Effectiveness evaluation of the food fortification program of Costa Rica: impact on anemia prevalence and hemoglobin concentrations in women and children

Abstract

Background Food fortification is one approach for addressing anemia, but information on program effectiveness is limited. Objective We evaluated the impact of Costa Rica’s fortification program on anemia in women aged 15–45 y and children aged 1–7 y. Design Reduced iron, an ineffective fortificant, was replaced by ferrous fumarate in wheat flour in 2002, and ferrous bisglycinate was added to maize flour in 1999 and to liquid and powdered milk in 2001. We used a one-group pretest-posttest design and national survey data from 1996 (baseline; 910 women, 965 children) and 2008–2009 (endline; 863 women, 403 children) to assess changes in iron deficiency (children only) and anemia. Data were also available for sentinel sites (1 urban, 1 rural) for 1999–2000 (405 women, 404 children) and 2008–2009 (474 women, 195 children), including 24-h recall data in children. Monitoring of fortification levels was routine. Results Foods were fortified as mandated. Fortification provided about one-half the estimated average requirement for iron in children, mostly and equally through wheat flour and milk. Anemia was reduced in children and women in national and sentinel site comparisons. At the national level, anemia declined in children from 19.3% (95% CI: 16.8%, 21.8%) to 4.0% (95% CI: 2.1%, 5.9%) and in women from 18.4% (95% CI: 15.8%, 20.9%) to 10.2% (95% CI: 8.2%, 12.2%). In children, iron deficiency declined from 26.9% (95% CI: 21.1%, 32.7%) to 6.8% (95% CI: 4.2%, 9.3%), and iron deficiency anemia, which was 6.2% (95% CI: 3.0%, 9.3%) at baseline, could no longer be detected at the endline. Conclusions A plausible impact pathway suggests that fortification improved iron status and reduced anemia. Although unlikely in the Costa Rican context, other explanations cannot be excluded in a pre/post comparison.

Iron homeostasis in the human body and nutritional iron deficiency and solutions in China

“…Inulin, a natural fructose polymer, has been found to form an inulin–iron complex with iron to enhance iron absorption within the colon (Pitarresi, Tripodo, Cavallaro, Palumbo, & Giammona, ). More recently, similar results were reported for bisglycinate iron (Martorell et al, ) and liposomal iron (Pisani et al, ). Iron from ferrous bisglycinate or ferrous liposomal is better absorbed than the iron from ferrous sulfate.…”

Prevalence of Anemia in Latin America and the Caribbean

“…32 In Colombia, 26 El Salvador, 24 Costa Rica, 16 Nicaragua, 20 Ecuador, 23 Mexico, 22 Peru, 27 Honduras, 29 and Argentina, 18 anemia in this population was a mild public health problem, with prevalence ranging from 7.6% to 18.7%. In Guatemala, 30 Brazil, 21 the Dominican Republic, 4 and Bolivia, 31 anemia was a moderate public health problem, with prevalence ranging from 21.4% to 38.3%.…”

Micronutrient deficiencies in pregnancy worldwide: health effects and prevention

“…86 In 53 countries worldwide, ranging from low-income to high-income, folic acid fortification of flour is mandatory (although this does not indicate compliance in all countries). 148 Other strategies currently being tested but with potential impact on pregnancy outcomes include dual fortified salt (iron and iodine), 149 iron-fortified flour, 150 and biofortification of staple crops such as rice and maize. 151 Overall, fortification is a promising strategy for improving micronutrient status during pregnancy, but data on health outcomes is scarce.…”