Prevention of Neural Tube Defects in Europe: A Public Health Failure

Objective: Thirty years ago it was demonstrated that folic acid taken before pregnancy and in early pregnancy reduced the risk of a neural tube defect (NTD). Despite Public Health Initiatives across Europe recommending that women take 0.4 mg folic acid before becoming pregnant and during the first trimester, the prevalence of NTD pregnancies has not materially decreased in the EU since 1998, in contrast to the dramatic fall observed in the USA. This study aimed to estimate the number of NTD pregnancies that would have been prevented if flour had been fortified with folic acid in Europe from 1998 as it had been in the USA.Design and Setting: The number of NTD pregnancies from 1998 to 2017 that would have been prevented if folic acid fortification had been implemented in the 28 countries who were members of the European Union in 2019 was predicted was predicted using data on NTD prevalence from 35 EUROCAT congenital anomaly registries and literature searches for population serum folate levels and folic acid supplementation.Results: From 1998 to 2017 an estimated 95,213 NTD pregnancies occurred amongst 104 million births in the 28 countries in the EU, a prevalence of 0.92 per 1,000 births. The median serum folate level in Europe over this time period was estimated to be 14.1 μg/L. There is a lack of information about women taking folic acid supplements before becoming pregnant and during the first trimester of pregnancy, with one meta-analysis indicating that around 25% of women did so. An estimated 14,600 NTD pregnancies may have been prevented if the European countries had implemented fortification at the level adopted by the USA in 1998 and 25% of women took folic acid supplements. An estimated 19,500 NTD pregnancies would have been prevented if no women took folic acid supplements.Conclusions: This study suggests that failure to implement mandatory folic acid fortification in the 28 European countries has caused, and continues to cause, neural tube defects to occur in almost 1,000 pregnancies every year.

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A Public Health Success Story: Folic Acid Fortification and Supplementation for Prevention of Neural Tube Defects

PsycEXTRA Dataset ◽

10.1037/e509012013-064 ◽

2004 ◽

Author(s):

Linda Longerich ◽

Roy West ◽

Ed Randell ◽

Marian Crowley ◽

Shiliang Liu ◽

...

Keyword(s):

Public Health ◽

Folic Acid ◽

Neural Tube ◽

Neural Tube Defects ◽

Success Story ◽

Folic Acid Fortification

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Impact of folic acid fortification of flour on neural tube defects: a systematic review

Public Health Nutrition ◽

10.1017/s1368980012003576 ◽

2012 ◽

Vol 16 (5) ◽

pp. 901-911 ◽

Cited By ~ 86

Author(s):

Cecilia Castillo-Lancellotti ◽

Josep A Tur ◽

Ricardo Uauy

Keyword(s):

Systematic Review ◽

Folic Acid ◽

Costa Rica ◽

Latin American ◽

Neural Tube ◽

Neural Tube Defects ◽

Folic Acid Fortification ◽

Potential Association ◽

The Usa ◽

The Impact

AbstractObjectiveTo review the impact of folic acid fortification of flour on the prevalence of neural tube defects (NTD).DesignSystematic review of the literature on MEDLINE via PubMed, Scopus, OvidSP and LILACS (Latin American and Caribbean Health Sciences Literature) reporting the impact of folic acid fortification of flour on the prevalence of NTD in 2000–2011. Focusing on Santiago of Chile's birth defects registry (1999–2009) and the monitoring of flour fortification, we analysed the prevalence (NTD cases/10 000 births) pre and post flour fortification and the percentile distribution of folic acid content in flour (2005–2009). We explored the potential association between median folic acid in flour (mg/kg) and the prevalence of NTD.SettingChile, Argentina, Brazil, Canada, Costa Rica, Iran, Jordan, South Africa and the USA.SubjectsLive births and stillbirths.ResultsTwenty-seven studies that met inclusion criteria were evaluated. Costa Rica showed a significant reduction in NTD (∼60 %). Prevalence in Chile decreased from 18·6 to 7·3/10 000 births from 1999 to 2007 and showed a slight increase to 8·5 in 2008–2009, possibly due to changes in fortification limits. When we related the prevalence of NTD with levels of flour fortification, the lowest prevalence was observed at a folic acid level of 1·5 mg/kg.ConclusionsFortification of flour with folic acid has had a major impact on NTD in all countries where this has been reported. Chile showed a 55 % reduction in NTD prevalence between 1999 and 2009. There is a need to constantly monitor the levels of flour fortification to maximize benefits and prevent the potential risk of folic acid excess, moreover to be vigilant for any new adverse effects associated with excess.

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Maternal folic acid supplement use in early pregnancy and child behavioural problems: The Generation R Study

British Journal Of Nutrition ◽

10.1017/s0007114509991954 ◽

2009 ◽

Vol 103 (3) ◽

pp. 445-452 ◽

Cited By ~ 67

Author(s):

Sabine J. Roza ◽

Tamara van Batenburg-Eddes ◽

Eric A. P. Steegers ◽

Vincent W. V. Jaddoe ◽

Johan P. Mackenbach ◽

...

Keyword(s):

Folic Acid ◽

Neural Tube ◽

Neural Tube Defects ◽

Early Pregnancy ◽

First Trimester ◽

Child Behaviour ◽

Folic Acid Supplement ◽

Supplement Use ◽

Acid Supplement ◽

Folic Acid Supplements

Folate deficiency during embryogenesis is an established risk factor for neural tube defects in the fetus. An adequate folate nutritional status is also important for normal fetal growth and brain development. The aim of the present research was to study the association between folic acid use of the mother during pregnancy and child behavioural development. Within a population-based cohort, we prospectively assessed folic acid supplement use during the first trimester by questionnaire. Child behavioural and emotional problems were assessed with the Child Behaviour Checklist at the age of 18 months in 4214 toddlers. Results showed that children of mothers who did not use folic acid supplements in the first trimester had a higher risk of total problems (OR 1·44; 95 % CI 1·12, 1·86). Folic acid supplement use protected both from internalising (OR of no supplement use 1·65; 95 % CI 1·24, 2·19) and externalising problems (OR 1·45; 95 % CI 1·17, 1·80), even when adjusted for maternal characteristics. Birth weight and size of the fetal head did not mediate the association between folic acid use and child behaviour. In conclusion, inadequate use of folic acid supplements during early pregnancy may be associated with a higher risk of behavioural problems in the offspring. Folic acid supplementation in early pregnancy, aimed to prevent neural tube defects, may also reduce mental health problems in children.

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