Folate fortification and supplementation in prevention of folate-sensitive neural tube defects: a systematic review of policy

Abstract

OBJECTIVENeural tube defects (NTDs) are common congenital neurological defects, resulting in mortality, morbidity, and impaired quality of life for patients and caregivers. While public health interventions that increase folate consumption among women who are or plan to become pregnant are shown to reduce folate-sensitive NTDs, public health policy reflecting the scientific evidence lags behind. The authors aimed to identify the types of policies applied, associated outcomes, and impact of folate fortification and supplementation on NTDs worldwide. By identifying effective legislation, the authors aim to focus advocacy efforts to more broadly effect change, reducing the burden of NTDs in neurosurgery.METHODSA systematic review was conducted exploring folate fortification and supplementation policies using the PubMed and Scopus databases. Titles and abstracts from articles identified were read and selected for full-text review. Studies meeting inclusion criteria were reviewed in full and analyzed for study design, aim, population, interventions, and outcomes.RESULTSOf 1637 resultant articles, 54 were included. Mandatory folate fortification was effective at reducing folate-sensitive NTDs. Mandatory fortification also decreased hospitalization rates and deaths after discharge and increased 1st-year survival for infants with NTDs. Recommended folate supplementation also resulted in decreased NTDs; however, issues with compliance and adherence were a concern and impacted effectiveness. Folate fortification and/or supplementation resulted in decreased NTD prevalence, although more change was attributed to fortification. Dual policies may hold the most promise. Furthermore, reductions in NTDs were associated with significant cost savings over time.CONCLUSIONSBoth mandatory folate fortification and recommended supplementation policies were found to effectively decrease folate-sensitive NTD rates when applied. A comprehensive approach incorporating mandatory folate fortification, appropriate folate supplementation, and improved infrastructure and access to prenatal care may lead to decreased NTDs worldwide. This approach should be context-specific, emphasize education, and account for regional access to healthcare and social determinants of health. With wide implications for NTDs, associated health outcomes, quality of life of patients and caregivers, and economic impacts, policy changes can drastically improve global NTD outcomes. As caretakers of children with NTDs, the authors as neurosurgeons advocate for a comprehensive policy, the engagement of stakeholders, and a broader global impact.

Preventing birth defects, saving lives, and promoting health equity: an urgent call to action for universal mandatory food fortification with folic acid

“…21 A policy review of supplementation and fortification concluded that a comprehensive approach that is contextspecific and combines both mandatory fortification and targeted supplementation might be most effective in preventing spina bifida and anencephaly. 22 Existing support and resources for implementing and evaluating fortification 23 Several organisations are working to build political will for fortification through sciencebased advocacy, including the Center for Spina Bifida Prevention, the Food Fortification Initiative, Nutrition International, and the Global Alliance for Improved Nutrition. These organisations aid governments in assessing need, relevance, and feasibility of fortification; implementing fortification, including optimising the design and harmonising efforts with other regional or national nutrition initiatives; assessing the quality and reach of fortified foods in the population; and evaluating costeffectiveness and nutritional impact.…”

Mandatory food fortification with folic acid – Authors' reply

“…We referred to a synergistic approach that is context-specific, combining mandatory fortification to reach the majority of the population, while adding a more targeted supplementation programme for populations that are hard to reach or high risk. 6 We have also cited a 2018 economic evaluation 7 in which the author found that investment in folic acid fortification in low-income and middle-income countries was favourable. We do not agree with Kar and colleagues that mandatory food fortification is a "costly" and "culturally questionable strategy", as the evidence points differently.…”

Educating the Next Generation of Global Neurosurgeons: Competencies, Skills, and Resources for Medical Students Interested in Global Neurosurgery

“…Although the incidence of neural tube defects has markedly decreased in countries that have implemented mandatory food fortification with folic acid, only 18% of folic acid-preventable cases of spina bifida and anencephaly are currently being prevented because the majority of countries globally do not have mandatory food fortification policies. 48,49 Economic considerations are central. Table 3 presents common terms in microeconomics, macroeconomics, and cost analysis, 50,51 though understanding these terms is insufficient alone.…”