Folic Acid Helps Prevent Neural Tube Defects
In the United States, 1,300 babies are born healthy each year because of folic acid fortification.1
Folic acid fortification success in the United States
Since starting mandatory fortification in the United States, more babies have been born healthy. About 1,300 babies are born healthy each year in the United States because of mandatory fortification.1 [Read the Key Findings]
Neural tube defects affect some groups of people more than others
Despite mandatory fortification, research shows that some U.S. women still do not get enough folic acid to prevent neural tube defects.3 Neural tube defects are major birth defects of the baby’s brain (anencephaly) and spine (spina bifida). Hispanic/Latina women are more likely to have a child born with a neural tube defect compared to non-Hispanic white and non-Hispanic black women.1,4,5
- Have lower levels of folate in their blood6 compared to non-Hispanic white women
- Are more likely than non-Hispanic white and non-Hispanic black women to have the MTHFR C677T gene variant1,7
- Are less likely to know about the benefits of folic acid8
- Are less likely to get folic acid from fortified foods or take a multivitamin with folic acid in it,8-14 particularly those women who
- Primarily speak Spanish;
- Were born outside of the United States; and
- Have lived in the United States for a shorter period of time.14
Expanding fortification efforts in the United States to prevent more neural tube defects
To help more women in the United States, specifically Hispanics/Latinas, get the recommended daily value of folic acid, the U.S. Food and Drug Administration allowed folic acid to be added voluntarily to corn masa flour.11 This is voluntary fortification.
Corn masa flour is a staple in the diets of many Hispanic/Latina women. Adding folic acid to corn masa flour will
- Increase the average amount of daily folic acid women get; and
- Prevent an estimated 40 additional neural tube defects among Hispanic infants per year.15
Data from 2017–2018 have shown that this voluntary fortification with folic acid has not yet had an impact on the folate status among Hispanic women of reproductive age in the United States. It is important to check the nutrition label on food packaging to see if it contains folic acid, as corn masa flours may or may not contain folic acid.
Daily multivitamin use among women of reproductive age has declined
Specifically, daily multivitamin use declined over time among
- Women aged 25–44 years; and
- Non-Hispanic white and Hispanic women.
In general, women aged 18–24 years reported the lowest daily multivitamin use, compared with women in the other age groups.
Between 2006 and 2012, women who responded to the survey could report their pregnancy status. Of those women who reported pregnancy status, the findings showed a decline in daily multivitamin use for women who were not pregnant and not trying to get pregnant.12
Women should eat a balanced diet rich in folate from food. Foods like leafy, green vegetables, citrus fruits, and beans have folate in them. However, it is very difficult for most women to get the daily recommended amount of folate through food alone (see Table 2: http://ods.od.nih.gov/factsheets/Folate-HealthProfessional).
In addition to eating foods with folate from a varied diet, women can get the recommended 400 micrograms (mcg) of folic acid by
- Taking a vitamin that has folic acid in it;
- Eating fortified foods; or
- Getting a combination of the two: taking a vitamin that has folic acid in it and eating fortified foods.
More neural tube defects can be prevented
A CDC study found that about half of U.S. women report enriched cereal grain products, like breads and pastas labeled as ‘enriched’, as their only source of folic acid.3 Consuming folic acid from a combination of sources like supplements and fortified foods
- Helps women to get the recommended daily dose of 400 micrograms (mcg) of folic acid; and
- Can prevent up to 700 additional neural tube defects each year.3 [Read the Key Findings]
All women of reproductive age should get 400 mcg of folic acid each day to help prevent neural tube defects. Getting more than 400 mcg of folic acid each day is not necessarily better at preventing neural tube defects unless a doctor recommends taking a different amount due to other health conditions.
- 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 Morb Mortal Wkly Rep. 2015;64(1):1–5.
- SD, Berry RJ, Mick Tilford J, Kucik JE, Waitzman NJ. Retrospective assessment of cost savings from prevention: Folic acid fortification and spina bifida in the U.S. Am J Prev Med. 2016;50(5 Suppl 1):S74–s80.
- KS, Qi YP, Devine O, Tinker SC, Berry RJ. Modeling the impact of folic acid fortification and supplementation on red blood cell folate concentrations and predicted neural tube defect risk in the United States: Have we reached optimal prevention? Am J Clin Nutr. 2018;107(6):1027–1034.
- Centers for Disease Control and Prevention (CDC). Racial/ethnic differences in the birth prevalence of spina bifida – United States, 1995–2005. MMWR Morb Mortal Wkly Rep. 2009;57(53):1409–1413.
- MA, Mai CT, Wang Y, et al. The association between race/ethnicity and major birth defects in the United States, 1999–2007. Am J Public Health. 2014;104(9):e14–23.
- Tinker SC, Hamner HC, Qi YP, Crider KS. U.S. women of childbearing age who are at possible increased risk of a neural tube defect-affected pregnancy due to suboptimal red blood cell folate concentrations, National Health and Nutrition Examination Survey 2007 to 2012. Birth Defects Research A Clin Mol Teratol. 2015;103(6):517–526.
- KS, Zhu JH, Hao L, et al. MTHFR 677C->T genotype is associated with folate and homocysteine concentrations in a large, population-based, double-blind trial of folic acid supplementation. Am J Clin Nutr. 2011;93(6):1365–1372.
- deRosset L, Mullenix A, Flores A, Mattia-Dewey D, Mai CT. Promotora de salud: Promoting folic acid use among Hispanic women. J Women’s Health (2002). 2014;23(6):525–531.
- Yang QH, Carter HK, Mulinare J, Berry RJ, Friedman JM, Erickson JD. Race-ethnicity differences in folic acid intake in women of childbearing age in the United States after folic acid fortification: Findings from the National Health and Nutrition Examination Survey, 2001–2002. Am J Clin Nutr. 2007;85(5):1409–1416.
- Wolff T, Witkop CT, Miller T, Syed SB, U.S. Preventive Services Task Force. Folic acid supplementation for the prevention of neural tube defects: An update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2009;150(9):632–639.
- 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 Research A Clin Mol Teratol. 2013;97(10):649–657.
- Wong EC, Rose CE, Flores AL, Yeung LF. Trends in multivitamin use among women of reproductive age: United States, 2006–2016. J Women’s Health (Larchmt). 2019;28(1):37–45.
- HC, Tinker SC, Flores AL, Mulinare J, Weakland AP, Dowling NF. Modelling fortification of corn masa flour with folic acid and the potential impact on Mexican-American women with lower acculturation. Public Health Nutr. 2013;16(5):912–921.
- HC, Cogswell ME, Johnson MA. Acculturation factors are associated with folate intakes among Mexican American women. J Nutr. 2011;141(10):1889–1897.
- Flores AL, Cordero AM, Dunn M, et al. Adding folic acid to corn masa flour: Partnering to improve pregnancy outcomes and reduce health disparities. Prev Med. 2018;106:26–30.