Evidence of Effectiveness of Flour Fortification on Iron Status and Anemia: A Literature Review.

Objectives: The effectiveness of wheat- and maize-flour fortification for improving iron status and anemia in real-world situations has not been documented. The objective was to review published and grey literature on the public-health impact of flour fortification. Methods: A systematic literature review was undertaken, including a search of 17 databases and an e-mail appeal for unpublished reports. Two researchers reviewed 1881 documents. Only studies on government-supported, large-scale fortification programs with anemia or iron outcomes measured prior to and > 12 months after initiation of fortification were included. Results: Twelve studies describing 25 sub-groups (n=13 for children < 15 years, n=12 for women of reproductive age (WRA)) were analyzed. Eight studies used a pre-post design, 4 included a control population, and none adjusted for possible confounding factors. From the pre- to the postfortification periods (and as difference-in-difference for those that included a control group), hemoglobin increased significantly in 4 of 11 studies with children and 5/11 studies with WRA; hemoglobin decreased significantly in 1/11 studies with children and 2/11 with WRA. Anemia prevalence decreased significantly in 4/8 studies with children and 3/10 studies with WRA; anemia prevalence increased significantly in 1/8 studies with children and 2/3 studies with WRA. The prevalence of low serum ferritin statistically decreased in 1/6 studies with children and 3/3 studies with WRA.Conclusions: Available studies confirm that large-scale fortification can positively impact iron and anemia status in children and women of reproductive age; however there is not enough evidence yet to understand under what conditions such impact is greatest.

Micronutrient Deficiencies in Pre-school Age Children and Women of Reproductive Age in Jordan.

Objectives: Jordan's 2010 National Micronutrient Survey assessed the prevalence and severity of anemia and micronutrient deficiencies in Jordanian women and children. Methods: A stratified multistage cluster sampling was used to establish a nationally representative household-based sample of Jordanian children (12 - 59 months) and non-pregnant women of reproductive age (15-49 years). Weighted descriptive statistics were used to calculate national prevalence and multivariate analyses were undertaken for the determination of risk factors of vitamin D deficiency Results: Anemia in children (hemoglobin < 110g/L) and women (hemoglobin < 120g/L) was a mild (17.0%) and moderate (30.6%) public health problem, respectively. Vitamin A deficiency (serum retinol < 0.70 umol/L) was prevalent in 18.3% of children and 4.8% of women. Vitamin D deficiency (25(OH)D3 < 11.0 ng/mL and < 12.0 ng/mL in children and women, respectively) was prevalent in 19.8% of children and 60.3% of women. Vitamin D deficiency was significantly more likely in women who routinely cover themselves with a scarf compared to those women who do not cover. In urban areas, children whose mothers were vitamin D deficient were more likely to be vitamin D deficient than children whose mothers were not deficient. Conclusions: With the exception of vitamin A, a higher burden of micronutrient deficiencies is seen in Jordanian women than children. Vitamin D deficiency in women is the most prevalent micronutrient deficiency in Jordan with approximately 3 out of 5 women being deficient.

Assessment of Jordan's Wheat Flour Fortification External Monitoring System.

Objectives: To assess the performance of the external monitoring system utilized in Jordan according to the CDC criteria for surveillance systems. Methods: The performance of the external monitoring system was assessed qualitatively following the CDC's Updated Guidelines for Evaluating Public Health Surveillance Systems. Specifically, seven attributes of the system (simplicity, flexibility, data quality, acceptability, representativeness, timeliness, and stability) were assessed. Results: The monitoring system uses five key indicators that are representative, simple to collect, and collected in a flexible manner. Indicators include 1) monthly production of wheat flour, 2) monthly number of 25 kg premix boxes used, 3) average addition rate (calculated), 4) addition rate as a % of 250 g/MT target (calculated), and 5) iron concentration in flour sample. While data on production of fortified flour and premix utilization can be provided in a timely manner, on-site mill monitoring and flour sample collection are more challenging due to resource constraints. Conclusions: The frequent collection of a small number of indicators can provide program managers with timely information with which to base decisions, and successfully documents the performance of each mill and the whole fortification program. Moreover, the system is acceptable to participating agencies and millers and is stable due to mandatory fortification legislation which provides the legal framework for external monitoring. This system can serve as a model for other national fortification programs considering external monitoring approaches. Citation: Wirth JP et al. Nutrients, 11:4741-4759,2013.

