Alina L. Flores

Decline in the Prevalence of Spina Bifida and Anencephaly by Race/Ethnicity: 1995–2002

Objective. In an effort to reduce the occurrence of neural tube defects (NTDs), folic acid fortification of US enriched grain products was authorized by the Food and Drug Administration in March 1996 and required by January 1998. Fortification has been shown to result in an important decline in the prevalence of spina bifida and anencephaly in the general US population; however, fortifications impact on specific racial/ethnic groups has not been well described. We sought to characterize the decline in the prevalence of spina bifida and anencephaly among specific racial/ethnic groups during the transition to mandatory folic acid fortification in the United States. Methods. Data from 21 population-based birth defects surveillance systems were used to examine trends in prevalence of spina bifida and anencephaly for specific racial/ethnic groups for the years 1995–2002. These years were divided into 3 periods: prefortification, optional fortification, and mandatory fortification. Race/ethnicity was defined as Hispanic, non-Hispanic white, and non-Hispanic black. Prevalence ratios were calculated for each racial/ethnic group by dividing the prevalence from the mandatory fortification period by the prevalence in the prefortification period. Results. The study included data on 4468 cases of spina bifida and 2625 cases of anencephaly. The prevalence of spina bifida and anencephaly was highest among Hispanic births, followed by non-Hispanic white births, with the lowest prevalence among non-Hispanic black births. Significant declines in spina bifida and anencephaly were observed among Hispanic births and non-Hispanic white births. The prevalence ratio for non-Hispanic black births was of borderline significance for spina bifida and was not significant for anencephaly. Conclusions. The results of this study suggest that folic acid fortification is associated with significant decreases in the prevalence of spina bifida and anencephaly among non-Hispanic white and Hispanic births. The magnitude of the reduction was similar between these 2 groups and was more pronounced for spina bifida than for anencephaly. The decline in the prevalence of spina bifida and anencephaly among non-Hispanic black births did not reach statistical significance. Efforts to increase folic acid consumption for the prevention of NTDs in pregnancies among women of all races/ethnicities should be continued, and studies to identify and elucidate other risk factors for NTDs are warranted.

Predicted contribution of folic acid fortification of corn masa flour to the usual folic acid intake for the US population: National Health and Nutrition Examination Survey 2001–2004

BACKGROUND Folic acid can prevent up to 70% of neural tube defects (NTDs) if taken before pregnancy. Compared with other race-ethnicities, Hispanic women have higher rates of NTDs, lower rates of folic acid supplement use, and lower total folic acid intakes. OBJECTIVE The objective was to assess potential effects of fortifying corn masa flour with folic acid on Mexican American women and other segments of the US population. DESIGN A model was developed by using data from the National Health and Nutrition Examination Survey 2001-2004 to estimate the folic acid content in foods containing corn masa flour if fortified at a level of 140 microg folic acid/100 g corn masa flour. RESULTS Had corn masa flour fortification occurred, we estimated that Mexican American women aged 15-44 y could have increased their total usual daily folic acid intake by 19.9% and non-Hispanic white women by 4.2%. Among the US population, estimated relative percentage increases in total usual daily folic acid intake with corn masa flour fortification were greatest among Mexican Americans (16.8%) and lowest among children aged 1-3 y (2%) and adults aged >51 y (0-0.5%). CONCLUSION Analyses suggest that corn masa flour fortification would have effectively targeted Mexican Americans, specifically, Mexican American women, without substantially increasing folic acid intake among other segments of the population. Such increases could reduce the disparity in total folic acid intake between Mexican American and non-Hispanic white women of childbearing age and implies that an additional NTD preventive benefit would be observed for Mexican American women.

Neural tube defects in Latin America and the impact of fortification: A literature review

OBJECTIVE Data on the prevalence of birth defects and neural tube defects (NTD) in Latin America are limited. The present review summarizes NTD prevalence and time trends in Latin American countries and compares pre- and post-fortification periods to assess the impact of folic acid fortification in these countries. DESIGN We carried out a literature review of studies and institutional reports published between 1990 and 2010 that contained information on NTD prevalence in Latin America. RESULTS NTD prevalence in Latin American countries varied from 0·2 to 9·6 per 1000 live births and was influenced by methods of ascertainment. Time trends from Bogota, Costa Rica, Dominican Republic, Guatemala City, Mexico and Puerto Rico showed average annual declines of 2·5 % to 21·8 %. Pre- and post-fortification comparisons were available for Argentina, Brazil, Chile, Costa Rica, Puerto Rico and Mexico. The aggregate percentage decline in NTD prevalence ranged from 33 % to 59 %. CONCLUSIONS The present publication is the first to review data on time trends and the impact of folic acid fortification on NTD prevalence in Latin America. Reported NTD prevalence varied markedly by geographic region and in some areas of Latin America was among the lowest in the world, while in other areas it was among the highest. For countries with available information, time trends showed significant declines in NTD prevalence and these declines were greater in countries where folic acid fortification of staples reached the majority of the population at risk, such as Chile and Costa Rica.

