Flour Fortification Resulted in 35,500 Healthier Babies Last Year

Total represents 13% of preventable neural tube defects

15 July 2016

Last year an estimated 35,500 babies – an average of 97 a day – were born without neural tube defects (NTDs) in 58 countries which implement mandatory programs to fortify flour with folic acid, according to research published this week in Birth Defects Research Part A: Clinical and Molecular Teratology. The research also notes that this figure only represents 13.2% of all NTDs that could be prevented globally. See the related editorial.

“We have known that folic acid prevents the majority of NTDs for 25 years, yet only a small fraction of these birth defects is being prevented worldwide,” said Vijaya Kancherla, one of the study authors. Kancherla is instructor in the Department of Epidemiology and researcher with the Center for Spina Bifida Prevention at Emory University in Atlanta, Georgia, in the United States. “We urgently need political will to improve the nutrition of women of reproductive age in all countries so that we can prevent serious birth defects that occur due to lack of enough folic acid in the mother.”

NTDs prevented in 2015

No prevention: 0% prevention in countries consuming less than 20 mcg/day of folic acid from fortified flour daily
Modest prevention: 05% prevention in countries consuming 100 mcg/day (range 20-150 mcg/day) of folic acid from fortified flour daily
High prevention: 100% prevention in countries consuming 200 mcg/day (>150 mcg/day) or more of folic acid from fortified flour daily
Click here for a larger version of the map.

The study estimates that 268,700 cases of folic acid-preventable spina bifida and anencephaly – the most common NTDs – would occur annually without any folic acid interventions. With spina bifida, the spine does not form correctly. Spina bifida health outcomes range from some loss of movement to loss of bladder control and paralysis. Children with spina bifida often do not live to be adults. Common causes of death are hydrocephalus, infections, pneumonia, and heart and lung problems. Anencephaly is caused by the brain not forming correctly; it is fatal within days after birth.

The recent analysis focused on 58 countries with mandates to fortify wheat flour alone or in combination with maize flour with at least one part folic acid per million parts flour. Countries were not included if fortification mandates were not implemented or if fortification was voluntary. The study also did not consider whether other foods were fortified with folic acid.

“We concentrated on mandatory flour fortification because it is a proven intervention that reaches the majority of the population in the country equitably,” Kancherla said. “It is safe, effective and extremely cost-saving. In contrast, voluntary fortification, as seen in Ireland, does not reliably prevent NTDs. Also, folic acid supplementation programs often fail because most women do not take folic acid pills before pregnancy, especially if they are not planning the pregnancy. So, mandatory fortification is the best strategy for quick, inexpensive, continuous results.”

The researchers found that Australia and Fiji plus most countries in North, Central, South America and the Caribbean have a high degree of prevention due to mandatory flour fortification. Several countries in Africa have achieved modest prevention. But Europe and most countries in Asia and Africa had no NTD prevention from flour fortification (see map).

Adding folic acid, a form of vitamin B9, to flour increases the population’s blood folate levels. The World Health Organization recommends a red blood folate cell concentration above 400 nanogram/milliliter (ng/mL) in women of reproductive age to prevent NTDs. At these levels, the NTD birth prevalence would be 0.5 to 0.6 per 1000.  Any prevalence higher than this should be considered as an epidemic and result in immediate action, Kancherla said.

A 2006 March of Dimes publication estimated that the average global birth prevalence of NTDs was 2.4 per 1000 live births. This figure did not include pregnancy loss, still births, and terminations of pregnancies due to NTDs. Countries with mandatory fortification programs, such as Canada, Costa Rica, and Australia, report less than the March of Dimes estimate of 2.4 NTDs per 1000 live births.

For this research, authors calculated that 200 micrograms of folic acid a day would prevent most cases of spina bifida and anencephaly. That is based on experiences in the United States where adding folic acid to enriched grain products contributes about 138 micrograms of folic acid a day to Americans’ diets. This is credited with preventing 1,326 NTDs annually. The US mandate has been effective since 1 January 1998. If the annual estimate of NTDs prevented was consistent throughout the past 18 years, 23,868 birth defects have been prevented thus far due to grain fortification in the US.

Infants born with spina bifida will undergo a lifetime of surgeries and face many health issues. Consequently the healthcare costs that are averted when spina bifida is prevented can be tremendous. In the US, preventing spina bifida by fortifying grains represents a net savings of US$ 603 million annually.

Most countries do not have birth defect surveillance systems which makes more accurate global estimates challenging. Country profiles on the Food Fortification Initiative website include the NTD prevalence from other sources if known and from the March of Dimes Global Report if other country data is not available.

For more information:

  • “Folic Acid: The best thing since sliced bread” video explains how NTDs are formed.
  • “Birth defects surveillance: a manual for programme managers” is a World Health Organization document that will help a country expand a hospital-based program or begin a population-based registry for birth defects.