Modeling shows high potential of folic acid‐fortified salt to accelerate global prevention of major neural tube defects

Abstract

Background: We estimated the global proportion of folic acid-preventable spina bifida and anencephaly (FAP SBA) potentially prevented through mandatory double fortification of iodized salt with folic acid. Methods: Using United Nations Children's Fund (UNICEF) and Global Fortification Data Exchange (GFDx) data sets, we modeled country-specific number of FAP SBA cases prevented annually using (a) current coverage of the salt in households worldwide and (b) expected daily amount of folic acid intake from folic acid-fortified iodized salt. Our evidence-based modeling strategy assumed mandatory folic acid fortification of salt at 20 ppm, and that at 200 μg/day intake of folic acid through fortified salt, should achieve 100% prevention of all FAP SBA in countries. Results: One hundred countries that have data on percent of households consuming iodized salt globally were examined; 55 of them have ≥80% households consuming iodized salt. Our model estimated approximately 180,000 cases of FAP SBA could be prevented in these 100 countries through folic acid-fortified iodized salt, and 150,000 of them would be in countries where ≥80% households consuming iodized salt that can be potentially fortified with folic acid. Salt fortification with folic acid could contribute to the prevention of about 65% global FAP SBA cases annually. Conclusions: Our evidence-based model shows that there is high potential to prevent FAP SBA using folic acid-fortified iodized salt. Prevention will reach countries where there is a limited reach of centrally processed folic acidfortified wheat or maize flour. If this intervention is made feasible by the salt industry, it can accelerate the prevention of FAP SBA significantly.

Folic Acid–Fortified Iodized Salt and Serum Folate Levels in Reproductive-Aged Women of Rural India

“…The high potential of accelerating the global prevention of folic acid–preventable SBA through use of folic acid–fortified iodized salt was modeled recently. 16 Our results provide the needed evidence to show the effectiveness of the intervention to inform SBA prevention policy. As India and other countries are working toward achieving 2030 Sustainable Development Goals on preventable mortality among neonates and children younger than 5 years, 20 folic acid fortification of iodized salt can serve as a promising strategy.…”

“…The folic acid concentration can be adjusted for lower daily salt consumption, keeping in focus the goal to reduce sodium intake. The high potential of accelerating the global prevention of folic acid–preventable SBA through use of folic acid–fortified iodized salt was modeled recently . Our results provide the needed evidence to show the effectiveness of the intervention to inform SBA prevention policy.…”

“…Salt iodization has been a global success in preventing iodine deficiency; according to the Global Fortification Data Exchange, iodization was implemented sustainably in 126 countries through mandatory legislation and an additional 21 countries as a voluntary policy in the year 2022 . Folic acid–fortified iodized salt can be an effective strategy to accelerate global SBA prevention . According to the 2018-2019 India Iodine Survey, 76% of Indian households have access to edible salt with adequate iodine (≥15 ppm) .…”

“…15 Folic acid–fortified iodized salt can be an effective strategy to accelerate global SBA prevention. 16 According to the 2018-2019 India Iodine Survey, 76% of Indian households have access to edible salt with adequate iodine (≥15 ppm). 17 Use of iodized salt in India offers a promising opportunity for wide-scale SBA prevention.…”

Global Neurosurgery: Progress and Resolutions at the 75th World Health Assembly

“…18,19 Other methods of dietary fortification, such as folic acid fortification of salt, have shown promise to decrease rates of SB-f, through mathematical modeling. 20 In 2018, neurosurgeons published the first article on advocacy related to folic acid fortification efforts. 15 Informed advocacy for folate fortification was recommended to be a central and integral part of the global neurosurgical approach to NTDs.…”