Integrated surveillance strategy to support the prevention of neural tube defects through food fortification with folic acid: the experience of Costa Rica.

PURPOSE: (1) To describe how Costa Rica implemented an integrated surveillance strategy of folate deficiency, neural tube defects (NTDs) prevalence, NTDs-associated infant mortality rate (NTDs-IMR), and folic acid food fortification (FAFF), to support with evidence NTDs prevention policies; (2) to disseminate updated data from monitoring programs. METHODS: We performed a cross-sectional analysis, using the databases of national surveillance systems for NTDs outcomes to compare NTDs-prevalence and NTDs-IMR observed in the pre-fortification (1987-1998) and post-fortification (2010-2020) periods. In addition, using data from FAFF monitoring program (2010-2020), means of folic acid concentration (mg/kg) and folic acid daily intake (µg/day) were calculated for each fortified food (corn and wheat flour, rice and milk), as well as its contribution to folic acid estimated average requirement (EAR). RESULTS: After FAFF Costa Rica showed a decrease of 84% in folic acid deficiency in women of childbearing age, as well as a 53% decrease in the prevalence of NTDs, falling from 11.82/10,000 to 5.52/10,000 livebirths. In addition, there was a 76% reduction in the NTDs-IMR from 77.01/100,000 to 18.66/100,000 livebirths. Between 2010 and 2020, all fortified foods provided an average contribution of 119% of the EAR of folic acid in the population. CONCLUSION: To reduce NTD risk, an integrated surveillance strategy is essential not only to base prevention strategies on evidence, but also to demonstrate their impact and improve interventions over time. The experience in Costa Rica provides evidence that this type of surveillance is feasible to be implemented in developing countries.

Neural tube defects in Costa Rica, 1987-2012: origins and development of birth defect surveillance and folic acid fortification.

Our aim was to provide a descriptive overview of how the birth defects surveillance and folic acid fortification programs were implemented in Costa Rica-through the establishment of the Registry Center for Congenital Anomalies (Centro de Registro de Enfermedades Congénitas-CREC), and fortification legislation mandates. We estimated the overall prevalence of neural tube defects (i.e., spina bifida, anencephaly and encephalocele) before and after fortification captured by CREC. Prevalence was calculated by dividing the total number of infants born with neural tube defects by the total number of live births in the country (1987-2012).A total of 1,170 newborns with neural tube defects were identified from 1987 to 2012 (1992-1995 data excluded); 628 were identified during the baseline pre-fortification period (1987-1991; 1996-1998); 191 during the fortification period (1999-2002); and 351 during the post-fortification time period (2003-2012). The overall prevalence of neural tube defects decreased from 9.8 per 10,000 live-births (95 % CI 9.1-10.5) for the pre-fortification period to 4.8 per 10,000 live births (95 % CI 4.3-5.3) for the post-fortification period. Results indicate a statistically significant (P < 0.05) decrease of 51 % in the prevalence of neural tube defects from the pre-fortification period to the post-fortification period. Folic acid fortification via several basic food sources has shown to be a successful public health intervention for Costa Rica. Costa Rica's experience can serve as an example for other countries seeking to develop and strengthen both their birth defects surveillance and fortification programs.

[Vitamin A deficiency among preschool children: a re-emerging problem in Costa Rica?]. / Deficiencia de vitamina A en niños preescolares: un problema reemergente en Costa Rica?

Based on the 1996 National Nutrition Survey, this study shows the prevalence of Vitamin A deficiency (VAD) among 567 Costa Rican urban and rural 12-83 months old-children. In overall, the prevalence of VAD (plasma retinol < or = 20 micrograms/dl) was 8.8%. No difference was found even when data were analyzed by area and gender. Around 30% of preschool children were at risk of VAD (plasma retinol between 20.1-30 micrograms/dl). The proportion of children at risk for retinol deficiency was significantly higher in rural area in comparison with urban area (38.9% and 28.0% respectively, p < 0.05). Lineal regression analysis showed that plasma retinol levels were negatively related to the number of family members and positively related to mother's schooling. Our results suggest a possible impairment in vitamin A status of preschool children.

Comparison of serum concentration and dietary intake of alpha-tocopherol in a sample of urban and rural Costa Rican adolescents.

Results from several studies have suggested that vitamin E intake could inhibit the progression of atherosclerotic lesions. Therefore, this study was designed to evaluate Costa Rican adolescents' serum alpha-tocopherol levels and their correlation with Body Mass Index (BMI) and the dietary intake of vitamin E and saturated and polyunsaturated fat. Ninety-five healthy, non-smoking adolescents and non-vitamin supplement users (aged 13-18) from urban and rural areas in San José, Costa Rica, were included in this study. Serum levels of lipid adjusted alpha-tocopherol were significantly higher in rural adolescents compared with urban youngsters (4.192 mumol/mmol +/- 0.831 and 3.486 mumol/mmol +/- 0.996, respectively). Likewise, reported mean daily 1000 kcal adjusted-vitamin E intake was higher in rural adolescents than in urban youngsters (9.2 +/- 3.7 mg. 16.0 +/- 8.7 mg). An important correlation was observed between intake of energy from saturated fat and adjusted-alpha-tocopherol serum levels (r = 0.430). Contrariwise, they correlated poorly with dietary alpha-tocopherol (r = 0.273), suggesting that serum is not a good biomarket of intake for alpha-tocopherol. Additionally, our results showed a negative relationship between BMI and adjusted-serum vitamin E levels (beta = 0.189; CI 95% -0.153, -0.013). The analysis of vitamin E intake showed that over 25% of adolescents have inadequate intake of the nutrient. This study suggests that nutritionists and pediatricians should encourage alpha-tocopherol intake and monitor the food sources of the nutrient and the adolescents' body weight as part of the strategies aimed at developing a healthy lifestyle.

Influencia de la deficiencia de vitamina A sobre la anemia en niños(as) preescolares en Costa Rica / Influency of the deficiency of A vitamin on the anemia in prescholastic children in Costa Rica

Objetivo: El objetivo de este estudio fue identificar y cuantificar la contribuición de la deficiencia de vitamina A en la anemia de los niños(as) preescolares para encontrar una estrategia, que permita realizar intervenciones integradas y resolver ambos problemas. Materiales y métodos: Basado en los resultados obtenidos en la Encuesta Nacional de Nutrición (ENN), realizada en 1996, se estudió la interrelación de la deficiencia de retinol con la anemia en niños(as) prescolares. En esta niños de edad preescolar (12-83 meses) con respecto a la vitamina A. Resultados: Se encontró una concentración plasmática media de 31.95±8,17 ug/dL. La prevalencia de la deficiencia de retinol (<-209 ug/dL) fue de 8,8 por ciento la cual, de acuerdo con la Organización Mundial de la Salud (OMS) es un problema leve de salud pública y el porcentaje de niños que están en riesgo de padecer la deficiencia por tener concentraciones de retinol bajas (entre 20-30 ug/dl) fue de 31.7 por ciento. Se realizó un análisis estadístico de regresión lineal entre la concentración de retinol en plasma sanguíneo y la hemoglobina, encontrándose una asociación positiva entre ambas variables, la cual es más crítica en niños menores a tres años. Palabras clave: Retinol, Vitamina A, Deficiencia, Anemia, Deficiencia marginal.