title: 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.
  
  
  METHODS
  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.
authors.affiliation: From the Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (RM, MFY, OYA, and RF-A); Dirección de Desarrollo Científico y Tecnológico en Salud, Ministerio de Salud, San José, Costa Rica (MA and LT); Centro Nacional de Referencia de Bromatología, Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud (INCIENSA), Cartago, Costa Rica (TA); Nutrition Division, Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, United States Agency for International Development (USAID), Washington, DC (OD); and the International Micronutrient Malnutrition Prevention and Control (IMMPaCt) Program, Nutrition Branch, Division of Nutrition, Physical Activity and Obesity, U.S. CDC, Atlanta, GA (RF-A).
authors.forename: Reynaldo
authors.initials: R
authors.lastname: Martorell
authors.affiliation: From the Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (RM, MFY, OYA, and RF-A); Dirección de Desarrollo Científico y Tecnológico en Salud, Ministerio de Salud, San José, Costa Rica (MA and LT); Centro Nacional de Referencia de Bromatología, Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud (INCIENSA), Cartago, Costa Rica (TA); Nutrition Division, Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, United States Agency for International Development (USAID), Washington, DC (OD); and the International Micronutrient Malnutrition Prevention and Control (IMMPaCt) Program, Nutrition Branch, Division of Nutrition, Physical Activity and Obesity, U.S. CDC, Atlanta, GA (RF-A).
authors.forename: Melany
authors.initials: M
authors.lastname: Ascencio
authors.affiliation: From the Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (RM, MFY, OYA, and RF-A); Dirección de Desarrollo Científico y Tecnológico en Salud, Ministerio de Salud, San José, Costa Rica (MA and LT); Centro Nacional de Referencia de Bromatología, Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud (INCIENSA), Cartago, Costa Rica (TA); Nutrition Division, Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, United States Agency for International Development (USAID), Washington, DC (OD); and the International Micronutrient Malnutrition Prevention and Control (IMMPaCt) Program, Nutrition Branch, Division of Nutrition, Physical Activity and Obesity, U.S. CDC, Atlanta, GA (RF-A).
authors.forename: Luis
authors.initials: L
authors.lastname: Tacsan
authors.affiliation: From the Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (RM, MFY, OYA, and RF-A); Dirección de Desarrollo Científico y Tecnológico en Salud, Ministerio de Salud, San José, Costa Rica (MA and LT); Centro Nacional de Referencia de Bromatología, Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud (INCIENSA), Cartago, Costa Rica (TA); Nutrition Division, Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, United States Agency for International Development (USAID), Washington, DC (OD); and the International Micronutrient Malnutrition Prevention and Control (IMMPaCt) Program, Nutrition Branch, Division of Nutrition, Physical Activity and Obesity, U.S. CDC, Atlanta, GA (RF-A).
authors.forename: Thelma
authors.initials: T
authors.lastname: Alfaro
authors.affiliation: From the Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (RM, MFY, OYA, and RF-A); Dirección de Desarrollo Científico y Tecnológico en Salud, Ministerio de Salud, San José, Costa Rica (MA and LT); Centro Nacional de Referencia de Bromatología, Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud (INCIENSA), Cartago, Costa Rica (TA); Nutrition Division, Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, United States Agency for International Development (USAID), Washington, DC (OD); and the International Micronutrient Malnutrition Prevention and Control (IMMPaCt) Program, Nutrition Branch, Division of Nutrition, Physical Activity and Obesity, U.S. CDC, Atlanta, GA (RF-A).
authors.forename: Melissa F
authors.initials: MF
authors.lastname: Young
authors.affiliation: From the Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (RM, MFY, OYA, and RF-A); Dirección de Desarrollo Científico y Tecnológico en Salud, Ministerio de Salud, San José, Costa Rica (MA and LT); Centro Nacional de Referencia de Bromatología, Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud (INCIENSA), Cartago, Costa Rica (TA); Nutrition Division, Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, United States Agency for International Development (USAID), Washington, DC (OD); and the International Micronutrient Malnutrition Prevention and Control (IMMPaCt) Program, Nutrition Branch, Division of Nutrition, Physical Activity and Obesity, U.S. CDC, Atlanta, GA (RF-A).
authors.forename: O Yaw
authors.initials: OY
authors.lastname: Addo
authors.affiliation: From the Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (RM, MFY, OYA, and RF-A); Dirección de Desarrollo Científico y Tecnológico en Salud, Ministerio de Salud, San José, Costa Rica (MA and LT); Centro Nacional de Referencia de Bromatología, Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud (INCIENSA), Cartago, Costa Rica (TA); Nutrition Division, Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, United States Agency for International Development (USAID), Washington, DC (OD); and the International Micronutrient Malnutrition Prevention and Control (IMMPaCt) Program, Nutrition Branch, Division of Nutrition, Physical Activity and Obesity, U.S. CDC, Atlanta, GA (RF-A).
authors.forename: Omar
authors.initials: O
authors.lastname: Dary
authors.affiliation: From the Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (RM, MFY, OYA, and RF-A); Dirección de Desarrollo Científico y Tecnológico en Salud, Ministerio de Salud, San José, Costa Rica (MA and LT); Centro Nacional de Referencia de Bromatología, Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud (INCIENSA), Cartago, Costa Rica (TA); Nutrition Division, Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, United States Agency for International Development (USAID), Washington, DC (OD); and the International Micronutrient Malnutrition Prevention and Control (IMMPaCt) Program, Nutrition Branch, Division of Nutrition, Physical Activity and Obesity, U.S. CDC, Atlanta, GA (RF-A).
authors.forename: Rafael
authors.initials: R
authors.lastname: Flores-Ayala
mesh_terms: D000293:Adolescent; D000328:Adult; D018798:Anemia, Iron-Deficiency / Q000097:blood / Q000178:diet therapy / Q000453:epidemiology / Q000517:prevention & control*; D000818:Animals; D002648:Child; D002675:Child, Preschool; D003364:Costa Rica / Q000453:epidemiology; D005260:Female; D005296:Ferrous Compounds / Q000008:administration & dosage / Q000627:therapeutic use*; D005527:Food, Fortified; D005998:Glycine / Q000008:administration & dosage / Q000627:therapeutic use*; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D007223:Infant; D019266:Iron, Dietary / Q000008:administration & dosage / Q000627:therapeutic use*; D008297:Male; D037141:Mandatory Programs; D008875:Middle Aged; D018673:Nutrition Policy; D009749:Nutrition Surveys; D015995:Prevalence; D015397:Program Evaluation; D018571:Sentinel Surveillance; D055815:Young Adult
chemical_list: D005296:Ferrous Compounds; D006454:Hemoglobins; D019266:Iron, Dietary; C031621:ferrous fumarate; C510030:ferrous bisglycinate; D005998:Glycine
keywords: Costa Rica; anemia; food fortification; hemoglobin; women and children