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Knowledge About Folic Acid and Use of Multivitamins Containing Folic Acid Among Reproductive-Aged Women -- Georgia, 1995

Neural tube defects (NTDs) are serious birth defects that affect an estimated 4000 pregnancies each year in the United States (1). However, women can substantially decrease the risk for this birth defect by consuming 400 ug (0.4 mg) of folic acid per day before conception and during early pregnancy. In September 1992, the Public Health Service (PHS) recommended that all women of childbearing age who are capable of becoming pregnant consume 400 ug of folic acid daily (2). To characterize knowledge about the benefits of folic acid and use of multivitamins containing folic acid among Georgia women, the Division of Public Health, Georgia Department of Human Resources (GDHR), analyzed data from the 1995 Georgia Women's Health Survey (GWHS) -- a comprehensive study of women's health that included questions about folic acid. This report summarizes the survey findings regarding knowledge and use of folic acid, which indicate that only 20% of Georgia women aged 15-44 years consumed a multivitamin containing greater than or equal to 400 ug of folic acid per day, and 71% did not know that folic acid can prevent some birth defects.

GDHR conducted the GWHS during January-July 1995. GWHS was a random-digit-dialed telephone survey of a probability sample of 4005 Georgia women aged 15-44 years; 3130 (78%) women responded (3). Data for households with more than one eligible woman or multiple residential phone numbers were weighted to adjust for the unequal probability of selection. The sample was highly representative of all childbearing-aged women in Georgia (3).

Survey respondents were asked, "During the past 30 days, how often have you taken multivitamins?"; responses were "every day," "several times a week," "once a week," "less than once a week," and "don't know." Respondents also were asked "What brand of multivitamins do you or did you take most often?" and "Have you heard or read that taking a vitamin called folic acid can help prevent some birth defects?" The amount of folic acid women consumed was estimated based on the amount in the multivitamin brand they reported using.

Overall, 20% (95% confidence interval {CI}=19%-21%) of respondents reported consuming a multivitamin containing greater than or equal to 400 ug of folic acid per day, 5% (95% CI=4%-6%) reported consuming a multivitamin containing greater than or equal to 400 ug of folic acid several times a week, and 29% (95% CI=27%-30%) reported defects. Of those who had heard folic acid can help prevent some birth defects, 30% (95% CI=27%-32%) reported consuming a multivitamin containing greater than or equal to 400 ug of folic acid per day, and 6% (95% CI=5%-8%) reported consuming a multivitamin containing greater than or equal to 400 ug of folic acid several times a week. Of the 71% (95% CI=70%-73%) who had not heard about folic acid, 16% (95% CI=15%-18%) reported consuming a multivitamin containing greater than or equal to 400 ug of folic acid per day, and 4% (95% CI=3%-5%) reported consuming a multivitamin containing greater than or equal to 400 ug of folic acid several times a week.

Prevalence of knowledge about folic acid varied directly by respondents' educational and income levels. Women with a college degree were more likely to have heard about folic acid than were those with only some high school (45% {95% CI=41%-49%} versus 12% {95% CI=9%-15%}), and women with incomes above 150% of poverty level were more likely than women with incomes below 150% of poverty level (31% {95% CI=29%-33%} versus 18% {95% CI=15%-21%}). * Women with higher educational levels were more likely to consume a multivitamin containing greater than or equal to 400 ug of folic acid per day than were less educated women (some high school education {10% (95% CI=7%-13%)}, high school diploma {20% (95% CI=17%-23%)}, some college education {23% (95% CI=20%-25%)}, and college or postgraduate degree {27% (95% CI=24%-30%)}), and women with incomes above 150% of poverty level were more likely than women with incomes below 150% of poverty level (22% {95% CI=20%-23%} versus 14% {95% CI=11%-17%}).

For each educational level, women who reported knowledge of folic acid were more likely to have consumed a multivitamin containing greater than or equal to 400 ug of folic acid per day than women who had not heard about folic acid. Among women who had heard about folic acid, the prevalence of consuming a multivitamin containing greater than or equal to 400 ug per day was 16% (95% CI=8%-24%) for those with some high school education; 32% (95% CI=26%-38%), with a high school diploma; 32% (95% CI=27%-37%), with some college education; and 29% (95% CI=25%-34%), with a college degree.

