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Anaemia prevalence may be reduced among countries that fortify flour

  • Jonathan S. Barkley (a1) (a2), Kathleen S. Wheeler (a1) (a2) and Helena Pachón (a1) (a2)
Abstract

The effectiveness of flour fortification in reducing anaemia prevalence is equivocal. The goal was to utilise the existing national-level data to assess whether anaemia in non-pregnant women was reduced after countries began fortifying wheat flour, alone or in combination with maize flour, with at least Fe, folic acid, vitamin A or vitamin B12. Nationally representative anaemia data were identified through Demographic and Health Survey reports, the WHO Vitamin and Mineral Nutrition Information System database and other national-level nutrition surveys. Countries with at least two anaemia surveys were considered for inclusion. Within countries, surveys were excluded if altitude was not consistently adjusted for, or if the blood-draw site (e.g. capillary or venous) or Hb quantification method (e.g. HemoCue or Cyanmethaemoglobin) differed. Anaemia prevalence was modelled for countries that had pre- and post-fortification data (n 12) and for countries that never fortified flour (n 20) using logistic regression models that controlled for time effects, human development index (HDI) and endemic malaria. After adjusting for HDI and malaria, each year of fortification was associated with a 2·4 % reduction in the odds of anaemia prevalence (PR 0·976, 95 % CI 0·975, 0·978). Among countries that never fortified, no reduction in the odds of anaemia prevalence over time was observed (PR 0·999, 95 % CI 0·997, 1·002). Among both fortification and non-fortification countries, HDI and malaria were significantly associated with anaemia (P< 0·001). Although this type of evidence precludes a definitive conclusion, results suggest that after controlling for time effects, HDI and endemic malaria, anaemia prevalence has decreased significantly in countries that fortify flour with micronutrients, while remaining unchanged in countries that do not.

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Corresponding author
* Corresponding author: H. Pachón, fax +1 404 727 9745, email helena.pachon@emory.edu
References
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1 Stevens, GA, Finucane, MM, De-Regil, LM, et al. (2013) Global, regional, and national trends in haemaglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995–2011: a systematic analysis of population-representative data. Lancet Glob Health 1, e16e25.
2 de Benoist, B, McLean, E, Egli, I, et al. (editors) (2008) Worldwide Prevalence of Anaemia 1993–2005: WHO Global Database on Anaemia. Geneva: WHO.
3 World Health Organization & Food and Agriculture Organization (2006) Guidelines on Food Fortification with Micronutrients. [Allen, L, de Benoist, B, Dary, O et al., editors]. Geneva: WHO.
4 Kraemer, K & Zimmermann, MB (2007) Nutritional Anaemia. Basel: Sight and Life Press.
5 Gera, T, Sachdev, HS & Boy, E (2012) Effect of iron-fortified foods on hematologic and biologic outcomes: systematic review of randomized controlled trials. Am J Clin Nutr 96, 309324.
6 Food Fortification Initiative. Food Fortification Initiative database [Internet]. Atlanta, GA: Food Fortification Initiative (accessed January 2015).
7 Food Fortification Initiative (2013) Impact of wheat flour fortification on anemia. http://www.ffinetwork.org/why_fortify/documents/Brief_4_Anemia_2013.pdf (accessed January 2015).
8 World Health Organization (2009) Recommendations on Wheat and Maize Flour Fortification. Meeting Report: Interim Consensus Statement. Geneva: WHO. http://www.who.int/nutrition/publications/micronutrients/wheat_maize_fort.pdf?ua = 1/ (accessed accessed January 2014).
9 Kamien, M, Woodhill, JM, Nobile, S, et al. (1974) Nutrition in the Australian aborigines–effects of the fortification of wheat flour. Aust N Z J Med 5, 123133.
10 Sadighi, J, Sheikholeslam, R, Mohammad, K, et al. (2008) Flour fortification with iron: a mid-term evaluation. Public Health 122, 313321.
11 Fujimori, E, Sato, APS, Szarfarc, SC, et al. (2011) Anaemia in Brazilian pregnant women before and after flour fortification with iron. Rev Saúde Publica 45, 10271035.
12 Tazhibayev, S, Dolmatova, O, Ganiyeva, G, et al. (2008) Evaluation of the potential effectiveness of wheat flour and salt fortification programs in five Central Asian countries and Mongolia, 2002–2007. Food Nutr Bull 29, 255265.
