Association between National Mandatory Flour Fortification Legislation and Anemia Prevalence among Non-Pregnant Women of Reproductive Age: Findings from the Demographic and Health Surveys in Selected Countries. translation missing: zh.hyrax.visibility.files_restricted.text

Konrad, Victoria (Spring 2019)

Permanent URL: https://etd.library.emory.edu/concern/etds/6682x4961?locale=zh
Published

Abstract

Background: Anemia affects more than 500 million women of reproductive age (WRA) worldwide and carries serious health consequences. Our multi-country analysis aimed at determining whether having national mandatory flour fortification policies for wheat or wheat and maize flour is associated with anemia prevalence among non-pregnant WRA.

Methods: We examined data from the Demographic and Health Surveys (DHS) from 11 countries (Armenia, Burundi, Ethiopia, Haiti, Malawi, Myanmar, Nepal, Tanzania, Timor-Leste, Uganda, and Zimbabwe). Accounting for the complex survey methods of DHS, we estimated the prevalence of anemia by country and conducted multivariable logistic regression considering residence in a country with (n=6) or without (n=5) mandatory flour fortification policy as a main predictor for anemia. Crude and adjusted prevalence odds ratios (cPOR, aPOR) and 95% confidence intervals (CIs) were estimated.

Results: A total of 193,463 non-pregnant WRA were examined from selected countries. Among countries with mandatory fortification for wheat or wheat and maize flour, pooled average anemia prevalence in countries with mandatory fortification was 36.72% (95% CI: 35.79, 37.64); and 34.64% (95% CI: 33.51, 35.77) in countries without fortification; the difference was not statistically significant (= 0.76). Our multivariate analysis found that having a mandatory flour fortification policy was associated with marginally significantly reduced prevalence odds of anemia (aPOR: 0.92, 95% CI: 0.860, 0.999) after controlling for age, Human Development Index classification of the country, urban-rural status and body mass index. 

Conclusions: Utilizing multinational DHS and global fortification data, our findings suggest that having a mandatory flour fortification policy for wheat or wheat and maize flour is associated with a marginally reduced prevalence odds for anemia in non-pregnant WRA. Future studies should examine the association based on longitudinal analyses, using biomarkers for anemia, and considering other potential confounders such as Human Immunodeficiency Virus (HIV) infection and malaria status in WRA that were not available in the DHS datasets.

Table of Contents

CHAPTER I - INTRODUCTION.. 1

CHAPTER II – LITERATURE REVIEW... 3

Anemia. 3

Diagnosis of Anemia. 3

Anemia and Pregnancy. 4

Global Burden of Anemia. 4

Consequences of Anemia. 5

Etiology of Anemia. 5

Food Fortification. 7

Nutrition Supplements. 8

Preconception Micronutrients. 8

Flour Fortification and Anemia Prevalence. 9

Study Rationale. 11

CHAPTER III - METHODS. 12

Demographic and Health Surveys (DHS) 12

Study Population. 12

Study Design. 13

Outcome Measure. 13

Exposure Assessment (Fortification status of a Country) 14

Covariates. 14

Statistical Analysis. 17

CHAPTER IV - RESULTS. 19

CHAPTER V - DISCUSSION.. 20

CHAPTER VI - REFERENCES. 23

CHAPTER VII – TABLES. 27

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