Folic Acid Fortification Reduces Birth Defects

Fortifying the U.S. food supply with the B vitamin folic acid has helped to decrease the number of birth defects known as neural tube defects (NTDs) since it became mandatory to do so, new research suggests. According to a study appearing in the June 20 issue of the Journal of the American Medical Association, there has been a 19 percent decrease in NTDs since mandatory fortification began.

Spina bifida (failure of the bones surrounding the spinal cord to fuse) and anencephaly (defects in the development of the brain and skull) are the two most common NTDs — they occur in nearly 4,000 pregnancies and affect

2,500-3,000 births each year in the U.S.  Folic acid is a necessary factor in the proper development of the fetus, and previous research has shown that folic acid supplementation during the first trimester of pregnancy decreases the occurrence of NTDs.

The U.S. PHS recommended that women of reproductive age take four hundred micrograms of folic acid per day to help prevent NTDs. A later survey revealed that only 29 percent of women were following this guideline.  Thus in 1996 the Food and Drug Administration allowed the suppletion of folic acid to fortified grain foods, such as breads, pastas, rice, flour and cereals, and made it a mandatory requirement by 1998. The current study evaluates whether this fortification has been effective in decreasing NTDs.

Margaret A. Honein, Ph.D., M.P.H., of the National Center on Birth Defects and Development Disabilities at the Center for Disease Control and Prevention in Atlanta, and colleagues evaluated birth certificate data in 45 states and Washington, D.C. The researchers compared the number of NTDs informed on birth certificates before fortification (October 1995 through December 1996) to that reported after mandatory fortification (October 1998 though December 1999).

The number of NTDs informed on birth certificates diminished from 37.7 per hundred thousand live births before fortification to 30.4 per hundred thousand after mandatory fortification — a 19 percent decline. Spina bifida decreased from 26.2 per 100,000 to 20.2 per 100,000 (23 percent), while anencephaly decreased from 11.6 per hundred thousand to 10.3 per hundred thousand (11 percent).

In an accompanying editorial, Lucinda England, M.D., M.S.P.H. and James L. Mills, M.D., M.S., of the Pediatric Epidemiology Section at the National Institutes of Health agree that this study provides important supporting information that food fortification helps to reduce NTDs. They express concerns, however, that the use of birth certificates to estimate NTD reduction as a result of fortification may be unreliable for two main reasons: first, fetal deaths and stillbirths, which are common in NTD pregnancies, are not recorded on birth certificates; and second, many fetuses with NTDs are identified by prenatal screening and these pregnancies are generally terminated. Thus birth certificates may not be reflective of the total number of pregnancies affected by NTDs.

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