Effectiveness of flour fortification with iron on anemia and iron deficiency: a systematic review

Anemia is the most common health problem, which affects a considerable number of world populations. Iron deficiency is responsible for more than 50% of all cases of anemia. Food fortification is an important strategy for improving the nutritional situation of populations and has been implemented in few countries for many years. Flour has been offered as a suitable food vehicle for fortification with iron. Fortification of staple foods such as flour must be subjected to evaluation to demonstrate whether or not fortification has been effective. We performed a systematic review of the literature by searching the electronic databases of Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE), PubMed, Clinicaltrials.gov, WHOLIS, SID and Google scholar. We also screened reference lists manually. We searched literature published up to December 2013 for English language literatures and up to 1392 for Persian language literatures to identify studies describing the effectiveness of flour fortification with iron. The selection criteria were trials of flour fortification with iron that assessed effects on hemoglobin, serum ferritin and prevalence of anemia, iron deficiency and iron deficiency anemia. In all 44 papers were included in this review. In general three types of studies were identified. (i): Data from 20 trials showed that flour fortification with iron resulted in a significant improvements in all iron status indicators. These trials were conducted in Uzbekistan, India, Brazil, China, Brazil, Kenya, Vietnam, Zambia, South Africa, Chile and Australia. (ii): Twenty-four trials categorized as moderately efficacious. The trial was considered to be “moderately efficacious” if some iron related parameters improved significantly. These trials were conducted in Iran, Azerbaijan, Kazakhstan, Mongolia, Tajikistan, Uzbekistan, Kenya, Kuwait, Bangladesh, Argentina, Venezuela, Sri Lanka, Morocco, Zambia, China and South Africa. (iii): There were no significant changes in iron related indicators in 28 trials. These trials were conducted in United States, Brazil, Bangladesh, China, Brazil, Thailand, Sri Lanka, South Africa, Kuwait, Argentina, Morocco, Ivory Coast and England. The findings were contradictory on the effectiveness of flour fortification with iron in different countries. A meta-analysis of the studies is recommended to identify the overall effect of flour fortification on anemia and iron deficiency.