Effectiveness evaluation of the food fortification program of Costa Rica: impact on anemia prevalence and hemoglobin concentrations in women and children
- PMID: 25527765
- PMCID: PMC5884061
- DOI: 10.3945/ajcn.114.097709
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.
Keywords: Costa Rica; anemia; food fortification; hemoglobin; women and children.
© 2015 American Society for Nutrition.
Conflict of interest statement
The authors’ responsibilities were as follows—RM: obtained funding, had full access to the data, wrote the first draft of the manuscript, and had final responsibility for the decision to submit for publication; MA, LT, and TA: were involved in implementing and monitoring the food fortification program in Costa Rica and provided data, government manuals, and reports; RM and MFY: reviewed the literature; RM, MFY, OYA, OD, and RF-A: designed the analyses; OYA: conducted the analyses; and OD: collated food fortification monitoring data. All authors contributed to later versions of the manuscript and read and approved the final version. None of the authors reported a conflict of interest related to the study. The sponsor of the study had no role in study design, data collection, data interpretation, or writing of the manuscript.
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