Association between National Mandatory Flour Fortification Legislation and Anemia Prevalence Among Non-Pregnant Women of Reproductive Age: A Difference in Differences Approach Pubblico

Abstract

Background: Anemia remains a public health concern for nearly one-third of the global population. Food fortification has shown to be a cost-effective, evidence-backed method to alleviate nutritional deficiencies, and recent literature indicates it may be a successful intervention to reduce anemia prevalence among non-pregnant women of reproductive age. Our multinational analysis attempted to determine if mandatory fortification policies have been effective in reducing anemia prevalence.

Methods: We utilized Demographic and Health Survey data from five countries: two with mandatory fortification legislation (exposed, including Nepal and Uganda) and three without (control, including Armenia, Ethiopia, and Haiti). We combined individual-level anemia status and covariates with country-level indicators before and after mandatory fortification policies were implemented and applied a difference in differences approach to estimate the differences in anemia prevalence between exposed and control countries, including means, odds, and corresponding confidence intervals (CIs).

Results: Our analysis included 68,484 non-pregnant women of reproductive age (WRA), with an average weighted anemia prevalence of 33.59% and 31.31% in pre- and post-fortification surveys, respectively. We found a decrease in anemia prevalence (mean difference estimate: -1.78, 95% CI: -2.93, -0.64) among countries with mandatory fortification policies (compared to not), between the time period before and after policy implementation, after controlling for age, body mass index, urban/ rural residential status, highest education level, oral contraceptive use, Human Development Index classification, and malaria endemicity.

Conclusions: Our results suggest a lower anemia prevalence among non-pregnant WRA after the implementation of mandatory fortification policies. Future research should expand this analysis to include more countries, across larger time periods, with an emphasis on incorporating accurate biomarker measurements to control for unmeasured confounders. Particular attention should also be paid to the individual- and/or household-level consumption of fortified products.

Table of Contents

CHAPTER I - BACKGROUND........................................................................................................................................... 1

Global Burden of Anemia................................................................................................................................................ 1

Food Fortification and Anemia....................................................................................................................................... 4

Current State of National Mandatory Flour Fortification Policies.................................................................................. 5

Fortifying Flour with Iron to Prevent Anemia................................................................................................................ 6

CHAPTER II - MANUSCRIPT.......................................................................................................................................... 8

Title, Authors, Abstract.................................................................................................................................................. 8

Introduction................................................................................................................................................................... 9

Methods........................................................................................................................................................................ 10

Results.......................................................................................................................................................................... 13

Discussion..................................................................................................................................................................... 14

References..................................................................................................................................................................... 17

Tables............................................................................................................................................................................ 21

CHAPTER III - PUBLIC HEALTH IMPLICATIONS.......................................................................................................... 28

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Global Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Nutrition Health Sciences, Epidemiology
Parola chiave	DID flour fortification mandatory anemia difference in differences
Committee Chair / Thesis Advisor	Vijaya Kancherla, Emory University
Committee Members	Helena Pachon, Emory University

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