Reported by: F Serbanescu, MD, R Rochat, MD, Office of Perinatal Epidemiology, Epidemiology and Prevention Br, V Floyd, MD, Family Health Br, KE Toomey, MD, State Epidemiologist, Div of Public Health, Georgia Dept of Human Resources. Birth Defects and Genetic Diseases Br, Div of Birth Defects and Developmental Disabilities, National Center for Environmental Health; Pregnancy and Infant Health Br, and Behavioral Epidemiology and Demographic Research Br, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report are subject to at least two limitations. First, folic acid consumption in the GWHS was measured on the basis of reported use of multivitamins only; no information was obtained about consumption of folic acid tablets or foods fortified with folic acid. Second, 22% of the sample did not participate in the survey, and the survey excluded households without telephones; therefore, prevalences of knowledge and use of folic acid may be overestimated.

In 1986 and 1995, nationwide surveys estimated that 20% and 25% of U.S. women, respectively, reported consuming a multivitamin containing greater than or equal to 400 ug of folic acid per day (4,5); in South Carolina, 12% of the women who gave birth during October 1992-September 1994 reported consuming a multivitamin containing greater than or equal to 400 ug per day (6). These studies and the GWHS findings underscore that 75%-88% of the 60 million women of reproductive age in the United States may not obtain the amount of folic acid recommended by PHS to reduce the risk for spina bifida and other NTDs. In addition, GWHS and a recent survey by the March of Dimes (5) indicate a substantial percentage of reproductive-aged women remain unaware of the potential benefits of folic acid despite publication of the PHS recommendation in 1992.

The results of the survey in Georgia underscore the need for continuing efforts to increase consumption of and awareness about the benefits of folic acid among women of childbearing age. Convenient approaches for ensuring that women obtain adequate amounts of folic acid to reduce the risk for NTDs include daily consumption of either a vitamin supplement or a fortified breakfast cereal containing 400 ug of folic acid. In March 1996, the Food and Drug Administration (FDA) required many enriched foods (e.g., most flours, corn meals, pasta, and rice) to be fortified with 140 ug of folic acid per 100 g of cereal grains by January 1, 1998 (7); this mandate will increase daily consumption of folic acid on average by 100 ug. FDA also issued a regulation that permits the labels of products containing sufficient amounts of folate to claim the products may reduce the risk for having a pregnancy with NTDs (8). The use of health claims on folic acid-containing products and folate-rich foods (e.g., orange juice and green leafy vegetables) will assist in increasing awareness about the benefits of folic acid.

Because women who know about the benefits of folic acid are more likely to consume daily a multivitamin containing 400 ug of folic acid, the design and implementation of health education programs for women of childbearing age will be important in educating them about these benefits at the earliest possible time before they become pregnant.

References

  1. CDC. Surveillance for anencephaly and spina bifida and the impact of prenatal diagnosis -- United States, 1985-1994. In: CDC surveillance summaries (August 25). MMWR 1995;44(no. SS-4).

  2. CDC. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR 1992;41(no. RR-14).

  3. Serbanescu F, Rochat R. Georgia Women's Health Survey, 1995: preliminary report, September 1996. Atlanta, Georgia: Georgia Department of Human Resources, Division of Public Health, Epidemiology and Prevention Branch, Office of Perinatal Epidemiology (in press).

  4. Moss AJ, Levy AS, Kim I, Park YK. Use of vitamin and mineral supplements in the United States: current users, types of products, and nutrients. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, National Center for Health Statistics, 1989.

  5. CDC. Knowledge and use of folic acid by women of childbearing age -- United States, 1995. MMWR 1995;44:716-8.

  6. CDC. Prevention program for reducing risk for neural tube defects -- South Carolina, 1992-1994. MMWR 1995;44:141-2.

  7. Food and Drug Administration. Food standards: amendment of standards of identity for enriched grain products to require addition of folic acid. Federal Register 1996;61:8781-97.

  8. Food and Drug Administration. Food labeling: health claims and label statements -- folate and neural tube defects. Federal Register 1996;61:8752-80.

    • Poverty statistics are based on a definition originated by the Social Security Administration in 1964, that was subsequently modified by federal interagency committees in 1969 and 1980, and prescribed by the Office of Management and Budget as the standard to be used by federal agencies for statistical purposes.




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