EXECUTIVE SUMMARY
While fortifying grain foods with the B vitamin folic acid has saved about 1,300 babies every year from being born with serious birth defects of the brain and spine known as neural tube defects, women of reproductive age still should be counseled to take a multivitamin with folic acid every day.
• Even with fortified grain products, many women still might not be getting enough of the vitamin.
• Recommendations call for all women of childbearing age, whether planning a pregnancy or not, to obtain 400 mcg of folic acid daily from fortified foods, supplements, or both, in addition to consuming folate-rich foods from a varied diet.
While fortifying grain foods with the B vitamin folic acid has saved about 1,300 babies every year from being born with serious birth defects of the brain and spine known as neural tube defects (NTDs), women of reproductive age still should be counseled to take a multivitamin with folic acid every day.1 Why? Even with fortified grain products, many women still might not be getting enough of the vitamin.
Neural tube defects are serious birth defects of the brain or spine that occur when a developing embryo’s neural tube, which forms the brain and the spine, fails to close by the 28th day of pregnancy, explains Jennifer Williams, MSN, MPH, FNP-BC, nurse epidemiologist with the Centers for Disease Control and Prevention’s (CDC’s) National Center for Birth Defects and Developmental Disabilities. Williams served as lead author of a recently published analysis that looked at the number of neural tube defects each year in the United States since mandatory folic acid fortification in enriched grains was implemented in 1998.1
The two most common neural tube defects are spina bifida and anencephaly, notes Williams. Anencephaly is a fatal condition that occurs when the neural tube that forms the brain does not close. The baby will lack parts or all of the brain, skull, and scalp. Spina bifida occurs when there is lack of closure at the lower end of embryo’s neural tube. With this condition, there is an opening in the backbone with exposure of the meninges, often accompanied by spinal cord herniation, Williams notes. Spina bifida can cause physical and intellectual disabilities that range from mild to severe.
“In mild cases, loss of some sensation or movement can occur; in severe cases there is loss of mobility and varying degrees of loss of bowel and bladder control,” says Williams. “Hydrocephalus is common in children with spina bifida.”
The CDC urges all women of childbearing age, whether planning a pregnancy or not, to obtain 400 mcg of folic acid daily from fortified foods, supplements, or both, in addition to consuming folate-rich foods from a varied diet. Getting the recommended amount of folic acid is an important way to help prevent these serious birth defects, Williams says.
To perform the current analysis, scientists looked at information from birth defects tracking systems to estimate the number of babies with an NTD in the years before and after folic acid fortification (1995-2011). The decline in the prevalence of such defects during the period after fortification suggests that folic acid fortification efforts have led to the prevention of many, but not all, neural tube defects, the analysis concludes.1 The number of babies born in the United States with neural tube defects has declined by 35% since 1998, the analysis shows.1
The number of babies born with an NTD each year differs by the mother’s race/ethnicity, analysis findings indicate.1 Hispanic mothers continue to be at the highest risk for having a baby with an NTD. One strategy to combat this risk might be to fortify masa flour with folic acid at the same level as enriched cereal grain products to help women get the proper intake. Implementation of corn masa flour fortification would likely prevent an additional 40 cases each year, research indicates.2
Healthcare providers should counsel all women of reproductive age, whether or not they are planning to have children, about the importance of folic acid supplementation, says Godfrey Oakley, MD, professor of epidemiology at Emory University in Atlanta and director of its Center for Spina Bifida Research, Prevention, and Policy. The Center is focused on helping countries develop and implement regulations that require folic acid, as well as iron, zinc, and vitamin B12, be added to flour, corn, and rice products. Its primary goal is worldwide prevention of spina bifida by 2022.
Spina bifida and anencephaly occur before a women knows she is pregnant; therefore, it is important to counsel all women of reproductive age who could become pregnant, says Oakley. Because approximately one-half of pregnancies occur in women not planning to be pregnant, including women using contraceptives, all women of reproductive age need such counseling, states Oakley.
“I think that all or almost all oral contraceptives should have folic acid in them to protect the fetus from spina bifida and anencephaly when there is a contraceptive failure,” states Oakley. “Such a product is especially needed in countries that do not require folic acid to be added to a centrally processed and widely eaten food, such as the flour that is required to have folic acid in it in the U.S., Canada, and 70 other countries.”
The United States has two oral contraceptives with folic acid supplementation: Beyaz and Safyral from San Francisco-based Bayer Healthcare Pharmaceuticals. Actavis of Parsippany, NJ, is seeking regulatory approval to produce generic equivalents of both pills.
How can you help women of reproductive age to obtain their daily levels of folic acid? Williams suggests that you offer the following three options:
• Take a vitamin supplement containing 400 mcg of folic acid every day.
• Eat a bowl of breakfast cereal every day that has 100% of the daily value (DV) of folic acid.
• Eat a diet with plenty of enriched cereal grain products (bread, rice, pasta, etc.) and other items such as beans, peas, leafy greens, and orange juice.
To emphasize the importance of daily folic acid intake, use a free patient handout from the CDC. Download it at http://1.usa.gov/1k0jOev.
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Williams J, Mai CT, Mulinare J, et al. Updated estimates of neural tube defects prevented by mandatory folic acid fortification — United States, 1995-2011. MMWR 2015; 64(1):1-5.
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Tinker SC, Devine O, Mai C, et al. Estimate of the potential impact of folic acid fortification of corn masa flour on the prevention of neural tube defects. Birth Defects Res A Clin Mol Teratol 2013; 97:649-657.
