title: Evidence of the effectiveness of flour fortification programs on iron status and anemia: a systematic review.
abstract: BACKGROUND
  More than 80 countries fortify flour, yet the public health impact of this intervention on iron and anemia outcomes has not been reviewed.
  
  
  OBJECTIVE
  The objective of this systematic review was to review published and gray literature pertaining to the impact of flour fortification on iron and anemia.
  
  
  METHODS
  A systematic review was conducted by searching 17 databases and appealing for unpublished reports, yielding 1881 documents.
  
  
  METHODS
  Only studies of government-supported, widely implemented fortification programs in which anemia or iron status was measured prior to and ≥12 months after initiation of fortification were included.
  
  
  METHODS
  Details about the design, coverage, compliance with national standards, and evaluation (e.g., anemia prevalence before and after fortification) of flour fortification programs were extracted from the reports.
  
  
  RESULTS
  Thirteen studies describing 26 subgroups (n = 14 for children ≤15 y, n = 12 for women of reproductive age) were included. During the period from pre- to postfortification (and as difference-in-difference for those studies that included a control group), there were statistically significant decreases in the prevalence of anemia in 4 of 13 subgroups of children and in 4 of 12 subgroups of women of reproductive age as well as significant decreases in the prevalence of low ferritin in 1 of 6 subgroups of children and in 3 of 3 subgroups of women of reproductive age.
  
  
  CONCLUSIONS
  . Evidence of the effectiveness of flour fortification for reducing the prevalence of anemia is limited; however, evidence of effectiveness for reducing the prevalence of low ferritin in women is more consistent.
authors.affiliation: H. Pachón is with the Food Fortification Initiative, Atlanta, Georgia, USA, and the Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA. R. Spohrer is with the Global Alliance for Improved Nutrition, Geneva, Switzerland. Z. Mei and M.K. Serdula are with the US Centers for Disease Control and Prevention, Atlanta, Georgia, USA. helena.pachon@emory.edu.
authors.forename: Helena
authors.initials: H
authors.lastname: Pachón
authors.affiliation: H. Pachón is with the Food Fortification Initiative, Atlanta, Georgia, USA, and the Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA. R. Spohrer is with the Global Alliance for Improved Nutrition, Geneva, Switzerland. Z. Mei and M.K. Serdula are with the US Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Spohrer
authors.affiliation: H. Pachón is with the Food Fortification Initiative, Atlanta, Georgia, USA, and the Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA. R. Spohrer is with the Global Alliance for Improved Nutrition, Geneva, Switzerland. Z. Mei and M.K. Serdula are with the US Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
authors.forename: Zuguo
authors.initials: Z
authors.lastname: Mei
authors.affiliation: H. Pachón is with the Food Fortification Initiative, Atlanta, Georgia, USA, and the Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA. R. Spohrer is with the Global Alliance for Improved Nutrition, Geneva, Switzerland. Z. Mei and M.K. Serdula are with the US Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
authors.forename: Mary K
authors.initials: MK
authors.lastname: Serdula
mesh_terms: D000328:Adult; D018798:Anemia, Iron-Deficiency / Q000097:blood / Q000178:diet therapy / Q000453:epidemiology*; D002648:Child; D016208:Databases, Factual; D005260:Female; D005293:Ferritins / Q000097:blood; D005433:Flour; D005527:Food, Fortified; D014943:Global Health; D006801:Humans; D007501:Iron; D008297:Male; D015995:Prevalence
chemical_list: D005293:Ferritins; D007501:Iron
keywords: enrichment; ferritin; hemoglobin; maize flour; wheat flour