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Designing and implementing effective monitoring and evaluation (M&E) is an integral element of wheat flour fortification programs. This review provides practical guidance for designing a M&E system for a flour fortification program. The Centers for Disease Control and Prevention's Framework for Program Evaluation in Public Health has been adapted to identify key issues in the development of an integrated M&E system. A clear understanding of 1) the stakeholders in flour fortification and their needs, 2) the description and context of the fortification program, 3) the country's wheat flour and flour products market, and 4) the resources available for the M&E component are critical and should be considered early in a program's design.

Governments and donor agencies have implemented pilot and large-scale iron fortification programs, but there has been no consensus on the best choice of indicators to monitor population response to these interventions. We analyzed data from 9 randomized iron intervention trials to determine which of the following indicator(s) of iron status show the largest response in a population: hemoglobin (Hb), ferritin, transferrin receptor (TfR), zinc protoporphyrin (ZPP), mean cell volume (MCV), transferrin saturation (TS), and total body-iron store. We expressed the change in each indicator in response to the iron intervention in SD units (SDU) for the intervention group compared with the control group. Ferritin increased by [greater than or equal to] 0.2 SDU in all trials and was significant in 7. Hb changed by [greater than or equal to]0.2 SDU in 6 and was significant in 5. TfR increased by [greater than or equal to] 0.2 SDU in 5 of 8 interventions in which it was measured and was significant in 4. ZPP increased by [greater than or equal to] 0.2 SDU and was significant in 3 of 6 interventions. Excluding Hb, the indicator with the largest change in SDU was ferritin in 4 trials, TS in 2 trials, body-iron store in 2 trials, and TfR in 1. In the 2 cases in which body-iron stores showed the largest change, the change in ferritin was nearly as large. Our results suggest that with currently available technologies, ferritin shows larger and more consistent response to iron interventions than ZPP or TfR. We cannot make confident inference about MCV or TS, which were included in only 4 and 2 trials, respectively. It is possible that the optimal indicator(s) may differ with age, sex, and pregnancy. There were too few trials in each age and sex group to allow us to explore this question. J. Nutr. 135: 1974-1980, 2005. KEY WORDS: * iron deficiency * hemoglobin * ferritin * transferrin receptor

Background: Hemoglobin and erythrocyte protoporphyrin (EP) tests are commonly used to screen for iron deficiency. However, little research has been done to systematically evaluate the sensitivity and specificity of these 2 tests. Objective: The objective of this study was to evaluate the sensitivity and specificity of hemoglobin and EP measurements in predicting iron deficiency in preschool children and in women of childbearing age. Design: We examined data from the third National Health and Nutrition Examination Survey (n = 2613 children aged 1-5 y and n = 5175 nonpregnant women aged 15-49 y). Children or women with blood lead ⩾ 10 μg/dL were excluded from this study. We used the receiver operating characteristic (ROC) curve to characterize the sensitivity and specificity of hemoglobin and EP measurements in screening for iron deficiency, defined as having abnormal values for ⩾ 2 of the following 3 indexes: mean cell volume, transferrin saturation, and serum ferritin. Results: The ROC performance of EP was consistently better than that of hemoglobin for detecting iron deficiency in preschool children. However, in nonpregnant women, we found no significant difference between EP and hemoglobin in ROC performance for detecting iron deficiency. We observed the same results when we stratified the analyses by sex and race of the children and by race of the women. Conclusions: For children aged 1-5 y, EP is a better screening tool for iron deficiency than is hemoglobin. However, for nonpregnant women, EP and hemoglobin have similar sensitivity and specificity for predicting iron deficiency. [ABSTRACT FROM AUTHOR]