 50 percent of the Recommended Dietary Allowance

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(RDAs) for Vitamin A, Iron, Folic Acid and Riboflavin. Diet surveys have found that daily
intake of most micronutrients is well below the RDA [2]. Iron deficiency appears to be the most
severe of all the micronutrient deficiencies with barely one-third of any age group (except adult
men) having normal hemoglobin levels (≥12g/dl). Based on computed data from NNMB diet

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surveys of 2001, the iron density in foods is ~7.2 mg/1000kcal while the requirements for
pregnant women, lactating women, and pre-school children are 17.5, 12.4, and 9.7 mg/1000
kcals, respectively [3].

Rajasthan has a high burden of under nutrition and micronutrient malnutrition. Per-capita

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consumption of micronutrient-rich foods like fruits, vegetables, egg, fish, and meat is quite low
across all socioeconomic groups. About 79 percent of children under 3 years of age, 54 percent
of married women between 15 and 49 years old, 62 percent of pregnant women and 21 percent of
married men suffers from anemia [4]. The tribal dominated districts of Banswara, Dungarpur and

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Udaipur, with difficult geographical terrain have consistently lagged behind on vital social
development indicators. For instance, the mortality rates among rural children and children

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belonging to SC/ST groups remain much higher (SRS & AHS 2010-11 data). A high percentage
of children under-three are undernourished i.e. stunted, severely wasted and anaemic, which puts
them at risk of impaired growth, serious illness and even early death. A high percentage of
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children under three are underweight and anaemic, which puts them at risk of serious illness and
even early death [5].

While a number of interventions including distribution of supplementary nutritional items and

take home rations under ICDS; provision of supplements by other lateral and bilateral agencies
are being implemented to address malnutrition, food fortification emerges as the least expensive
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and most effective measure to address the large-magnitude micronutrient deficits.

The current article is an attempt to bring into light an innovative intervention project of staple
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food fortification which can go a long way in addressing the problem of micronutrient
deficiency. The intervention is in the last leg of its implementation and would probably be rolled
back in view of lack of funding. The article attempts to showcase the achievements and the
potential benefits of not only continuing the intervention but also up scaling it for the benefit of
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wider community struggling with rampant micronutrient deficiency.

About the Initiative

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The project on food fortification is being implemented on pilot basis in two tribal blocks of
Udaipur, Rajasthan since February 2013. It is being funded by Global Alliance for Improved
Nutrition (GAIN), Geneva, Switzerland.

Government of Rajasthan was providing fortified wheat flour to Above Poverty Line (APL)
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families and wheat to Below Poverty Line (BPL) families through Public Distribution System
(PDS). This policy in a way prevented BPL families to take benefits of fortified wheat flour as

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 they were being given wheat which was not fortified. It was identification of this inequity which

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led to the conceptualization of this intervention.

A rapid assessment was carried out which indicated that most of the APL and BPL families get
their wheat grinded at small chakkis to fulfill their wheat flour requirement. The villages in these

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blocks are being habituated by people who are either from low socio-economic status so
financially cannot afford to buy packaged fortified flour available in market or culturally inclined
to buy wheat only and at some places, they get wheat as compensation against their labour and
therefore they do not need to buy flour. Many of them are daily wagers who get their flour from
chakki owners on day today or weekly basis.

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An innovative project was planned to provide facility of flour fortification at the level of small
chakkis (local wheat millers) where anyone could get their wheat grinded and also get it fortified
with Iron, Folic Acid and Vitamin B-12 at no additional cost.

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Designing and Planning of the Intervention

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Earlier studies have well established the role of food fortification. One of such project was done
in Udaipur. A community-level iron fortification program was designed by the NGO, Seva
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Mandir, to provide an option for iron supplementation for families who do not buy commercially
processed grain. The program was implemented in 68 of 134 villages, with the remainder serving
as comparison. On average, each village had four chakkis (local millers), of which up to two
were offered a flat monthly payment to participate. The technology used for fortification begins
with a micronutrient premix, which is initially diluted with flour at Seva Mandir to avoid health
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risks associated with over-ingestion of iron. This produces a pre-blend, which is supplied to the
chakkis. Customers brought their grain to the chakkis where it was milled and supplemented
with the pre-blend at no additional cost. The final concentration of iron supplied 20-40 percent of
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the recommended daily intake of iron for males and 10-20 percent for females, based on average
daily flour consumption.
Midline survey shown a significant difference in anemia rate between treatment and comparison
villages, of about 7 percentage points, but by endline, when the uptake had fallen, there was no
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difference in anemia between treatment and comparison groups [10].

