Reduction in Neural-Tube Defects after Folic Acid Fortification in Canada

Department of Social and Preventive Medicine, Laval University, Quebec City, Quebec, Canada
New England Journal of Medicine (Impact Factor: 55.87). 08/2007; 357(2):135-42. DOI: 10.1056/NEJMoa067103
Source: PubMed


In 1998, folic acid fortification of a large variety of cereal products became mandatory in Canada, a country where the prevalence of neural-tube defects was historically higher in the eastern provinces than in the western provinces. We assessed changes in the prevalence of neural-tube defects in Canada before and after food fortification with folic acid was implemented.
The study population included live births, stillbirths, and terminations of pregnancies because of fetal anomalies among women residing in seven Canadian provinces from 1993 to 2002. On the basis of published results of testing of red-cell folate levels, the study period was divided into prefortification, partial-fortification, and full-fortification periods. We evaluated the relationship between baseline rates of neural-tube defects in each province and the magnitude of the decrease after fortification was implemented.
A total of 2446 subjects with neural-tube defects were recorded among 1.9 million births. The prevalence of neural-tube defects decreased from 1.58 per 1000 births before fortification to 0.86 per 1000 births during the full-fortification period, a 46% reduction (95% confidence interval, 40 to 51). The magnitude of the decrease was proportional to the prefortification baseline rate in each province, and geographical differences almost disappeared after fortification began. The observed reduction in rate was greater for spina bifida (a decrease of 53%) than for anencephaly and encephalocele (decreases of 38% and 31%, respectively).
Food fortification with folic acid was associated with a significant reduction in the rate of neural-tube defects in Canada. The decrease was greatest in areas in which the baseline rate was high.

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Available from: Michiel Van den Hof
    • "Spina bifida describes a spectrum of neurological impairment resulting from failure of fusion of the caudal neural tube. It is one of the most common congenital disorders leading to disability (Mitchell et al. 2004) with a prevalence of 4.1 affected children per 10 000 births in Canada (8.6 per 10 000 births for all neural-tube defects) (De Wals et al. 2007). Children born with spina bifida are at risk for hydrocephalus, leg weakness and paralysis, sensory loss, and bladder and bowel incontinence (Mitchell et al. 2004). "
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    ABSTRACT: Background Urinary incontinence is frequently experienced by children with spina bifida, putting them at increased risk for low self-esteem and impacting upon participation in home, school and leisure activities. However, little is known about children's experiences of these continence issues.Objective This study explored the experiences of children and young people with spina bifida around continence issues, social participation and peer relationships, in order to identify potential areas of support healthcare professionals can provide.Methods Children and youth aged 6–18 years with diagnoses of spina bifida and neurogenic bladder and their parents were invited to participate in semi-structured interviews. Descriptive thematic analysis was employed.ResultsEleven children (with a range of mobility levels, types of spina bifida and degrees of bladder control) and their parents participated in the study. Three broad themes were identified, which encompassed the following: (1) normal versus different; (2) independence, ownership and the road to continence; and (3) peer relationships and acceptance.DiscussionThe experiences discussed by the children and parents in this study ranged from minimal impact of incontinence on their day-to-day living to significant social isolation and rejection. The stigma of incontinence was apparent in all interviews. Children and youth who were able to control their bladder with minimal accidents had greater independence and more opportunities for social participation. Healthcare professionals need to take into account that parents and their children may differ in attitudes and desires about the management of incontinence.
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    • "One environmental change, with the potential to affect all residents, was the addition of folic acid to cereals starting in 1998. This was done to reduce the incidence of neural tube defects in newborns [23]. "
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    • "The multifactorial etiology of NTDs includes genetic predisposition, maternal nutritional deficiencies and other environmental factors (Eskes, 1998; Melvin et al., 2000). Notably, folate deficiency during pregnancy is one of the most important risk factors for NTDs and the periconceptional supplementation of folic acid has proven to prevent 50-70% of NTDs (Wald et al., 1991; De Wals et al., 2007). "
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