A Randomized Crossover Trial of Acceptability of Quadruple-Fortified Salt in Women and their Households in Southern India

Double-fortified salt (DFS; iron, iodine) improved iron status in randomized trials and was incorporated into India’s social safety net programs, suggesting opportunities to address other micronutrient deficiencies. To evaluate the acceptability of quadruple-fortified salt (QFS; iron, iodine, folic acid, and vitamin B12) in women and their households, using a randomized crossover trial design and triangle tests. Women 18–49 y (n = 77) and their households were randomly assigned to receive QFS or DFS in a randomized crossover design over a 3-wk period (week 1: QFS/DFS, week 2: iodized salt, week 3: DFS/QFS). Each week, participants completed a 9-point hedonic questionnaire (1 = dislike extremely to 9 = like extremely) to evaluate 5 sensory domains (color, odor, taste, texture, and overall acceptability) of the intervention, and the remaining salt was weighed using a digital scale. Triangle tests were conducted among women to evaluate sensory discrimination of salt consumed in rice dishes prepared using standardized recipes. Mixed models were used to examine hedonic ratings and salt use; salt type, sequence, and period were included as fixed effects, and household was included as a random effect. Binomial tests were used to evaluate sensory discrimination of salt type in triangle tests. Mean hedonic ratings for most of the 5 sensory domains were ≥7 (like moderately) and did not differ by salt type [overall acceptability mean (SD): QFS: 7.8 (0.7) compared with DFS: 7.7 (1.2); P = 0.68]. Household salt use (weighed) did not differ by salt type. During the 3-wk intervention period, weighed salt use and hedonic ratings significantly increased, indicating a period effect independent of salt type or sequence. In triangle tests, rice samples prepared with QFS, DFS, or iodized salt were not distinguishable. Acceptability of QFS was high, based on individual hedonic ratings and weighed household salt use. Rice dishes prepared with DFS, QFS, and iodized salt were not distinguishable. Findings informed the design of a randomized trial of QFS in this population. This trial was registered at clinicaltrials.gov as NCT03853304 and REF/2019/03/024479.