Before starting the intervention, using a case-control study design, a baseline study was
conducted in August-September 2013. The study was conducted in three blocks of Udaipur, i.e.
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Salumbar, Sarada (intervention blocks) and Jhadol (control block). Cluster sampling technique
was used to select the villages among the blocks. The baseline study informed that prevalence of
malnutrition among children was high in both intervention and control blocks. Seventeen and
19.4 percent of the children were severely underweight; 27.5 percent and 37.6 percent were
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severely stunted and 8.1 percent and 6.7 percent were severely wasted in intervention and control

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 blocks respectively. Only 19 out of 2856 respondents (i.e. general population, pregnant women

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and lactating women) had reported to have heard about fortified wheat flour [6].

In addition, a census of available small chakkis in both blocks was done and 194 and 203 chakkis
were identified in Salumbar and Sarada block respectively. The chakkis identified were

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categorized according to their daily grinding capacity and out of them those which were grinding
wheat upto 100 kg and above on daily basis were made partners in this initiative. In total, 200
chakkis were engaged in two blocks of Sarada and Salumbar. Hundred chakki owners had
participated in each of the blocks which were set up in 46 and 44 villages of Sarada and
Salumbar respectively. In all, the intervention is being implemented in 90 villages of Udaipur

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covering population over 1,20,000 individuals. Table 1 shows the details of the coverage area
and population.

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Households
Number of Chakkis Chakkis Total HH in
S.No Block Covered under Total Population
Village identified selected blocks
Project

1
2
Salumbar
Sarada
44
46
194
203
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100
100
10652
13151
5275
5525
52924
67342
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TOTAL 90 395 200 23803 10800 120266
Table 1: Coverage details of both blocks

Operationalization of the Intervention

After the baseline, the intervention was implemented in the blocks of Sarada and Salumbar. All
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the chakki owners (millers) were provided training on the proportion of premix to be mixed with
flour and mechanism to be followed for evenly mixing the premix, storage of premix, and record
management. Under the interventions, additionally, logistic support like a tin box for premix
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storage for preventing it from absorbing moisture, direct sunlight and air, a pictorial chart
showing the quantity of premix to be mixed in accordance to the weight of wheat was provided
to them.
For creating awareness among the community regarding benefits of fortified wheat flour, various
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activities like meeting with community members, mass awareness camps, street plays and puppet
shows, videos on malnutrition, school children awareness activities were organized on monthly
basis in blocks. Posters, Banners were displayed and pamphlets having information on
malnutrition and fortified foods were distributed among the community at prominent places like
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bus stands, hospitals, panchayat bhawan, market area etc.

To ensure the quality of fortified wheat flour, samples were also collected randomly and tested
on monthly basis through a NABL accredited laboratory. The results of tests were shared with
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chakki owners and in case, substantial number of samples did not conform to specifications,
reorientation trainings were conducted for the chakki owners.

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 Monitoring of the Intervention

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To ensure that the intervention is working in the expected direction, an independent rapid
assessment was conducted for the key stakeholders after 15 months of baseline and 12 months
post intervention in intervention blocks (Salumbar, Sarada) of Udaipur district. It took nearly 3

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months to roll out the intervention in the blocks. The objective was to assess the practices of
millers regarding fortification and to document any change in the awareness and perception of
consumers for fortified wheat flour.

A total of 1085 households were visited and about 64 percent and 46 percent of the respondents
in Salumbar and Sarada block respectively were found aware of fortified wheat flour. It was a

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very encouraging finding in view of the fact that only a handful of the people were aware of
fortified flour at the time of initiation of project activities- a mere 15 months back. Specifically
speaking, about 42 percent respondents reported fortified wheat flour as beneficial for mother

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and new born, about 41 percent reported fortified flour as helpful in reducing anemia. Close to
40 percent of the respondents reported that fortified flour reduces fatigue and physical weakness
and 32 percent stated that it sharpens mind of children. About 54 percent respondents mentioned

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that fortified wheat flour is beneficial for all family members.

