Impact of Folic Acid Fortification of the US Food Supply on the Occurrence of Neural Tube Defects | Congenital Defects | JAMA | JAMA Network
Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 35.175.212.130. Please contact the publisher to request reinstatement.
JAMA Network Home
JAMA
full text icon
Full Text
 contents icon
Contents
 figure icon
Figures /
Tables
 multimedia icon
Multimedia
 attach icon
Supplemental
Content
 references icon
References
 related icon
Related
 comments icon
Comments
1.
Mulinare J, Erickson D. Prevention of neural tube defects.  Teratology.1997;56:17-18.Google Scholar
2.
CDC.  Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects.  MMWR Morb Mortal Wkly Rep.1992;41(RR-14):1-7.Google Scholar
3.
MRC Vitamin Study Research Group.  Prevention of neural tube defects.  Lancet.1991;338:131-137.Google Scholar
4.
Czeizel AE, Dudas I. Prevention of the first occurrence of neural tube defects by periconceptional vitamin supplementation.  N Engl J Med.1992;327:1832-1835.Google Scholar
5.
Cornel MC, Erickson JD. Comparison of national policies on periconceptional use of folic acid to prevent spina bifida and anencephaly (SBA).  Teratology.1997;55:134-137.Google Scholar
6.
CDC.  Knowledge and use of folic acid by women of childbearing age.  MMWR Morb Mortal Wkly Rep.1999;48:325-327.Google Scholar
7.
Food and Drug Administration.  Food Standards.  Federal Register.1996;61:8781-8797.Google Scholar
8.
Gregory III JF. Bioavailability of folate.  Eur J Clin Nutr.1997;51(suppl 1):554-559.Google Scholar
9.
Romano PS, Waitzman NJ, Scheffler RM, Pi RD. Folic acid fortification of grain.  Am J Public Health.1995;85:667-676.Google Scholar
10.
Freire WB, Hertrampf E, Cortes F. Effect of folic acid fortification in Chile: prelimary results.  Eur J Pediatr Surs.2000;10 Suppl 1:42-43.Google Scholar
11.
Adams T, Jeffreson S. Australia implements voluntary folate fortification.  Am J Public Health.1996;86:593-594.Google Scholar
12.
Turner LA, McCourt C. Folic acid fortification.  CMAJ.1998;158:773-774.Google Scholar
13.
Skeaff M, Mann J. Should folate be added to flour to prevent neural tube defects?  N Z Med J.1998;111:417-418.Google Scholar
14.
Daly S, Scott JM. The prevention of neural tube defects.  Curr Opin Obstet Gynecol.1998;10:85-89.Google Scholar
15.
Wynn M, Wynn A. Fortification of grain products with folate.  Nutr Health.1998;12:147-161.Google Scholar
16.
Committee on Medical Aspects of Food and Nutrition Policy (COMA).  Folic acid and the prevention of disease. London, England: Department of Health; 2000.
17.
Tolson GC, Barnes JM, Gay GA, Kowaleski JL. The 1989 revision of the US standard certificates and reports.  Vital Health Stat.June 1991;No.28:1-34. DHHS publication PHS 91-1465.Google Scholar
18.
Freedman MA, Gay GA, Brockert JE, Potrzebowski PW, Rothwell CJ. The 1989 revisions of the US standard certificates of live birth and death and the US standard report of fetal death.  Am J Public Health.1988;78:168-172.Google Scholar
19.
Taffel SM, Ventura SJ, Gay GA. Revised US certificate of birth.  Birth.1989;16:188-193.Google Scholar
20.
Watkins ML, Edmonds L, McClearn A, Mullins L, Mulinare J, Khoury M. The surveillance of birth defects.  Am J Public Health.1996;86:731-734.Google Scholar
21.
Piper JM, Mitchel EF, Snowden M, Hall C, Adams M, Taylor P. Validation of the 1989 Tennessee birth certificates using maternal and newborn hospital records.  Am J Epidemiol.1993;137:758-768.Google Scholar
22.
Olsen CL, Polan AK, Cross PK. Case ascertainment for state-based birth defects registries.  Paediatr Perinat Epidemiol.1996;10:161-174.Google Scholar
23.
Jacques PF, Selhub J, Bostom AG, Wilson PWF, Rosenberg IH. The effect of folic acid fortification on plasma folate and total homocysteine concentrations.  N Engl J Med.1999;340:1449-1454.Google Scholar
24.
Lawrence JM, Petitti DB, Watkins M, Umekubo MA. Trends in serum folate after food fortification.  Lancet.1999;354:915-916.Google Scholar
25.
Rosenfield A. Women's reproductive health.  Am J Obstet Gynecol.1993;169:128-133.Google Scholar
26.
Cohen SA, Saul R. The campaign against partial-birth abortion.  Guttmacher Rep Public Policy.1998;1:6-10.Google Scholar
27.
Ventura SJ, Martin JA, Curtin SC, Mathews TJ, Park MM. Births: Final Data for 1998. National Vital Statistics Report. Hyattsville, Md: National Center for Health Statistics; 2000. Vol 48. No 3.
28.
Crowder SV. Average run lengths of exponentially weighted moving average charts.  J Qual Technol.1987;19:161-164.Google Scholar
29.
CDC.  Trends in spina bifida and anencephalus in the United States, 1991-1999. Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/folic/folic.htm. Accessed December 12, 2000.
30.
CDC.  Folate status in women of childbearing age-United States, 1999.  MMWR Morb Mortal Wkly Rep.2000;49:962-965.Google Scholar
31.
Watkins ML, Erickson JD, Mulinare JRE. The effect of folic acid fortification on plasma folate and total homocysteine concentrations.  N Engl J Med.1999;341:923-924.Google Scholar
32.
Daly LE, Kirke PN, Molloy A, Weir DG, Scott JM. Folate levels and neural tube defects.  JAMA.1995;274:1698-1702.Google Scholar
33.
Wald NJ, Law M, Jordan R. Folic acid food fortification to prevent neural-tube defects.  Lancet.1998;351:834.Google Scholar
34.
Daly S, Mills JL, Molloy AM.  et al.  Minimum effective dose of folic acid for food fortification to prevent neural-tube defects.  Lancet.1997;350:1666-1669.Google Scholar
35.
Rader JI, Weaver CM, Angyal G. Total folate in enriched cereal-grain products in the United States following fortification.  Food Chem.2000;70:275-289.Google Scholar
36.
Hook EB, Czeizel AE. Can terathanasia explain the protective effect of folic-acid supplementation on birth defects?  Lancet.1997;350:513-515.Google Scholar
37.
Nelen W, Blom H, Steegers E, Den Heijer M, Thomas C, Eskes T. Homocysteine and folate levels as risk factors for recurrent early pregnancy loss.  Obstet Gynecol.2000;95:519-524.Google Scholar
38.
Wald NJ, Hackshaw AK. Folic acid and miscarriage.  Am J Med Genet.2001;98:204.Google Scholar
39.
Grevengood C, Shulman LP, Dungan JS.  et al.  Severity of abnormality influences decision to terminate pregnancies affected with fetal neural tube defects.  Fetal Diagn Ther.1994;9:273-277.Google Scholar
40.
Pryde PG, Isada NB, Hallak M, Johnson MP, Odgers AE, Evans MI. Determinants of parental decision to abort or continue after non-aneuploid ultrasound-detected fetal abnormalities.  Obstet Gynecol.1992;80:52-56.Google Scholar
41.
Roberts HE, Moore CA, Cragan JD, Fernhoff PM, Khoury MJ. Impact of prenatal diagnosis on the birth prevalence of neural tube defects, Atlanta, 1990-1991.  Pediatrics.1995;96:880-882.Google Scholar
42.
Velie EM, Shaw GM. Impact of prenatal diagnosis and elective termination on prevalence and risk estimates of neural tube defects in California, 1989-1991.  Am J Epidemiol.1996;144:473-479.Google Scholar
43.
Allen WP, Stevenson RE, Thompson SJ, Dean JH. The impact of prenatal diagnosis on surveillance.  Prenat Diagn.1996;16:531-535.Google Scholar
44.
Forrester MB, Merz RD, Yoon PW. Impact of prenatal diagnosis and elective termination on the prevalence of selected birth defects in Hawaii.  Am J Epidemiol.1998;148:1206-1211.Google Scholar
This Issue
Citations 691
View Metrics
Original Contribution
June 20, 2001

