Objectives: To determine whether there is an association between anemia prevalence in children aged 24-59 months and national mandatory flour fortification legislation.
Design: We conducted an ecologic analysis using retrospective, cross-sectional, population-based, multi-country Demographic and Health Surveys from 2015 through 2018. National-level flour fortification legislation was applied as individual-level exposure. Anemia was defined by hemoglobin concentrations under 11.0 g/dL. Crude and adjusted prevalence odds ratios (cPOR & aPOR) and 95% confidence intervals (CI) were estimated using logistic regression analysis, accounting for complex survey design.
Setting: Demographic and Health Surveys, conducted using two-stage sampling design, from 18 countries.
Participants: Children between 24 and 59 months of age residing in the selected countries whose mothers were interviewed and who were tested for hemoglobin (n=53,576).
Results: In countries with national mandatory flour fortification legislation, 48.72% of children were anemic compared to 45.88% in countries without such legislation. Residence in a country with mandatory flour fortification legislation was associated with a 12% increased prevalence odds of anemia among children aged 24-59 months (cPOR=1.12; 95% CI: 1.05, 1.20). However, after adjusting for potential confounding due to country of residence and interactions with urban-rural residence and education, the association was no longer significant (aPOR: 0.96, 95% CI: 0.73, 1.26).
Conclusions: Our study suggests that nationally mandated flour fortification legislation is not associated with child anemia prevalence. The cross-sectional nature of our study design limits our ability to make a causal inference; our findings are hypothesis-generating. Longitudinal studies are needed to examine fortification policy and childhood anemia.
Table of Contents
Study Population 5
Study Design 6
Outcome Variable 6
Primary Exposure Variable 7
Statistical Analysis 10
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