“The children’s health has increased considerably, especially in terms of strength and energy, and
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children in our village are now running. The positive results in Sheshpur are attributable to an extremely
active Anganwadi centre and awareness activities including a puppet play regarding fortification, which
majority of the community members attended. In addition, there is only one chakkiwalla for the entire
village, thereby simplifying the process of fortified wheat flour distribution”.
- Vijay Joshi, Physical Training Instructor in Government School, Sheshpur, Salumbar
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“Before the use of fortified flour I use to suffer from knee pain. Now I feel better and pain has also
reduced. Fortified flour means no body pain and increasing blood level in the body and same taste of
chapattis. I suggest to everyone to use fortified flour for better health. If the free premix is not available
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then, I can purchase the same, it has many benefits”.

- Sovni Bai Meena, Daily Wager, Lakapa Village, Salumbar

A total of 73 chakki owners were interviewed. About 70 percent of them reported that they
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fortify flour every time they grind it whereas 24 percent reported to be fortifying only on the
demand of customers for it. However, only 16 percent chakki owners opined favorably that
people will be willing to pay additional cost for fortification [7].
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Current status of the Intervention

The acceptance level of fortified wheat flour among the community may be assessed by the
monthly production of fortified wheat flour by chakkis. From February 2013 till January 2015,
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the average production by 200 chakkis in both blocks collectively is 340 MT per month.
Assuming the per capita per day consumption of wheat flour to be 250gm, given by NNMB, it

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 can be assumed that per month 340 MT of fortified wheat flour is being consumed by

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approximately 45,000 people in both blocks.

Production of Fortified Wheat Flour in Sarada and Salumber

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1000
900 943 852
893
800 789
700 717
630 668
600 569 594
558
500 520
400 419

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300
200
100
0

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Figure 1: Chart depicting the monthly fortification by small chakkis in both blocks

Out of the total 6800 approximate number of house-holds in both the blocks, more than 50%
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house-holds i.e. around 3,700 demand chakki owners for wheat flour fortification. Though a
scientific end-line evaluation is due in coming months, the preliminary observations gathered
through monthly monitoring reports indicate that the results will be promising and in the
expected direction. Other similar interventions which attempted to implement fortification in the
past have also shown inspiring results. One of such interventions was implemented in Guna,
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Shivpuri and Sheopur districts of Madhya Pradesh by World Food Program (WFP) during
December 2010 to July 2012 focusing on 162,000 tribal populations in these districts through
fortification by 543 millers [8]. This project was implemented by WFP with the help of the
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village mill owners who have been trained to add a premix of micronutrients during the milling
of wheat. The key components of the project were to raise awareness about flour fortification,
train the mill workers, and establish and sustain the provision of the micronutrient premix. About
19,592 Metric Tons of wheat flour was fortified through this project utilizing 29.4 MT of iron
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premix. This intervention have brought four percent reduction in anemia among targeted tribal
population (91% to 87%), enhanced knowledge on causes, consequences and prevention of
micronutrient malnutrition and anaemia (14.9 % to 29.5%) [9]. This pilot project endeavored to
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ensure that the benefits of fortification are available to the 162,000 people participating in the
project on a sustainable basis by making fortification a financially viable option for the millers.

Since the intervention in Rajasthan is on similar lines and the initial findings reflect
positive impact of the program, it is imperative that the intervention is sustained to see results.
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Challenges
Even after successful implementation of the intervention, its sustainability after completion of
the project is the biggest challenge. The current flour fortification is becoming possible due to

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the support of funding agency in providing the premix. The chakki owners mix the premix in the
specified way to fortify the flour. The cost incurred on premix and other logistics is borne by the
funding agency. Sustainability demands regular availability of premix. In case the funding of
premix is stopped, new avenues for ensuring the availability are to be searched. One mechanism
is provision of premix in sachets/pouches in markets for the community to purchase. The success
of such interventions will depend on the willingness of the community for bearing the additional

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cost. The possibility of covering the additional cost from the community however appears
premature. The milling cost is Rs 1:50 per kg (Rs 7.5/ 5 kg) and if the cost of premix is added it
would be around Rs 0.60 per kg (Rs 3.0/5 kg). The additional cost is of 60 paise per kilogram.
While the cost incurred is not very big, in view of the findings mentioned above, the

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acceptability of fortified flour at additional cost is uncertain.
We might assume that some proportion of people who have appreciated the value of fortification

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might be ready to bear the additional cost but for them also, there would be no avenues to
procure premix once the project gets over.
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It is true that a large proportion of people are already sensitized to the value and importance of
fortification but it is equally true that the results of the fortified food have not been visibly
witnessed by the community and therefore there is uncertainty attached to the fact that additional
efforts- both financially and personally would be made to procure fortified flour. For such
people, it is important that sensitization activities undertaken under this project are continued but
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these will come to an end with the intervention.

