Anemia Among Pregnant Women Participating in the Special Supplemental Nutrition Program for Women, Infants, and Children - United States, 2008-2018.

Among pregnant women, anemia, a condition of low hemoglobin concentration, can increase risk for maternal and fetal morbidity and mortality, including premature delivery, and other adverse outcomes (1). Iron deficiency is a common cause of anemia, and during pregnancy, iron requirements increase (2). Surveillance of anemia during pregnancy in the United States is limited. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Participant and Program Characteristics (PC) data provide an opportunity to establish national and WIC state agency-level* anemia surveillance for WIC participants. National and state agency anemia prevalences among pregnant WIC participants at enrollment were examined using 2008-2018 WIC-PC data. Across all 90 WIC agencies (50 states, the District of Columbia [DC], five territories, and 34 Indian Tribal Organizations), anemia prevalence among pregnant WIC participants at enrollment increased significantly, from 10.1% in 2008 to 11.4% in 2018 (13% increase). Anemia prevalence increased significantly in 36 (64%) of the 56 agencies in states, DC, and territories, and decreased significantly in 11 (20%). Prevalence of anemia overall and by pregnancy trimester were higher among non-Hispanic Black or African American (Black) women than among other racial or ethnic groups. Anemia prevalence was higher among women assessed during the third trimester of pregnancy than among those assessed during first or second trimesters. Routine anemia surveillance using WIC enrollment anemia data can identify groups at higher risk for iron deficiency. Findings from this report indicate that anemia continues to be a problem among low-income women and reinforces the importance of efforts that ensure these women have access to healthier, iron-rich foods before and during pregnancy. This includes ensuring that eligible women are enrolled in WIC early during pregnancy.

Food Preparation Practices for Infants Aged From 7 to 13 Months.

OBJECTIVE: To examine infant food preparation practices at age 7, 9, 11, and 13 months overall and by sociodemographic characteristics. DESIGN: Data from a longitudinal study from the US Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Infant and Toddler Feeding Practices Study-2 (ITFPS-2) were used. PARTICIPANTS: A sample of 1,904 infants (970 males and 934 females) enrolled in WIC who had been introduced to solid foods and were consuming food prepared at home. MAIN OUTCOME MEASURES: Food preparation practices included pureeing, mashing, chopping/dicing, and prechewing. Estimates were provided overall and by sociodemographics. ANALYSIS: Prevalence estimates were calculated for each survey month overall and by sociodemographics. Chi-square tests for independence were used to test for differences. RESULTS: Food preparation practices changed as infants aged. Pureeing and mashing were common in month 7 (57.8% and 59.6%, respectively), but chopping/dicing were the most prevalent by month 13 (85.4%). Food preparation practices did not vary by education status, but statistical differences were consistently observed by race and ethnicity and inconsistently observed by maternal age at birth. CONCLUSIONS AND IMPLICATIONS: Exposing children to a range of food textures at an appropriate age is important for developmental progress. Continued culturally relevant efforts by WIC educators and health care providers can emphasize the importance of early experiences with food textures.

Iron Content of Commercially Available Infant and Toddler Foods in the United States, 2015.

OBJECTIVES: To describe the iron content of commercially available infant and toddler foods. METHODS: Nutrition Facts label data were used from a 2015 database of 1037 commercial infant and toddler food and drink products. Products were grouped into food categories on the basis of name, ingredients, target age, and reference amounts customarily consumed (RACC). Mean and median iron content per 100 g and per RACC were calculated. The proportion of products considered good and excellent sources of iron were determined on the basis of percent daily value (% DV) thresholds. RESULTS: Among products marketed for infants (aged 4-12 months), infant cereals had the highest mean (6.19 mg iron per RACC; 41.25 iron mg per 100 g) iron content. Among products marketed for toddlers (aged 12-36 months), vegetable-based mixtures or meals contained the highest mean iron in mg per RACC (mean: 2.97 mg) and dry, grain-based desserts had the highest mean iron in mg per 100 g (mean: 6.45 mg). Juice and drink products had the lowest mean iron contents in both infant and toddler products. CONCLUSIONS: Most commercially available infant cereals are considered to be an excellent source of iron, likely from fortification, but wide variability was observed in iron content by food category. Products that are considered good or excellent sources of iron (≥10% DV) can help consumers identify products with higher iron content, such as infant cereals or toddler vegetable-based mixtures/meals.