Impact of Folic Acid Fortification of the US Food Supply on the Occurrence of Neural Tube Defects

Margaret A. Honein, PhD, MPH; Leonard J. Paulozzi, MD; T. J. Mathews, MS; et al J. David Erickson, DDS, PhD; Lee-Yang C. Wong, MS
Author Affiliations

Author Affiliations: National Center on Birth Defects and Developmental Disabilities (Drs Honein, Paulozzi, and Erickson, and Ms Wong) and Division of Vital Statistics, National Center for Health Statistics (Mr Mathews), Centers for Disease Control and Prevention, Atlanta, Ga.

JAMA. 2001;285(23):2981-2986. doi:10.1001/jama.285.23.2981
visual abstract icon
Visual
Abstract
 editorial comment icon
Editorial
Comment
 related articles icon
Related
Articles
 author interview icon
Interviews
 multimedia icon
Multimedia
Abstract

Context Daily consumption of 400 µg of folic acid before conception and during early pregnancy dramatically reduces the occurrence of neural tube defects (NTDs). Before food fortification, however, only an estimated 29% of US reproductive-aged women were taking a supplement containing 400 µg of folic acid daily. The US Food and Drug Administration authorized addition of folic acid to enriched grain products in March 1996, with compliance mandatory by January 1998.

Objective To evaluate the impact of food fortification with folic acid on NTD birth prevalence.

Design, Setting, and Population National study of birth certificate data for live births to women in 45 US states and Washington, DC, between January 1990 and December 1999.

Main Outcome Measure Birth certificate reports of spina bifida and anencephaly before fortification (October 1995 through December 1996) compared with after mandatory fortification (October 1998 through December 1999).

Results The birth prevalence of NTDs reported on birth certificates decreased from 37.8 per 100 000 live births before fortification to 30.5 per 100 000 live births conceived after mandatory folic acid fortification, representing a 19% decline (prevalence ratio [PR], 0.81; 95% confidence interval [CI], 0.75-0.87). During the same period, NTD birth prevalence declined from 53.4 per 100 000 to 46.5 per 100 000 (PR, 0.87; 95% CI, 0.64-1.18) for women who received only third-trimester or no prenatal care.

Conclusions A 19% reduction in NTD birth prevalence occurred following folic acid fortification of the US food supply. However, factors other than fortification may have contributed to this decline.

×