Prevalence of Spina Bifida and Anencephaly During the Transition to Mandatory Folic Acid Fortification in the United States

Williams, Laura; Cara, T.; Edmonds, Larry D.; Shaw, Gary M.; Kirby, Russell S.; Hobbs, Charlotte A.; Sever, Lowell E.; Miller, Lisa; Meaney, F. John; Levitt, Miriam

doi:10.1097/00006254-200302000-00004

Cited by 98 publications

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“…The smallest decrease occurred in the state of California in the USA (15?5 %) (23) . Twenty-one articles reported on the prevalence of spina bifida before and after flour fortification (15,16,19,(21)(22)(23)25,26,28,(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41) . The largest reductions reported were in Costa Rica (61 %) (28) , Canada (55 %) (21) and Chile (55 %) (25) The latter study examined the number of NTD cases between the years 1998 and 2007.…”

Section: Resultsmentioning

confidence: 99%

“…The smallest decline was in blacks, who also had the lowest prevalence of spina bifida before fortification (36) . With respect to anencephaly (15,16,19,(21)(22)(23)25,26,29,30,(32)(33)(34)(35)(36)(37)39,40) , the greatest reductions after fortification observed were in Costa Rica (68 %) (28) the province of Ontario in Canada (58 %) (16) Argentina (57 %) (25) and Chile (50 %) (35) . The smallest reduction was in South Africa (9?8 %) (22) and in African Americans in the USA (9?1 %) (36) .…”

Section: Resultsmentioning

confidence: 99%

“…Williams et al looked at the prevalence of spina bifida and anencephaly in different ethnic groups in the USA. They found the largest reductions in the Hispanic population and the smallest reduction in the African-American population, which had a lower initial prevalence and, therefore, a lower potential reduction (32) . These differences must be considered in addition to food consumption patterns, which differ in intake of folate-rich foods and vitamin supplements.…”

Section: References Identified Medline Viamentioning

confidence: 98%

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Impact of folic acid fortification of flour on neural tube defects: a systematic review

Castillo-Lancellotti

Tur

Uauy

2012

Public Health Nutr.

188

141

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Objective: To review the impact of folic acid fortification of flour on the prevalence of neural tube defects (NTD). Design: Systematic review of the literature on MEDLINE via PubMed, Scopus, OvidSP and LILACS (Latin American and Caribbean Health Sciences Literature) reporting the impact of folic acid fortification of flour on the prevalence of NTD in 2000-2011. Focusing on Santiago of Chile's birth defects registry (1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009) and the monitoring of flour fortification, we analysed the prevalence (NTD cases/ 10 000 births) pre and post flour fortification and the percentile distribution of folic acid content in flour (2005)(2006)(2007)(2008)(2009). We explored the potential association between median folic acid in flour (mg/kg) and the prevalence of NTD. Setting: Chile, Argentina, Brazil, Canada, Costa Rica, Iran, Jordan, South Africa and the USA. Subjects: Live births and stillbirths. Results: Twenty-seven studies that met inclusion criteria were evaluated. Costa Rica showed a significant reduction in NTD ( , 60 %). Prevalence in Chile decreased from 18?6 to 7?3/10 000 births from 1999 to 2007 and showed a slight increase to 8?5 in 2008-2009, possibly due to changes in fortification limits. When we related the prevalence of NTD with levels of flour fortification, the lowest prevalence was observed at a folic acid level of 1?5 mg/kg. Conclusions: Fortification of flour with folic acid has had a major impact on NTD in all countries where this has been reported. Chile showed a 55 % reduction in NTD prevalence between 1999 and 2009. There is a need to constantly monitor the levels of flour fortification to maximize benefits and prevent the potential risk of folic acid excess, moreover to be vigilant for any new adverse effects associated with excess. Keywords Folic acid Neural tube defects Spinal dysraphism Food fortification Systematic reviewThe importance of nutrition in the aetiology of neural tube defects (NTD) was suggested by Hibbard and Smithells, who found that women deficient in folate had an increased number of abortions, placental abruptions and fetal malformations and intra-uterine growth retardation (1) . The first reports on folate deficiency and NTD, published by Smithells et al. (2,3) , showed the protective effect of folic acid on the recurrence of NTD. A randomised study by Czeizel and Dudas (4) showed a decrease in first NTD occurrence in women supplemented with twelve vitamins containing 0?8 mg of folic acid, but not in women supplemented with trace elements and a very low dose of vitamin C. A rigorous double-blind randomised controlled trial supported by the UK Medical Research Council showed that supplementing women who had a history of children with NTD with 4 mg of folic acid daily decreased recurrence by 72 % (5) . Although some studies were retrospective, their results revealed an inverse relationship between NTD and folic acid consumption of 100-400 mg/d (6,7) . Based on this information, in 1992 the US Public Health Service r...

