Academic journal article Canadian Journal of Public Health

Folic Acid and the Prevention of Neural Tube Defects (NTDs): Challenges and Recommendations for Public Health

Academic journal article Canadian Journal of Public Health

Folic Acid and the Prevention of Neural Tube Defects (NTDs): Challenges and Recommendations for Public Health

Article excerpt

ABSTRACT

Objective: To outline specific challenges facing public health in Canada that need to be addressed to ensure that all women of childbearing years can attain optimal folate status for prevention of NTDs.

Methods: The new Dietary Reference Intake (DRI) for folate was examined in terms of the literature on the effective form of the vitamin, the level of folic acid provided by the Canadian food supply and the folic acid content of available supplements.

Findings: There are six major challenges facing public health in Canada on this issue. These include confusion among health professionals and the general public on the effective form of the vitamin, requirements, and the necessity of taking supplements. Further obstacles to ensuring optimal folate status in all women of childbearing age in Canada include the limited amounts of folic acid that are currently permitted in foods and the difficulties involved in identifying the amount of folic acid provided in these foods in relation to needs.

Interpretation: These challenges must be addressed to enable women in Canada to make an informed choice about folic acid. This has the potential to prevent up to 70% of the 300 births affected by NTDs each year.

In Canada, approximately 300 (or 1 of every 1000) births are affected by Neural Tube Defects (NTDs) each year, with spina bifida being the most common NTD.1 Direct health care costs for children with spina bifida could be up to $1.7 million per year. These costs do not account for the physical and emotional tolls upon the families affected nor do they reflect the lost economic potential associated with NTDs. While prenatal screening for NTDs can be performed with reasonable accuracy and reliability, no treatment is available in utero for the correction of NTDs. One of the most important medical breakthroughs in recent times was the discovery that taking a simple B vitamin, folic acid, in the peri-conceptual period could protect as many as 70% of babies affected by neural tube defects.2-4 Given the limitations of prenatal screening, primary prevention of NTDs is an issue of tremendous importance. However, by the time most women realize that they are pregnant, the period where folic acid is protective will have passed because the neural tube closes within 3 to 4 weeks after conception. Therefore, one of the greatest challenges for public health is to ensure that all women of childbearing years have optimal folate status for prevention of NTDs. This paper outlines the specific challenges facing Public Health in Canada.

Challenge 1: Health professionals and the public do not fully understand that it is folic acid, the synthetic form of the B vitamin, rather than the folate found naturally in foods that plays a role in the prevention of NTDs.

Scientific evidence has demonstrated that a maternal red blood cell folate level of >400 ng/mL, at the time of conception, is optimal in reducing risk of NTDs developing in the fetus.5 This optimal level is much greater than the cut-off level used to determine folate deficiency leading to megaloblastic anemia (red cell folate <= 140 ng/mL.)6 It has been demonstrated that the optimal level of folate status can only be achieved through the consumption of 0.4 mg of the synthetic form of the vitamin (folic acid) and not through the consumption of foods naturally rich in folate.6-9 This is because folic acid is much more stable and bioavailable than its natural form, folate.

In 1998, Canada and the United States harmonized nutrition recommendations, and introduced a special recommendation that all women of childbearing age consume 0.4 mg/day of synthetic folic acid from fortified foods or vitamin supplements (see Table I) in addition to natural food folate to help prevent NTDs.6

Challenge 2: All women need to be aware of their specific folic acid requirements for occurrence and recurrence of NTDs.

Factors that put women at much higher risk of having a pregnancy affected by NTDs include having had a previously affected pregnancy (i. …

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