Anemia Prevalence May Be Reduced Among Countries that Fortify Flour

Abstract

The effectiveness of flour fortification in reducing anemia prevalence is equivocal. The goal of this study was to utilize existing national‐level data to assess whether anemia in non‐pregnant women was reduced after countries began fortifying wheat flour, alone or in combination with maize flour, with at least iron, vitamin A, vitamin B9 or vitamin B12. Nationally representative anemia data were identified through DHS reports, the WHO‐VMNIS database, and other surveys. Countries with at least 2 anemia surveys were considered for inclusion. Within countries, surveys were excluded if data were not available for non‐pregnant women, if altitude was not consistently adjusted for, or if the blood‐draw site (e.g., capillary or venous) or hemoglobin‐quantification method (e.g., HemoCue or Cyanmethaemoglobin) differed. Anemia prevalence was modeled 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 flour fortification was associated with a 2.4% reduction in the odds of anemia prevalence (PR=0.976, 95%CI: 0.975, 0.978). Among countries that never fortified, no reduction in the odds of anemia prevalence over time was observed (PR=0.999, 95%CI: 0.997, 1.002). Although this type of evidence precludes a definitive conclusion, available evidence from national‐level surveys suggests that after controlling for time effects, HDI, and endemic malaria, anemia prevalence has decreased significantly in countries that fortify flour with micronutrients, while remaining unchanged in countries that do not. Funding: Emory, FFI.