Motherisk alert: Folic acid fortification of flour—three years later
Fortification of flour with folic acid aims to prevent neural tube defects. In Canada, flour fortification began in 1997. The objective of this study was to quantify the changes in women's erythrocyte folic acid levels. Comparing these levels among normocytic women revealed an almost twofold increase (from 517+/-215 nmol/L in 1995 to 901+/-318 nmol/L in 1998) (P<0.00001). While the mean value increased substantially, even now, women at the low range of measured values (367 nmol/L) confer a relative risk of 3.2 for neural tube defects. For these women, higher intake of nutritional folic acid and perinatal supplementation of folic acid tablets continue to be crucial.
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ABSTRACT: ABSTRACT: The need to increase the number of physicians who incorporate folic acid nutritional counseling for female patients of childbearing age, and their limited training in this area, prompted the development and evaluation of two versions of a Web-based instruction about folic acid. The overall goal was to increase the number of clinicians who are prepared to offer folic acid counseling, and to motivate them to adopt such counseling. We sought to determine whether an abbreviated (15 minute) module more effectively promoted knowledge and behavior competency than an extended (40 minute) module. To assess the impact of the modules on knowledge, attitudes, and behavior, this study tested them among 271 students at three medical schools. Assessments were done at baseline, post-instruction, and 7 weeks after the instruction. There was a significant increase in competency over the measurement periods (p<0.001). After their participation, students expressed confidence and preparedness to advise patients about the vitamin, and expressed intent to implement folic acid counseling in clinical practice. There were no significant differences in results for the two versions of the module, but the amount of time spent in a module was a significant variable. Students who spent >15 minutes in either program were twice as likely to achieve competency at the posttest versus those who spent less than or equal to 15 minutes in either training (OR 2.05; 95% CI=1.13-4.76; p=0.0216). Additionally, significantly higher scores were found among females than among males in two of three assessment periods, at baseline (p=0.003) and retest (p=0.009), suggesting that the female participants knew more about the subject at baseline, and retained more information than males. The number of females reporting daily folic acid intake also rose significantly from 36% at baseline to 46% at retest (p=0.004). These results suggest that the modules provided effective instruction, and also effectively promoted behavior change among the females, who are both clinicians and women of childbearing age. This study appears to be the first of its kind and has yielded a variety of data that may be useful for determining the length, content, and design of Web-based programs for folic acid education and nutrition education in general. KEYWORDS: nutrition, birth defects, pregnancy, folic acid, vitamins, medical education System requirements: World Wide Web browser and PDF reader. Mode of access: World Wide Web. Title from title page of source document. Document formatted into pages; contains viii, 246 p.; also contains graphics. Thesis (Ph. D.)--University of Florida, 2001. Includes vita. Includes bibliographical references.
Available from: Bhushan M Kapur
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ABSTRACT: Three quarters of neural tube defects (NTD) can be prevented by sufficient dietary folate supplementation. Despite this knowledge, most women do not supplement their diet effectively. Red cell folate concentrations correlate with the risk of NTD, and levels of less than 900 nM are associated with an increased risk of these serious congenital anomalies.
Laboratory tests to assess anemia include testing for folate. This study was conducted to estimate the potential benefits of informing women of reproductive age who are unaware of their low folate levels, uncovered in their anemia tests.
The number of Ontario women of reproductive age who undergo folate tests and are at an increased risk of NTD was calculated. In addition, the authors calculated the number of NTD cases that could have been prevented if these women were informed of the possible consequences of their low folate levels should they become pregnant.
In 1998, red cell folate concentrations were measured in 23,109 women of childbearing age (15-45 y). Approximately half of the women [n = 11,392 (49.3%)] had folate levels below 900 nM and thus were at an increased risk of giving birth to a child with NTD should they have become pregnant. Their overall mean relative risk (RR) of NTD was 1.95, or 1:512 births. If they would have been informed of this risk and subsequently increased their consumption of folate before becoming pregnant, 22.3 cases of NTD per year could have possibly been prevented at no extra cost, since the folic acid results were a part of investigational blood tests performed for another reason (anemia).
Women of reproductive age who are being evaluated for the cause of anemia and have low red cell folate results constitute a high-risk group for NTD in their children. These women should be informed of the increased risk and of methods of dietary folate supplementation.
Therapeutic Drug Monitoring 11/2002; 24(5):628-30. DOI:10.1097/00007691-200210000-00008 · 2.38 Impact Factor
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ABSTRACT: Neuroblastoma, an embryonic tumor, is the second most common pediatric tumor and is the most prevalent extracranial solid tumor in children. Results of previous studies have suggested that maternal vitamin intake may decrease the risk of several childhood cancers. In January 1997, Canada began fortifying flour with folic acid for the prevention of neural tube defects. The effect of folic acid fortification on the rate of neuroblastoma in offspring is not known.
We investigated the rates of neuroblastoma (<1 year), acute lymphoblastic leukemia, and hepatoblastoma registered by the Pediatric Oncology Group of Ontario, which captures 95% of all pediatric cancers in Ontario, before and after the introduction of folate fortification.
An interventional time series analysis showed that the incidence of neuroblastoma declined from 1.57 cases per 10,000 births before to 0.62 case per 10,000 births after folic acid fortification (P <.0001). The crude incidence rate ratio (0.40; 95% confidence interval, 0.25-0.64) remained significant after adjustment for both age and disease stage at diagnosis (adjusted incidence rate ratio, 0.38; 95% confidence interval, 0.23-0.62). In contrast, there was no significant change in the rate of infant acute lymphoblastic leukemia (incidence rate ratio, 0.97; 95% confidence interval, 0.41-2.27) or hepatoblastoma (incidence rate ratio, 0.81; 95% confidence interval, 0.35-1.89).
Folic acid fortification was associated with a 60% reduction in neuroblastoma but was not associated with any change in the rate of infant acute lymphoblastic leukemia or hepatoblastoma. Further investigation is needed into the role of metabolism in the formation and prevention of neuroblastoma and other embryonically determined cancers.
Clinical Pharmacology & Therapeutics 09/2003; 74(3):288-94. DOI:10.1016/S0009-9236(03)00200-5 · 7.90 Impact Factor
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