13 Nestel, P, Nalubola, R, Sivakeneshan, R, et al. (2004) The use of iron-fortified wheat flour to reduce anaemia among the estate population in Sri Lanka. Int J Vitam Nutr Res 74, 3551.
14 ICF International (2012) Demographic and Health Surveys (Various) [Datasets]. Calverton, MD: ICF International (distributor).
15 World Health Organization. Vitamin and Mineral Nutrition Information System. Micronutrients Database. Geneva: WHO. http://www.who.int/vmnis/database/en/ (accessed accessed January 2014).
16 United Nations Children's Fund. Multiple Indicator Cluster Surveys. New York: UNICEF. http://www.unicef.org/statistics/index_24302.html (accessed accessed January 2014).
17 United States Agency for International Development, Demographic and Health Survey Program. Using Datasets for Analysis. Rockville, MD: ICF International. http://www.measuredhs.com/data/Using-Datasets-for-Analysis.cfm (accessed accessed January 2014).
18 United Nations Development Program. Human Development Reports. New York: UNDP. http://hdr.undp.org/en/content/human-development-index-hdi-table (accessed accessed December 2013).
19 World Health Organization (2011) World Malaria Report. http://www.who.int/malaria/world_malaria_report_2011/en/ (accessed accessed December 2013).
20 Stetler, HC & Huong, AY (1981) Epidemiología de la anaemia en niños de edad preescolar y sus madres en El Salvador (Epidemiology of anaemia in preschool children and their mothers in El Salvador). Arch Latinoam Nutr 31, 4250.
21 Salvadoran Demographic Association & Interinstitutional Consultative Committee (2000) Encuesta nacional de salud familiar FESAL-98 (National Family Health Survey FESAL-98). San Salvador: Salvadoran Demographic Association.
22 Salvadoran Demographic Association, United States Agency for International Development & Centers for Disease Control and Prevention (2004) Encuesta nacional de salud familiar FESAL 2002–2003: Informe final (FESAL National Family Health Survey 2002–2003: Final Report). San Salvador: Salvadoran Demographic Association.
23 Salvadoran Demographic Association, United States Agency for International Development & Centers for Disease Control and Prevention (2009) Encuesta nacional de salud familiar FESAL 2008: Informe final (FESAL National Family Health Survey 2008: Final Report). San Salvador: Salvadoran Demographic Association.
24 Ministerio de Salud Pública y Asistencia Social (1996) Encuesta nacional de micronutrients (National Micronutrient Survey). Guatemala City: Ministerio de Salud Pública y Asistencia Social.
25 Ministerio de Salud Pública y Asistencia Social, Instituto Nacional de Estadística, Universidad del Valle de Guatemala, et al. (2003) Encuesta nacional de salud materno infantil 2002 (National Maternal and Infant Health Survey 2002). Guatemala City: Ministerio de Salud Pública y Asistencia Social.
26 Ministerio de Salud Pública y Asistencia Social, Instituto Nacional de Estadística, Universidad del Valle de Guatemala, et al. (2010) Encuesta nacional de salud materno infantil 2008–2009 (National Maternal and Infant Health Survey 2008–2009). Guatemala City: Ministerio de Salud Pública y Asistencia Social.
27 Branca, F, Burkholder, B, Hamel, M, et al. (1996) Health and Nutrition Survey of Internally Displaced and Resident Population of Azerbaijan. Atlanta, GA: CDC.
28 Serbanescu, F, Morris, L, Rahimova, S, et al. (editors) (2003) Reproductive Health Survey Azerbaijan, 2001 [Final Report]. Atlanta, GA: CDC.
29 Ministère de la Santé Publique [Guinée] (2001) Enquête nationale sur l'anémie ferriprive en Guinée (National Survey of Iron Deficiency Anaemia in Guinea). Conakry, Republic of Guinea: Ministry of Health and Public Hygiene.
30 Mulder-Sibanda, M, Dahn, B, Duworko, M, et al. (1999) National Micronutrient Survey. A National Prevalence Study on Vitamin A Deficiency, Iron Deficiency Anaemia, Iodine Deficiency. Monrovia: Ministry of Health and Social Welfare.
31 Ministério da Saúde & Direcção Nacional de Saúde (2003) Inquérito nacional seovre a deficiência de vitamina A, prevalência de anaemia e malária em crianças dos 6–59 meses e respectivas mães (National Survey of Vitamin A Deficiency, Prevalence of Anaemia and Malaria in Children Aged 6–59 Months and their Mothers). Maputo: Instituto Nacional de Saúde.
