Folate deficiency epidemiology and demographics

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

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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. Surveys conducted in several countries show that without fortification, folate deficiency can be a public health problem. The primary age groups affected include preschool children, pregnant women and older people. 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.

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.

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.

Incidence

• The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.
• In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.

Prevalence

• The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.
• In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.
• The prevalence of [disease/malignancy] is estimated to be [number] cases annually.

Case-fatality rate/Mortality rate

• In [year], the incidence of [disease name] is approximately [number range] per 100,000 individuals with a case-fatality rate/mortality rate of [number range]%.
• The case-fatality rate/mortality rate of [disease name] is approximately [number range].

Age

• Patients of all age groups may develop folate deficiency.
• Pregnant women are at higher risk of developing folate deficiency because of increased requirements.
• Certain elderly people also may be more susceptible to folate deficiency, as a result of their predisposition to mental status changes, social isolation, low intake of leafy vegetables and fruits, malnutrition, and comorbid medical conditions.
• The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.
• [Disease name] commonly affects individuals younger than/older than [number of years] years of age.
• [Chronic disease name] is usually first diagnosed among [age group].
• [Acute disease name] commonly affects [age group].

Race

• There is no racial predilection to [disease name].
• [Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].
• The prevalence has reported to be higher in African and Asian population.

Gender

• [Disease name] affects men and women equally.
• [Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.

Region

• The majority of [disease name] cases are reported in [geographical region].

• [Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].

Developing Countries

Among US couples who have had a child with an NTD, the recurrence risk is 2% to 3% in subsequent pregnancies. The Medical Research Council (MRC) Vitamin Study Group reportedthe results of a trialof folic acid supplementation for the prevention of NTDs in pregnanciesof women who had a previous child with an NTD and the CDC publishedits recommendations

National Health and Nutrition Examination Survey 1999-2000.The prevalence of low serum folate concentrations (<6.8 nmol/L) decreased from 16% before to 0.5% after fortification.

Subsequently, 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; prevalence of inadequate and excessive intakes is presented. 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.