Cost-effectiveness of mandatory folic acid fortification of flours in prevention of neural tube defects: A systematic review

Abstract

Background Neural tube defects (NTDs) constitute the most frequent group among congenital malformations and are the main cause of neonatal morbimortality. Folic acid (FA) can reduce the risk of pregnancies affected by NTDs. Objective We aimed to investigate whether mandatory folic acid (FA) fortification of flours is cost-effective as compared to non-mandatory fortification, and to verify whether FA dosage, cost composition, and the quality of economic studies influence the cost-effectiveness of outcomes. Methods We conducted a systematic review. The protocol was registered on PROSPERO (CRD 42018115682). A search was conducted using the electronic databases MEDLINE/PubMed, Web of Science, Embase, Scopus, and EBSCO/CINAHL between January 2019 and October 2020 and updated in February 2021. Eligible studies comprised original economic analyses of mandatory FA fortification of wheat and corn flours (maize flours) compared to strategies of non-mandatory fortification in flours and/or use of FA supplements for NTD prevention. The Drummond verification list was used for quality analysis. Results A total of 7,859 studies were identified, of which 13 were selected. Most (77%; n = 10) studies originated from high-income countries, while three (23%) were from upper-middle-income countries. Results of a cost-effectiveness analysis showed that fortification is cost-effective for NTD prevention, except for in one study in New Zealand. The cost-benefit analysis yielded a median ratio of 17.5:1 (0.98:1 to 417.1:1), meaning that for each monetary unit spent in the program, there would be a return of 17.5 monetary units. Even in the most unfavorable case of mandatory fortification, the investment in the program would virtually payoff at a ratio of 1:0.98. All FA dosages were cost-effective and offered positive health gains, except in one study. The outcomes of two studies showed that FA dosages above 300 μg/100 g have a higher CBA ratio. The studies with the inclusion of “loss of consumer choice” in the analysis may alter the fortification cost-efficacy ratio. Conclusion We expect the findings to be useful for public agencies in different countries in decision-making on the implementation and/or continuity of FA fortification as a public policy in NTD prevention.

Effect of Amino Acids on Folates Accumulation in Wheat Seedlings during Germination under Red Light Radiation

“…Unfortunately, it is difficult to reach the RDI of folates from one’s daily diet—especially for pregnant women and the elderly—without supplements. The mandatory fortification of folic acid—the man-made form of folates—in food has been applied in many countries and a significantly lower occurrence of folate-related disorders, such as neural tube defects, spina bifida, and encephalocele, was achieved [ 3 , 4 ]. However, reports of adverse health outcomes from excess intake of folic acid have aroused wide concern regarding this mandatory fortification [ 5 ], so developing food enriched with a natural form of folates is required.…”

Prevented cases of neural tube defects and cost savings after folic acid fortification of flour in Brazil

“…A systematic review [ 15 ] of 13 cost-effectiveness studies of the mandatory FA fortification of flour found that FA dosages above 0.30 mg/100 g had a higher cost-effectiveness ratio and provided greater benefits (prevented cases and direct cost savings). This systematic review indicated a median return ratio of 17.5:1.…”

“…Studies indicate a heavy economic burden of NTDs on health systems, which can be substantially reduced with preventive measures, such as flour fortified with FA [ 13 , 14 ]. Most economic analyses of the cost of these disorders have been conducted in the context of high-income countries, which tend not to reflect the economic burden of NTDs in low- and middle-income countries [ 15 ].…”

Integrated surveillance strategy to support the prevention of neural tube defects through food fortification with folic acid: the experience of Costa Rica

“…Supplementation faces many challenges as public health intervention, including that more than half the pregnancies on a global level are not planned [ 32 ], which makes it more challenging to consume the required supplements before conception. Therefore, large-scale FAFF has emerged as the most cost-effective intervention to improve folate status at the population level [ 7 , 33 ]. Currently, about 80 countries have mandatory FAFF programs [ 34 ], but few have monitored their effectiveness establishing proper quality assurance monitoring and evaluation practices, and even fewer have established appropriate NTDs surveillance systems or correlated these with folate determinations, both at the biological level and in the fortified foods.…”