Broadcasting Behavior Change A Comparison of the Effectiveness of Paid and Unpaid Media to Increase Folic Acid Awareness, Knowledge, and Consumption Among Hispanic Women of Childbearing Age

Awareness about folic acids effectiveness in reducing the risk of certain birth defects has increased among women in the United States; however, few Hispanic women are consuming enough folic acid daily. A 1998 survey conducted by the Gallup Organization for the National March of Dimes Birth Defects Foundation found that English-speaking Hispanic women had lower folic acid awareness (53% vs. 72%) and lower daily consumption (29% vs. 33%) than non-Hispanic White women. In 1999, the Centers for Disease Control and Prevention (CDC) conducted baseline surveys with Spanish-speaking Hispanic women in selected U.S. markets to measure folic acid awareness, knowledge, and consumption. A Spanish-language public service announcement (PSA) volunteer campaign and a paid Spanish-language media and community education campaign were conducted in 2000 and 2002, respectively. Comparisons of postcampaign surveys indicate that the paid media campaign was significantly more effective than the PSA campaign in increasing folic acid awareness, knowledge, and consumption among Spanish-speaking Hispanic women.

Modelling fortification of corn masa flour with folic acid and the potential impact on Mexican-American women with lower acculturation.

OBJECTIVE Hispanics with lower acculturation may be at higher risk for neural tube defects compared with those with higher acculturation due to lower total folic acid intake or other undetermined factors. Modelling has indicated that fortification of corn masa flour with folic acid could selectively target Mexican Americans more than other race/ethnicities. We assessed whether fortification of corn masa flour with folic acid could selectively increase folic acid intake among Mexican-American women with lower acculturation, as indicated by specific factors (language preference, country of origin, time living in the USA). DESIGN We used dietary intake and dietary supplement data from the National Health and Nutrition Examination Survey 2001-2008, to estimate the amount of additional total folic acid that could be consumed if products considered to contain corn masa flour were fortified at 140 μg of folic acid per 100 g of corn masa flour. SETTING USA. SUBJECTS Non-pregnant women aged 15-44 years (n 5369). RESULTS Mexican-American women who reported speaking Spanish had a relative percentage change in usual daily total folic acid intake of 30·5 (95 % CI 27·8, 33·4) %, compared with 8·3 (95 % CI 7·3, 9·4) % for Mexican-American women who reported speaking English. We observed similar results for other acculturation factors. An increase of 6·0 percentage points in the number of Mexican-American women who would achieve the recommended intake of ≥400 μg folic acid/d occurred with fortification of corn masa flour; compared with increases of 1·1 percentage points for non-Hispanic whites and 1·3 percentage points for non-Hispanic blacks. An even greater percentage point increase was observed among Mexican-American women who reported speaking Spanish (8·2). CONCLUSIONS Fortification of corn masa flour could selectively increase total folic acid intake among Mexican-American women, especially targeting Mexican-American women with lower acculturation, and result in a decrease in the number of pregnancies affected by neural tube defects.

Understanding Optimal Nutrition Among Women of Childbearing Age in the United States and Puerto Rico: Employing Formative Research to Lay the Foundation for National Birth Defects Prevention Campaigns

Neural tube defects (NTDs) are serious birth defects of the brain and spine that affect approximately 3,000 pregnancies in the United States each year and affected 404 pregnancies in Puerto Rico from 1996 to 2002. Consuming the B vitamin folic acid can reduce the incidence of NTDs 50%–70%, and recent efforts to reduce NTD rates have focused on increasing the number of childbearing-aged women who take a vitamin containing folic acid every day. As the first stage of formative research in campaign planning, two exploratory, qualitative studies were conducted in order to (a) understand the complexity of vitamin use among women in the United States and Puerto Rico and (b) serve as a foundation on which to develop national communication and education interventions. Also, this information shed light on theories that might be used to guide campaign development. Results indicated that campaign messages designed to increase folic acid use through multivitamin supplementation in the United States must address womens barriers to vitamin use (e.g., cost, time), increase womens perceived need for multivitamins (e.g., identify immediate, tangible results from taking a daily multivitamin), and address the relationship between daily food choices and the need for supplementation. Future campaign messages in Puerto Rico must focus on many of these same issues, in addition to increasing womens knowledge about when folic acid should be taken in relation to pregnancy and addressing womens perceptions that vitamins cause weight gain (an undesirable outcome for most participants). The practical and theoretical implications of these results are discussed in terms of their contribution to the development of a creative new approach to increase multivitamin consumption among women of childbearing age in the United States and Puerto Rico.

Promotora de salud: promoting folic acid use among Hispanic women.

