A Decade of Folic Acid Fortification: Time to Reassess Strategies?

Flour fortification to prevent neural tube defects was mandated in the United States in January, 1998. Canada, Chile and a number of other countries in Central and South America have also fortified flour and other staple foods. In the intervening years, these countries, on the whole, saw a substantial decline in the prevalence of NTDs that range from 25% to 55%; the relative change appears to be dependent on the magnitude of the prevalence prior to fortification. While the rates for all race and ethnic groups have fallen, there remain disparities by race and ethnicity. Most notable in the United States is the disparity among Hispanics. Prior to fortification, Hispanics had about twice the prevalence of NTDs; with fortification the prevalence declined in all race/ethnic groups, but the disparity among Hispanics remains. While there has been much success preventing the occurrence of NTDs in countries that fortify wheat flour, much of the world's supply of this staple food product remains unfortified. A global effort is underway to mobilize country leaders and the milling industry to fortify all flour manufactured in large mills, where fortification can be carried out safely and economically. These initiatives include the Flour Fortification Initiative, a network of public, private and civic sector organizations working to make fortification a routine practice. The current era of flour fortification has generated interest in the potential additional benefits and potential unforeseen health consequences of folic acid. Issues range from reduced risk for other birth defects (heart defects and cranial facial malformations) to, more recently, possible promotion of the precursors of colorectal cancer. This special session will discuss the following four topics providing current perspectives on the scientific evidence and the public health measures needed to address each: (1) A global perspective on impact of flour fortification on NTD rates (J. Mulinare); (2) An examination of additional prevention strategies that may impact NTD disparities among Hispanics in the United States and in other countries (JF Cordero); (3) A review of other health effects of folic acid and their implications for public health prevention strategies (RJ Berry); and (4) A global effort to fortify flour and other cereal grains with folic acid and other important micronutrients (I Parvanta.)