Nutrient Content of Squeeze Pouch Foods for Infants and Toddlers Sold in the United States in 2015.

BACKGROUND: To describe the availability and nutrient composition of U.S. commercially available squeeze pouch infant and toddler foods in 2015. MATERIALS AND METHODS: Data were from information presented on nutrition labels for 703 ready-to-serve, pureed food products from 24 major U.S. infant and toddler food brands. We described nutritional components (e.g., calories, fat) and compared them between packaging types (squeeze pouch versus other packaging types) within food categories. RESULTS: 397 (56%) of the analyzed food products were packaged as squeeze pouches. Differences in 13 nutritional components between squeeze pouch versus other packaging types were generally small and varied by food category. Squeeze pouches in the fruits and vegetables, fruit-based, and vegetable-based categories were more likely to contain added sugars than other package types. CONCLUSION: In 2015, squeeze pouches were prevalent in the U.S. commercial infant and toddler food market. Nutrient composition differed between squeeze pouches and other packaging types for some macro- and micronutrients. Although it is recommended that infants and toddlers under two years old not consume any added sugars, a specific area of concern may be the inclusion of sources of added sugar in squeeze pouches. Linking this information with children's dietary intake would facilitate understanding how these differences affect overall diet quality.

Food and Beverage Intake From 12 to 23 Months by WIC Status.

: media-1vid110.1542/5984243449001PEDS-VA_2018-2274Video Abstract BACKGROUND: In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) revised its food packages to align with updated nutrition science. Understanding how these revisions may impact current consumption patterns could be important. METHODS: Dietary data from the 2011-2014 NHANES were used to estimate the percentage of children who were aged 12 to 23 months consuming selected food and beverage categories on any given day by age and WIC status (children who were on WIC, those who were eligible for but not receiving WIC benefits, and those who were not eligible for WIC). RESULTS: Consumption of food and beverage categories differed by WIC status. On a given day, a lower percentage of children who were eligible for but did not receive WIC benefits consumed vegetables (excluding white potatoes; 42.3%) and grains (76.5%) compared with children who were participating in WIC (vegetables [excluding white potatoes]: 60.4%; grains: 85.5%) and those who were not eligible for WIC benefits (vegetables [excluding white potatoes]: 58.1%; grains: 87.2%; P < .05). A lower percentage of both children who were eligible for but not receiving WIC benefits and those who were participating in WIC consumed fruits (57.6% and 70.6%, respectively) and snacks (45.9% and 48.5%, respectively) than those who were not eligible for WIC (fruits: 86.4%; snacks: 69.1%; P < .05). A lower percentage of children who were receiving WIC consumed dairy than children who were not eligible for WIC (91.7% and 97.2%, respectively; P < .05). A higher percentage of those who were receiving WIC consumed 100% juice (70.6%) than children who were eligible for but not receiving WIC (51.6%) and children who were not eligible for WIC (50.8%; P < .05). CONCLUSIONS: Improving early WIC participation and retention could positively impact some diet-related disparities among young children who are eligible for WIC.

Applying inappropriate cutoffs leads to misinterpretation of folate status in the US population.