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: References Identified Medline Viamentioning

confidence: 98%

See 1 more Smart Citation

Impact of folic acid fortification of flour on neural tube defects: a systematic review

Castillo-Lancellotti

Tur

Uauy

2012

Public Health Nutr.

188

141

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“…8,9 Indeed, studies in the United States have suggested a significant decrease in the prevalence of spina bifida and anencephaly as the Food and Drug Administration (FDA) mandated the addition of folic acid to all enriched cereal grain products by January 1998. [10][11][12] Cancer Low-plasma folate levels have been associated with an increased incidence of a number of types of cancer. Folate deficiency seems to predispose normal tissue to neoplastic transformation, and folate supplementation can suppress the development of tumors in normal tissue.…”

Section: Neural Tubule Defectsmentioning

confidence: 99%

Investigation of inter-individual variability of the one-carbon folate pathway: a bioinformatic and genetic review

2009

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“…Unfortunately, compliance with this advice has been poor (8)(9)(10)(11)(12)(13)(14) , and this fact, plus the recognition that as many as 50 % of all pregnancies are unplanned (15) and unlikely to be protected, has led governments in the USA, Canada, Chile and other countries to introduce mandatory folic acid fortification of grain products (16)(17)(18)(19) . These policies have succeeded in reducing NTD occurrence by approximately 20-50 % (20)(21)(22)(23)(24) and may also have reduced stroke-related mortality in the general population (25,26) , as well as having had some benefit against CHD through their effect on lowering homocysteine (27) .…”

mentioning

confidence: 99%

Use of FAO food balance sheets to estimate the potential ability of novel folate-enriched eggs to increase the folate supply in European Union countries

Sheehy

Sharma

2010

Public Health Nutr.

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Objective: European governments have yet to introduce mandatory folic acid fortification of foods for neural tube defect prevention because of uncertainty about the long-term safety of high intake of folic acid. Novel folate-enriched eggs have been proposed as offering a practical way of increasing intake of natural folates, which do not have the same safety concerns as synthetic folic acid. Our objective was to estimate the potential increase in folate supply that could occur in European Union (EU) countries if normal eggs were replaced by folate-enriched eggs. Design: FAOSTAT data on daily per capita availability of eggs were linked to mean folate concentrations of un-enriched and folate-enriched eggs from three representative feeding trials from the recent literature. Setting: Data were collated in Microsoft Excel. Subjects: The study used food balance sheets for Europe for 1961-2003 and for twenty-six individual EU countries for 2003.Results: There has been little variation in egg supply in Europe over the past 40 years, with eggs providing only about 1?3-1?6 % of total energy. In 2003, the average per capita egg supply across twenty-six EU countries was 32?8 g/d, equivalent to a little over half an egg. Even if the folate concentrations of all eggs across the EU were increased two-to threefold, per capita folate supply would increase only by about 25 mg/d. Conclusions: At current enrichment levels, the availability of novel folate-enriched eggs will have little impact on folate supply in EU countries. In the absence of mandatory fortification, additional natural folate sources are needed urgently.

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Prevalence of Spina Bifida and Anencephaly During the Transition to Mandatory Folic Acid Fortification in the United States

Cited by 98 publications

References 0 publications

Impact of folic acid fortification of flour on neural tube defects: a systematic review

Impact of folic acid fortification of flour on neural tube defects: a systematic review

Investigation of inter-individual variability of the one-carbon folate pathway: a bioinformatic and genetic review

Use of FAO food balance sheets to estimate the potential ability of novel folate-enriched eggs to increase the folate supply in European Union countries

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