Folate deficiency epidemiology and demographics

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The prevalence of folate deficiency is quite variable across the world.Patients of all age groups may develop folate deficiency however primary age groups affected by Folate deficiency include preschool children, pregnant women and older people.

Epidemiology and Demographics

• The prevalence of folate deficiency is quite variable across the world.
• The deficiency is more commonly seen in countries without folic acid fortification of cereal-grain products.
• Folate deficiency can be a public health problem, revealed in one of the survey conducted in several countries.
• Folate deficiency affects 5% of total US population.
• In the US, folate deficiency was present in school-age children (2.3% of the folate-deficient population), adults (24.5%), and older people (10.8%) before folic acid fortification was introduced.
• In 1998, the FDA has required folic acid fortification of all enriched cereal-grain products in the U.S to to explore the changes in serum and erythrocyte folate status of the adult U.S. population following folic acid fortification of enriched cereal-grain products.
• Subsequent surveys have shown that serum and RBC folate concentrations have increased in the general population of all age and sex groups.
• National Health and Nutrition Examination Survey conducted during 1999-2000 shows that the prevalence of low serum folate concentrations (<6.8 nmol/L) decreased from 16% before to 0.5% after fortification.

DEMOGRAPHICS

Each year in the United States

• There are 3,000 pregnancies affected by neural tube defects (NTDs) caused by the incomplete closing of the spine and skull.
• About 1,300 babies are born without a neural tube defect since folic acid fortification.
• Many, but not all, neural tube defects could be prevented if women took 400 mcg of folic acid daily, before and during early pregnancy.
• Folate deficiency complicates between 1% and 4% of pregnancies in the United States and affects approximately one-third of pregnancies worldwide.
• Many epidemiologic studies indicate that higher intakes of folate, either from dietary sources or from supplements may lower the risk of colorectal adenoma and cancer.
• In US, patients with previous history of child with neural tube defect, the recurrence risk is 2% to 3% in subsequent pregnancies.The Medical Research Council Vitamin Study Group reported the results of a trial of folic acid supplementation for the prevention of NTDs in pregnancies of women who had a previous child with an NTD and the CDC published its recommendations.
• Later on, The National Health and Nutrition Examination Survey conducted a study to determine differences in dietary and total folate intake, for age and racial-ethnic groups by sex and prevalence of inadequate and excessive intakes is presented as well and it was concluded that measures need to be made both to monitor for over-supplementation in certain groups and to target increased supplementation in the groups at risk for deficiency like women of child bearing age and non-Hispanic black women.

Hispanic/Latina Women

• Have the highest rate among women having a child affected by these birth defects.
• Have lower blood folate levels and are less likely to consume foods fortified with folic acid.
• Are less likely to have heard about folic acid, or take vitamins containing folic acid before pregnancy.

Use of Supplements Containing Folic Acid Among Women of Childbearing Age — United States

2007 Survey Data

Among all women of childbearing age:

• 40% reported taking folic acid daily.
• 81% reported awareness of folic acid.
• 12% reported knowing that folic acid should be taken before pregnancy.

Women of childbearing age who were aware of folic acid reported hearing about it from:

• Health care provider (33%)
• Magazine or newspaper (31%)
• Radio or television (23%)

• Women aged 18-24 years were more likely to hear about folic acid from a magazine or newspaper (25%) or school or college (22%) than from their health care provider (17%). Whereas 37% of women aged 25-34 years and 36% of women 35-45 years reported hearing about folic acid from their health care provider.

Among women who reported not taking a vitamin or mineral supplement on a daily basis, the most common reasons were:

• “Forgetting” (33%)
• “No need” (18%)
• “No reason” (14%)
• “Already get balanced nutrition” (12%)

2005 Survey Data

Among all women of childbearing age:

• 33% reported taking folic acid daily.
• 84% reported awareness of folic acid.
• 7% reported knowing that folic acid should be taken before pregnancy.

Among women who reported not taking a vitamin or mineral supplement on a daily basis, the most common reasons were:

• Forgetting to take supplements (28%)
• Perceiving they do not need them (16%)
• Believing they get needed nutrients and vitamins from food (9%)

When asked, “For what specific need would you start taking a vitamin or mineral supplement?” The most common reported needs were:

• Being sick or in poor health (20%)
• A doctor’s recommendation (20%)
• The need for energy (9%)
• Being pregnant (8%)
• Being deficient in any vitamins or minerals (7%)
• Balancing the diet (6%)
• Keeping bones strong (6%)
• In addition, 11% cited no specific need that would motivate them to begin taking a vitamin or supplement. Among women who reported not consuming a vitamin or mineral supplement daily, 31% indicated they had received a doctor’s recommendation.

Economic Cost

• The annual medical care and surgical costs for people with spina bifida exceed $200 million.
• The total lifetime cost of care for a child born with spina bifida is estimated to be $791,900.

Age

• Patients of all age groups may develop folate deficiency however primary age groups affected by Folate deficiency include preschool children, pregnant women and older people.
• Pregnant women are at higher risk of developing folate deficiency because of increased requirements. Upto 20% of the pregnant women are folate deficient because of five fold increased daily requirement of folate during pregnancy
• Elderly people may be more susceptible to folate deficiency, as a result of their predisposition to mental health status, social isolation, low dietary intake, malnutrition, and co morbid medical conditions.
• According to the department of the health and social security survey approximately 15% of elderly people living in the community are likely to be deficient in folate.

Race

• The prevalence has reported to be higher in African and Asian population.

Gender

• National Health and Nutrition Examination Survey shows that women of childbearing age were at high risk of folic acid deficiency due to an inadequate folic acid intake

Region

• There is no evidence that prevalence is associated with the level of development or the geographical location.