The interventions are in correct direction and community in the interventions area have started
appreciating the value of fortified flour, however much more time is needed for converting their
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appreciation into conviction. In view of the fact that the tenure of the project is going to
complete, the concern is that the spade work which has gone into this intervention is not wasted
and the change is strengthened and sustained.
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Recommendations

In view of the gravity of the problem of malnutrition and our struggle in addressing it, it goes
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without saying that successful interventions should be given an opportunity to sustain and show
results. Since the acceptance for flour fortification has increased exponentially within a short
period of 15 months, it can be assumed that the acceptance will grow further if dedicated efforts
are made which is possible only if the awareness generation activities started during the
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intervention is sustained. For increasing the acceptance of fortified flour among the community,

This preprint research paper has not been

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available Electronic copy available at: https://ssrn.com/abstract=2664456
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 some counseling sessions under MCHN days should be organized and it should be included in

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routine awareness activities of the concerned departments.

The intervention could be adopted by the Government of Rajasthan by associating it with various
ongoing programs like Mahatma Gandhi National Rural Employment Guarantee Scheme

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NREGS or some development scheme like ICDS or Mid Day Meal. Premix could be made
available by the Government at subsidized cost so that it becomes affordable to the community.

The government could also think of revising its policy of distribution of Fortified Wheat Flour
through Public Distribution System, the lack of which adversely affect the purpose or atleast
prevents the benefits from reaching the most vulnerable and needy sections of society.

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The funding agency for this project could think of both extending the project duration and
coverage or some alternative strategy can be thought of so that results could be seen at a larger
level. Only few chakkis were made part of intervention, the remaining could be included in the

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intervention so that more number of households could be benefitted. Other vulnerable areas like
desert districts could also be taken up with high micronutrient deficiency.

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If the intervention is stretched for longer period, it would turn out to be a viable project for
reducing anemia. In the long run, it will increase the working capacity of the manpower from
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rural and tribal areas and thereby contribute in their overall development.

References

[1]. NNMB Technical Report No. 22, National Nutrition Monitoring Bureau prevalence of
micronutrient deficiencies National Institute of Nutrition Indian Council of Medical
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Research Hyderabad – 500 007. 2003.

[2]. Nutrient Requirements and Recommended Dietary Allowances for Indians (RDA) An ICMR
Expert Committee report, ICMR 2010
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[3]. Sesikeran B. “The Changing Scenario of Micronutrient Deficiencies in India”. Bulletin of

Nutrition Foundation of India. 34.2 (2013): 2. Print
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[4]. Global Alliance for Improved Nutrition. “India Integrated Food Fortification.” Global
Alliance for Improved Nutrition. Web. 18 February 2015.
<http://www.gainhealth.org/knowledge- centre/project/ india- integrated-food-fortification>
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[5]. SIHFW Rajasthan.” Electronic Newsletter”. State Institute of Health and Family Welfare,
Rajasthan. December 2013: 2. Web. 20 February 2015.
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[6]. Indian Institute of Health Management Research. “Use of Fortified Wheat flour by
Community using Small Chakki for Flour Fortification in Tribal Blocks of Udaipur“.
Jaipur: 2012. Print

This preprint research paper has not been

Electronic copypeer reviewed.
available Electronic copy available at: https://ssrn.com/abstract=2664456
at: https://ssrn.com/abstract=2664456
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[7]. Indian Institute of Health Management Research. “Rapid Assessment of Promotion of
Fortification of Wheat Flour through Small Millers in Sarada and Salumber Blocks of
Udaipur District “. Jaipur: 2014. Print

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[8]. World Food Program. “India Biennial Report 2010 – 2011- World Food Program”. Web. 27
February2015. <https://www.wfp.org/sites
/default/files/India_Biennial_Report_2010_2011.pdf>

[9]. Department of Food and Public Distribution, Madhya Pradesh.”World Food Program”. Web.

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28 February 2015. <http://dfpd.nic.in /fcamin/intcoop/wfd.doc>.

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