Achieving Healthier Pregnancies

1
Achieving Healthier Pregnancies NTD Prevention
with Increased Folic Acid Consumption
Joseph Mulinare, M.D., M.S.P.H.
National Center on Birth Defects
and Developmental Disabilities
2
Outline

• Introduction, preconception planning
• Define folic acid, neural tube defects (NTD)
• Describe recent prevention efforts
• Describe changes in blood folates and NTD rates
• Discuss current and future issues on prevention

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Preconception Planning National Foundation
March of Dimes

• Medical check-up
• Family history
• Medical conditions (diabetes, epilepsy, blood
  pressure)
• Vaccination (chickenpox, rubella, influenza)
• Prescription drug use (consult with M.D.)

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Preconception Planning (contd) National
Foundation March of Dimes

• Balanced diet
• Folic acid (400 micrograms daily)
• Weight (avoid underweight, overweight)
• Healthy lifestyle (exercise, reduce stress)
• Alcohol use (binge drinking)
• Smoking (active and passive)
• Drug use (prescription, cocaine, heroin)
• Toxin avoidance (heavy metals, solvents,
  chemicals)
• Toxoplasmosis (cat litter and undercooked meat)

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Perspective on Folate Deficiency
Megaloblastic Anemia
Normal Folate
Adequate Folate Healthy Cells
Deficient Folate Unhealthy Cells
Adapted from Perspectives in Nutrition 4th ed.
1999
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Folic Acid Nutrition A Paradigm Shift
The folic acid / folate transition in public
health
Past red blood cell production, prevents
anemia.
Most women who become pregnant do not have severe
anemia.

• Present based on health of embryo,
• NTDs, other birth defects
• low birth weight, and prematurity
• heart attacks, stroke
• colo-rectal cancer
• cervical dysplasia

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Background

• About 4 million infants are born in the U.S. each
  year
• Over 120,000 with birth defects
• Birth defects are the leading cause of infant
  death
• Developmental disability occurs in about 1 in 5
  children under 18 or about 800,000 children
• The lives of thousands of American families are
  affected greatly by birth defects and
  developmental disabilities
• The resulting costs to the health care and
  educational systems are high

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Neural Tube Defects

• 1 in every 1,000 pregnancies
• 4,000 NTD-affected pregnancies in US
• 300,000 worldwide

• Increased consumption of folic acid can
  prevent 50 to 70

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Neural Tube Defects

• Serious birth defects of the spine and brain
• Incomplete closure/formation of the neural tube
• Leading cause of infantile paralysis in U.S.
• Spina bifida is most frequently occurring
  permanently disabling birth defect

From NEJM 1999
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1992 U.S. Public Health Service Folic Acid
Recommendation

• All women capable of becoming pregnant should
  consume
• - 400 micrograms (0.4mg) folic acid daily
• - to reduce their risk of a pregnancy affected by
  spina bifida or other neural tube defects (NTDs)

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1992 U.S. Public Health Service Folic Acid
Recommendation

• Approaches to increase consumption of folic
  acid/folate
• Improve dietary habits
• Take daily folic acid supplement
• Consume fortified foods

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Methods to get folic acid
Dietary change is important, and orange juice is
the most commonly consumed source of folate in
the United States. Trying to get 400 micrograms
of folate each day from foods is
difficult. Taking vitamin supplement containing
folic acid is a sure way of getting 400
mcgs. Fortification of enriched foods by the FDA
has enabled many women to get additional folic
acid from their regular diet.
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FDA Actions to Prevent Spina Bifida and
Anencephaly

• Required that all products made with enriched
  grain products contain additional folic acid
• Approved the use of health claims on products
  that contain significant amounts of folic acid

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Importance of timing in getting folic acid
50 of U.S. pregnancies are unplanned Folic acid
is needed before conception NTDs occur very
early in pregnancy
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Median serum and red blood cell folate levels,
before and after folic acid fortification, U.S.
women, aged 15-44 years, NHANES
ng/mL
Serum folate
20
15
13.0
10
4.8
5
0
Before
After
SOURCE CDC/NCHS, National Health and Nutrition
Examination Surveys, 1988-94 and 1999-2000
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Spina Bifida and Anencephaly per 100,000 live
births, NCHS vital statistics, 1991-2001
Spina Bifida
Spina Bifida
Higher CI
Lower CI
Anencephaly
Anencephaly
Higher CI
Lower CI
1996
2001
NOTE Excludes data for Maryland, New Mexico,
and New York which did not require reporting for
spina bifida and anencephaly for some years.
CI is 95 confidence interval. 2001 data are
preliminary. SOURCE National Vital Statistics
System, NCHS, CDC
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Evaluation of the change in NTD prevalence, U.S.
Goal - NTD decline
Actual NTD decline
U.S.
50-70
20-25
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Folic Acid Preventable Neural Tube Defects Are we
done yet?
4000 estimated NTD-affected pregnancies yearly
2000 50 of NTD-affected pregnancies that are
preventable
- 1000 estimated 25 fewer NTD pregnancies.
due to fortification
1000 estimated NTD-affected pregnancies
remaining that are folic acid preventable
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Use and Knowledge of Folic Acid Women of
Childbearing Age
2003
1995
79
52
Heard of folic acid
Knew FA can prevent birth defects
13
9
Knew FA should be taken before pregnancy
7
2
32
28
Took folic acid daily
March of Dimes Birth Defects Foundation, Gallup
Polls 1995, 2003
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Percent women taking vitamin with folic acid
daily All women age 18-45
50
40
34
33
32
32
32
29
28
30
Percent
20
10
0
1995
1997
1998
2000
2001
2002
2003
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Concluding remarks
NTD prevalence has fallen about 25 in the United
States. Observed changes in NTD rates are
consistent with an increase in folic acid
consumption from food fortification. The need
still exists to prevent the occurrence of an
additional 1,000 NTD-affected
pregnancies More opportunities are needed to
provide additional folic acid to ALL
reproductive-age women who are at risk for having
folic-acid-preventable neural tube defects