BACKGROUND The U.S. Public Health Service recommends that all women in the United States capable of becoming pregnant consume 400 μg of folic acid daily to reduce their risk of having a pregnancy affected by a neural tube defect (NTD). However, disparities exist in the consumption of folic acid, with Hispanic women having lower rates of folic acid consumption than non-Hispanic white women. METHODS A community-based feasibility study was designed to assess the utility of the promotora de salud model to promote consumption of multivitamins containing folic acid for the prevention of NTDs among Spanish-speaking Hispanic women in North Carolina. The study consisted of an educational intervention given by a promotora (a lay, community health worker), with data collection occurring at baseline and four months post-intervention to measure changes in knowledge and behavior. Overall, 52% (n=303) of participants completed all components of the study. RESULTS Self-reported daily multivitamin consumption increased from 24% at baseline to 71% four months post-intervention. During the same time frame, awareness of folic acid increased from 78% to 98% and knowledge of the role of folic acid in the prevention of birth defects increased from 82% to 92%. CONCLUSIONS The results of this study indicate that the promotora de salud model may be effective in reaching a subpopulation of women with the folic acid message. Additional studies with larger population sizes are warranted to validate these findings.

Effects of folic acid awareness on knowledge and consumption for the prevention of birth defects among Hispanic women in several U.S. communities.

BACKGROUND The neural tube defects (NTDs) anencephaly and spina bifida, are serious birth defects of the brain and spine that affect about 3000 pregnancies per year in the United States. Research has found a strong link between periconceptional folic acid consumption and NTD prevention. METHODS Because Hispanic women have higher rates of NTD-affected births, targeted folic acid promotion efforts were conducted in several major cities from 1999 to 2002. Efforts included paid and unpaid placements of Spanish language public service announcements (PSAs) and community-level education through the use of promotoras. Analyses focused on whether or not womens reported awareness of folic acid, regardless of promotion type, impacted their knowledge or behavior. RESULTS AND CONCLUSIONS Women who reported awareness of folic acid had greater folic acid knowledge and use of vitamins containing folic acid than those not aware. Analyses also examined the use of vitamins containing folic acid by pregnancy intention among women who reported awareness of folic acid. The results were varied. Pregnancy wanters were most likely to use vitamins containing folic acid daily. For this group, however, awareness did not play as large a role in whether they reported consuming a vitamin containing folic acid or not, as it did for pregnancy waiters and avoiders.

Postpartum women in the Honduran health system: folic acid knowledge, attitudes, and practices

OBJECTIVES This study had two purposes: first, to determine the knowledge, attitudes, and practices related to folic acid and birth defects among a convenience sample of postpartum Honduran women; and second, to identify food consumption patterns in this population and determine high-consumption staples for potential folic acid fortification. METHODS Convenience sampling methodology was used to recruit potential study participants. Participants for this study were 2 619 postpartum Honduran women who had had a normal, in-hospital delivery in one of 16 public hospitals located throughout the country or the two social security hospitals that provide services to the Honduran working class population. Over a 10-month period, in-depth, face-to-face oral interviews, supervised by the research coordinator and staff, were conducted in-hospital prior to discharge. RESULTS The majority of the women were between 16 and 29 years of age. Approximately half of the respondents (46.4%) had heard of folic acid and over one-third (37.6%) knew that it was a vitamin related to preventing birth defects. Birth defects were most often attributed to drug and alcohol use (20.6%) and lack of vitamin intake (18.1%), but 23.0% related defects to mystical, mythical, or religious causes. Aside from red beans, oranges, and natural fruit juices, folate-rich foods are not widely consumed by this population. The highest consumption frequency of staple foods with the potential to be fortified with folic acid were rice, white flour, corn flour, and pasta. CONCLUSIONS Results from this study provide potential avenues for food fortification, as well as underscore the need for further education about the role of folic acid in the prevention of neural tube defects. Results highlight that standardized health education for Honduran women of reproductive age is needed if folic acid consumption through fortification and supplementation is to be successful and sustainable.

Effect of different dosage and administration schedules of folic acid on blood folate levels in a population of Honduran women of reproductive age

BACKGROUND Observational studies and clinical trials have shown conclusive evidence that periconceptional folic acid supplementation prevents up to 70 % of neural tube defects (NTD). The Honduran government wanted to implement a supplementation programme of folic acid but needed to assess the relative effects of two dosages of folic acid. OBJECTIVE To determine the effect of two dosages of folic acid on blood folate levels in Honduran female factory workers aged 18 to 49 years. DESIGN This was a randomized, double-blind control supplementation trial conducted in Choloma, Honduras. A total of 140 eligible women were randomly assigned to two dosage groups and followed up for 12 weeks. One group received a daily dosage of 1 mg folic acid and the other a once weekly dosage of 5 mg. Serum folate and red blood cell folate levels were determined by radioassay at baseline, 6 weeks and 12 weeks. RESULTS Serum folate levels increased from 6.3 (se 0.2) to 14.9 (se 0.6) ng/ml (P < 0.0001) in women assigned to the 1 mg/d group and from 6.9 (se 0.3) to 10.1 (se 0.4) ng/ml (P < 0.0001) in those assigned to the 5 mg/week group. Red blood cell folate concentrations also increased significantly in both groups, albeit more slowly. Educational level, age and BMI were not associated with the changes in serum and red blood cell folate levels during the supplementation period. However, a differential effect on serum folate levels by dosage group and time was observed. CONCLUSIONS Although both folate supplementation regimens increased serum and red blood cell folate levels significantly among the women studied, blood folate levels that are considered to be protective of NTD were reached faster with the daily dosage of 1 mg folic acid.