32 Mudalige, R & Nestel, P (2001) Prevalence of anaemia in Sri Lanka. Ceylon Med J 39, 916.
33 Piyasena, C & Mahamithawa, A (2003) Assessment of Anaemia Status in Sri Lanka 2001 [Survey Report]. Colombo: Ministry of Health, Nutrition and Welfare, Department of Health Services, Medical Research Institute.
34 Harvey, P, Carlot, M & Menere, R (1998) Report of the Second National Nutrition Survey 1996. Port Vila: Department of Health.
35 Yip, R (1996) Final Report of the 1995 Viet Nam National Nutrition Anaemia and Intestinal Helminth Survey: A Recommended Plan of Action for the Control of Iron Deficiency for Viet Nam. Jakarta: United Nations Children's Fund.
36 Khoi, HH, Khan, NC, Tam, NC, et al. (2001) Report on Viet Nam National Anaemia Survey, 2000. Hanoi: National Institute of Nutrition.
37 Pena-Rosas, JP & Sinclair, BM (2007) Wheat flour fortification for prevention and control of iron deficiency anaemia in Latin America: issues to consider in a systematic evaluation. Rev Med Minas Gerais 1/2 Suppl. 1, 17, S66S73.
38 Ministerio de Salud (1986) Encuesta nacional de nutrición: evaluación dietética 1982 (National Nutrition Survey: Dietary Assessment 1982). San José: Ministerio de Salud.
39 Rodriguez, S, Blanco, A, Cunningham, L, et al. (2001) Prevalencia de las anaemias nutricionales de mujeres en edad fértil, Costa Rica: encuesta nacional de nutrición, 1996 (Prevalence of nutritional anaemias of women of childbearing age, Costa Rica: National Nutrition Survey, 1996). Arch Latinoam Nutr 51, 1924.
40 Ministerio de Salud (2009) Encuesta nacional de nutrición 2008–2009 (National Nutrition Survey 2008–2009). San José: Ministerio de Salud.
41 National Food and Nutrition Centre (2007) Report on the Micronutrient Status of Women in Fiji. 2004 Report. Suva: National Food and Nutrition Centre.
42 National Food and Nutrition Centre (2012) Impact of Iron Fortified Flour in Childbearing Age Women in Fiji. 2010 Report. Suva: National Food and Nutrition Centre.
43 Ministerio de Salud Pública, Secretaría de Salud, Fundación Internacional de Ojos et al. (1997) Encuesta nacional de micronutrientes Honduras, 1996 (Honduras National Micronutrient Survey, 1996). Tegucigalpa: Secretaría de Salud, Ministerio de Salud Pública.
44 Frankenberg, E & Thomas, D (2000) The Indonesian Family Life Survey (IFLS): Study Design and Results from Waves 1 and 2. Santa Monica, CA: RAND.
45 Strauss, J, Beegle, K, Sikoki, B, et al. (2004) The Third Wave of the Indonesian Family Life Survey (IFLS): Overview and Field Report. Santa Monica, CA: RAND.
46 Strauss, J, Witoelar, F, Sikoki, B, et al. (2009) The Fourth Wave of the Indonesian Family Life Survey (IFLS4): Overview and Field Report. Santa Monica, CA: RAND.
47 Martínez, H, González, T, Flores, , et al. (1995) Anemia en mujeres de edad reproductiva. Resultados de una encuesta probabilística nacional (Anaemia in women of reproductive age. Results of a national probabilistic survey). Salud Pública de México 37, 108119.
48 Ministerio de Salud (2001) Encuesta Nacional de Nutrición 1999. Estado nutricio de niños y mujeres en México (National Nutrition Survey 1999. Nutritional Status of Children and Women in Mexico). Cuernavaca: Instituto Nacional de Salud Pública.
49 Ministerio de Salud (2007) Resultados de nutrición de la Encuesta nacional de salud y nutrición 2005–2006 (Nutrition Results from the National Survey of Health and Nutrition 2005–2006). Cuernavaca: Instituto Nacional de Salud Pública.
50 Ministerio de Salud (2012) Encuesta nacional de nutrición: resultados nacionales 2012 (National Nutrition Survey: National Results 2012). Cuernavaca: Instituto Nacional de Salud Pública.
