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Frequently Asked Questions

Folic Acid Fortification and Supplementation

What does it mean to fortify foods?

  • Fortification is a way to add vitamins or minerals, or both, to foods that are staples for most of the country’s population. In the United States, fortified foods can contain added vitamins, minerals, or both, according to regulations set by the U.S. Food and Drug Administration. These regulations allow for both voluntary and mandatory fortification.

What is supplementation?

  • Dietary supplements are products taken by mouth that contain a dietary ingredient that is meant to supplement nutrients in the diet. Folic acid supplements are typically vitamin pills that contain folic acid. Folic acid supplementation is the act of taking a folic acid supplement every day.

What is the history of fortification and supplementation in the United States?

  • In 1992, the U.S. Public Health Service recommended that all women who can become pregnant get 400 micrograms (mcg) of folic acid (vitamin B9) daily to prevent neural tube defects 1. In 1998, the Institute of Medicine’s Food and Nutrition Board of the National Academy of Sciences recommended that, to reduce the risk of having a baby with a neural tube defect, all women who can become pregnant take 400 mcg of folic acid daily (from fortified foods or supplements, or a combination of the two), in addition to consuming food with folate from a varied diet 15.
  • In 1998, the United States began a public health intervention that required manufacturers to fortify cereal grain products labeled as enriched with 140 mcg of folic acid per 100 grams of flour 12. Right after this intervention was started, the number of pregnancies affected by and babies born with neural tube defects began to decline.
  • Using data from a number of birth defects tracking systems, researchers have found that since the beginning of folic acid fortification in the United States, about 1,300 babies are born each year without a neural tube defect who might otherwise have had a neural tube defect 46. Therefore, these data confirm that folic acid fortification is an important way to prevent neural tube defects.
  • Mandatory folic acid fortification has been shown to be an effective public health intervention. Still, not all women of reproductive age are getting the recommended amount of folic acid. This puts them at higher risk for having a baby affected by a neural tube defect. Additional public health interventions targeting these women could help further reduce the number of neural tube defects that occur each year.

What are the differences between voluntary and mandatory fortification?

  • Voluntary fortification allows food manufacturers to add vitamins or minerals, or both, to foods, as long as they abide by the Food and Drug Administration (FDA) food additive regulations.
  • Mandatory fortification requires food manufacturers to add certain vitamins or minerals, or both, to specified foods. Mandatory fortification is done to address a significant public health need. For example, in the 1940s, the FDA required addition of several B vitamins—thiamin, riboflavin, and niacin—to flour to eliminate these vitamin deficiencies in the U.S. population. In 1998, the FDA required that the B vitamin, folic acid, be added to enriched cereal grain products to reduce the risk of neural tube defects.

How much folic acid does an adult consume from foods that are required to be fortified?

How much folic acid does an adult consume from foods that are voluntarily fortified?

Which populations are folic acid supplementation and fortification designed to reach?

Why do the folic acid recommendations include the use of supplements or fortification?

  • The use of dietary supplements and consuming fortified foods can provide the amount of folic acid needed for the prevention of neural tube defects. A woman of reproductive age can decide to take a supplement containing folic acid or to eat foods fortified with folic acid, or both, depending on her dietary habits.

What are the differences between supplementation and fortification?

  • A dietary supplement can provide the full recommended amount of folic acid to a woman of reproductive age to help prevent her baby from having a neural tube defect. However, this approach requires remembering to take the supplement every day. Moreover, while they are relatively inexpensive, supplements can be costly for some women.
  • With mandatory fortification of staple foods, a large proportion of the population is getting more folic acid; therefore, getting enough folic acid to prevent neural tube defects does not require behavior change (such as taking a daily vitamin). Additionally, the added cost to the consumer for fortified food products is low 47.

How have supplementation and fortification affected the number of babies born each year with neural tube defects?

  • Consuming folic acid from fortified foods and vitamin supplements has been proven to prevent neural tube defects, which can be fatal or cause varying degrees of disability. Since fortification started in the United States in 1998, and with the use of folic acid supplements, on average, 1,300 babies are born each year without a neural tube defect who might otherwise have had a neural tube defect. This means that the number of babies born in the United States each year with a neural tube defect has been reduced by about 35% 46.