Monitoring of Flour Fortification Programs: Case Studies in Three Countries.

Objectives: Although monitoring should be an integral part of any fortification program, little is publicly known about the design, implementation, and results of flour fortification monitoring systems. The objectives are to assess the monitoring systems in three countries including the strengths and weaknesses of each system, how weaknesses are addressed, and lessons learned. Methods: South Africa, Indonesia, and Chile were selected using predetermined criteria (e.g., mandatory fortification legislation, represent different world regions, importation of flour, and existence of a functioning flour fortification monitoring system). Eight categories of regulatory and household/individual monitoring were assessed. Results: The monitoring systems for each country had different strengths and weaknesses. Overall, strengths included having a structured plan for at least some aspects of monitoring, an adequate number of trained inspectors, and the ability to modify regulations and protocols. Monitoring weaknesses included an insufficient multiple agency approach with poor communications within and between organizations, absent commercial monitoring, and lack of laboratory resources and funds. None of the countries had a cohesive monitoring program with regular collection of regulatory and household/individual monitoring information. Conclusions: A functioning flour fortification program depends on having an effective monitoring system in place. Critical to a successful monitoring system was the planning, budget, human resources, and political will necessary to implement monitoring and review monitoring data on a regular basis.

The Micronutrient Survey Manual: A Manual for Assessing Vitamin and Mineral Nutritional Status and Interventions Using Cross-sectional Surveys.

Objectives: An important component of public health nutrition programs is the periodic assessment of vitamin and mineral nutritional status and coverage of micronutrient interventions. Performing high quality cross-sectional surveys can be enhanced by the availability of guidance on steps in survey methods, sample size, sampling methods, data collection, analysis and interpretation, dissemination of results, and appropriate feedback to improve intervention programs. A manual to assist implementers is described. Methods: A previously published manual, "Indicators and Methods for Cross-Sectional Surveys of Vitamin and Mineral Status of Populations", by the Centers for Disease Control and Prevention (CDC) and the Micronutrient Initiative (MI) served as the basis for this newer manual. New technical partners, WHO and UNICEF, have collaborated in the development of this up-to-date "Micronutrient Survey Manual". Results: In addition to updated resources for the assessment of anemia and iodine, iron, and vitamin A deficiencies, the manual has added information on folate and zinc deficiencies. Program indicators for assessing fortification of staple foods, point-of-use fortification with micronutrient powders, micronutrient supplementation, and dietary counselling are included. The manual contains detailed information on biologic sample collection and processing, sample size calculations, and analysis of survey data. Quality assurance throughout the survey process is emphasized. The issues of ethics, confidentiality, and informed consent are addressed. Conclusions: The "Micronutrient Survey Manual" can assist survey managers to improve the validity, efficiency, and standardization of cross-sectional surveys to better serve public health practice.

Micronutrient Supplementation during Pregnancy among Mildly and Non-anemic Women: Effects on Iron Status and Hemoglobin.

Objectives: Universal prenatal iron-folic acid and other micronutrient supplements are recommended to prevent anemia during pregnancy, but the evidence of their effect on iron status among women with mild or no anemia is limited. This study is to describe the iron status [serum ferritin (SF), serum transferrin receptor (sTfR), and body iron (BI)] before and after micronutrient supplementation during pregnancy. Methods: Among 834 pregnant women with mild or no anemia (Hb >110 g/L) from a subset of participants in a randomized, double-blind trial in China, women were randomly assigned to daily 400 µg folic acid (FA) (control), folic acid plus 30mg iron (IFA,), or folic acid, iron, plus 13 additional multiple micronutrients (MM) provided before 20 weeks gestation to delivery. Venous blood was collected during study enrollment (<20 weeks gestation) and at 28-32 weeks gestation. Results: At 28-32 weeks gestation , compared to FA group, both the IFA and MM group showed significantly lower prevalence of iron deficiency (ID) no matter which indicator (SF, sTfR, or BI) was used for defining ID. The prevalence of ID at 28-32 weeks gestation for IFA, MM, and FA were 35.3%, 42.7%, and 59.6% respectively using low SF; were 53.6%, 59.9%, and 69.9% respectively using high sTfR; and were 34.5%, 41.2%, and 59.6% respectively using low BI. However, there was no difference on anemia prevalence between FA and IFA or MM groups. Conclusions: Compared to FA alone, prenatal IFA and MM supplements provided to women with no or mild anemia improved later pregnancy iron status but did not affect perinatal anemia.