51 Darnton-Hill, I, Mora, JO, Weinstein, H, et al. (1999) Iron and folate fortification in the Americas to prevent and control micronutrient malnutrition: an analysis. Nutr Rev 57, 2531.
52 Ministerio de Salud (1994) Encuesta nacional sobre deficiencia de micronutrientes en Nicaragua 1993: resumen ejecutivo (National Survey on Micronutrient Deficiency in Nicaragua 1993: Executive Summary). Managua: Ministerio de Salud.
53 Ministerio de Salud (2002) Encuesta nacional de micronutrientes 2000 (National Micronutrient Survey 2000). Managua: Ministerio de Salud.
54 Ministerio de Salud (2006) Sistema integrado de vigilancia de intervenciones nutricionales 2003–2005 (Integrated System for Monitoring Nutritional Interventions 2003–2005). Managua: Ministerio de Salud.
55 Food and Nutrition Research Institute (1984) Second National Nutrition Survey, Philippines, 1982. Manila: Food and Nutrition Research Institute.
56 Food and Nutrition Research Institute (1987) Third National Nutrition Survey, Philippines, 1987. Manila: Food and Nutrition Research Institute, Department of Science and Technology.
57 Food and Nutrition Research Institute (1993) Fourth National Nutrition Survey. Manila: Food and Nutrition Research Institute.
58 Food and Nutrition Research Institute, Department of Science and Technology & United Nations Children's Fund (2001) Philippine Nutrition Facts & Figures. Manila: Food and Nutrition Research Institute.
59 Food and Nutrition Research Institute (2008) Seventh National Nutrition Survey, Philippines: 2008 Initial Results. Manila: Food and Nutrition Research Institute, Department of Science and Technology.
60 Northrop-Clewes, C, Hund, L, Valadez, J, et al. (2013) Global Alliance for Improved Nutrition LC-LQAS Survey Report. Uzbekistan: Ministry of Health.
61 Ministry of Health, Republic of Maldives (2001) Multiple Indicator Cluster Survey (MICS 2), Maldives. Malé: Ministry of Health.
62 Ministry of Health and Family [Maldives] & United Nations Children's Fund (2007) Project Report: National Micronutrient Survey 2007. Malé: Ministry of Health.
63 Ministry of Health Nepal, Child Health Division, New ERA, et al. (1999) Nepal Micronutrient Status Survey 1998. Kathmandu: Ministry of Health.
64 Branca, F, Ferrari, M & Rossi, L (2004) Micro-nutrient Status Survey in Tajikistan, 2003. Rome: National Institute for Research on Food and Nutrition, Kazakh Academy of Nutrition.
65 Ministry of Health Republic of Tajikistan & United Nations Children's Fund (2010) Micronutrient Status Survey in Tajikistan, 2009. Dushanbe: Ministry of Health Republic of Tajikistan.
66 Luo, C, Mwela, CM & Campbell, J (1999) National Baseline Survey on Prevalence and Aetiology of Anaemia in Zambia: A Random Cluster Community Survey Involving Children, Women and Men. Lusaka: National Food and Nutrition Commission.
67 Micronutrient Operational Strategies and Technologies (MOST), United Nations Children's Fund, Centers for Disease Control and Prevention, et al. (2003) Report of the National Survey to Evaluate the Impact of Vitamin A Interventions in Zambia, July and November 2003. Lusaka: MOST, United States Agency for International Development (USAID) Micronutrient Program.
68 Kassenbaum, NJ, Jasrasaria, R, Naghavi, M, et al. (2014) A systematic analysis of global anemia burden from 1990 to 2010. Blood 123, 615624.
69 Hurrell, R, Ranum, R, de Pee, S, et al. (2010) Revised recommendations for iron fortification of wheat flour and an evaluation of the expected impact of current national wheat flour fortification programs. Food Nutr Bull 31, S7S21.
70 Teta, N, Kuate-Defo, B & Receveur, O (2008) Multilevel modelling of sociodemographic predictors of various levels of anaemia among women in Mali. Public Health Nutr 12, 14621469.
71 Hay, SI, Guerra, CA, Tatem, AJ, et al. (2004) The global distribution and population at risk of malaria: past, present, and future. Lancet Infect Dis 4, 327336.
72 Masimo Corporation (2009) Total Haemoglobin Measurements: Accuracy of Laboratory Devices and Impact of Physiologic Variation. Irvine, CA: Masimo Corporation. http://www.masimo.com/pdf/sphb/lab5527a.pdf (accessed accessed January 2014).
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