BACKGROUND: Folate cutoffs for risk of deficiency compared with possible deficiency were originally derived differently (experimental compared with epidemiologic data), and their interpretations are different. The matching of cutoffs derived from one assay with population-based data derived from another assay requires caution. OBJECTIVE: We assessed the extent of folate-status misinterpretation with the use of inappropriate cutoffs. DESIGN: In the cross-sectional NHANES, serum and red blood cell (RBC) folate were first measured with the use of a radioprotein-binding assay (RPBA) (1988-2006) and, afterwards, with the use of a microbiologic assay (2007-2010). We compared prevalence estimates for assay-matched cutoffs (e.g., with the use of an RPBA cutoff with RPBA data) and assay-mismatched cutoffs (e.g., with the use of microbiologic assay cutoff with RPBA data) for risk of deficiency on the basis of megaloblastic anemia as a hematologic indicator in persons ≥4 y of age (e.g., serum folate concentration <7 nmol/L and RBC folate concentration <305 nmol/L derived with the use of a microbiologic assay), possible deficiency on the basis of rising homocysteine as a metabolic indicator in persons ≥4 y of age (e.g., serum folate concentration <10 nmol/L and RBC folate concentration <340 nmol/L derived with the use of an RPBA), and insufficiency on the basis of elevated risk of neural tube defects in women 12-49 y old (e.g., RBC folate concentration <906 nmol/L derived with the use of a microbiologic assay). RESULTS: Pre-folic acid fortification (1988-1994), risks of deficiency for assay-matched compared with assay-mismatched cutoffs were 5.6% compared with 16% (serum folate), respectively, and 7.4% compared with 28% (RBC folate), respectively; risks declined postfortification (1999-2006) to <1% compared with <1% (serum folate), respectively, and to <1% compared with 2.5% (RBC folate), respectively. Prefortification (1988-1994), risks of possible deficiency for assay-matched compared with assay-mismatched cutoffs were 35% compared with 56% (serum folate), respectively, and 37% compared with 84% (RBC folate), respectively; risks declined postfortification (1999-2006) to 1.9% compared with 7.0% (serum folate), respectively, and to 4.8% compared with 53% (RBC folate), respectively. Postfortification (2007-2010), risks of insufficiency were 3% (assay matched) compared with 39% (assay mismatched), respectively. CONCLUSIONS: The application of assay-mismatched cutoffs leads to a misinterpretation of folate status. This confusion likely applies to clinical assays because no comparability data are available, to our knowledge.

Usual Intake of Key Minerals among Children in the Second Year of Life, NHANES 2003-2012.

Iron, calcium, and zinc are important nutrients for the young, developing child. This study describes the usual intake of iron, calcium, and zinc among US children in the second year of life using two days of dietary intake data from the National Health and Nutrition Examination Survey 2003-2012. Estimates were calculated using PC-SIDE to account for within and between person variation. Mean usual iron, calcium, and zinc intakes were 9.5 mg/day, 1046 mg/day, and 7.1 mg/day, respectively. Over a quarter of children had usual iron intakes less than the Recommended Dietary Allowance (RDA) (26.1%). Eleven percent of children had usual calcium intakes below the RDA and over half of children had usual intakes of zinc that exceeded the tolerable upper intake level (UL). Two percent or less had usual intakes below the Estimated Average Requirement (EAR) for iron, calcium, and zinc. Our findings suggest that during 2003-2012, one in four children and one in ten children had usual intakes below the RDA for iron and calcium, respectively. Children who are not meeting their nutrient requirements could be at increased risk for developing deficiencies such as iron deficiency or could lead to a shortage in adequate nutrients required for growth and development. One in every two children is exceeding the UL for zinc, but the interpretation of these estimates should be done with caution given the limited data on adverse health outcomes. Continued monitoring of zinc intake and further assessment for the potential of adverse health outcomes associated with high zinc intakes may be needed.

Blood folate concentrations among women of childbearing age by race/ethnicity and acculturation, NHANES 2001-2010.

Hispanic women have higher rates of neural tube defects and report lower total folic acid intakes than non-Hispanic white (NHW) women. Total folic acid intake, which is associated with neural tube defect risk reduction, has been found to vary by acculturation factors (i.e. language preference, country of origin, or time spent in the United States) among Hispanic women. It is unknown whether this same association is present for blood folate status. The objective of this research was to assess the differences in serum and red blood cell (RBC) folate concentrations between NHW women and Mexican American (MA) women and among MA women by acculturation factors. Cross-sectional data from the 2001-2010 National Health and Nutrition Examination Survey (NHANES) were used to investigate how blood folate concentrations differ among NHW or MA women of childbearing age. The impact of folic acid supplement use on blood folate concentrations was also examined. MA women with lower acculturation factors had lower serum and RBC folate concentrations compared with NHW women and to their more acculturated MA counterparts. Consuming a folic acid supplement can minimize these disparities, but MA women, especially lower acculturated MA women, were less likely to report using supplements. Public health efforts to increase blood folate concentrations among MA women should consider acculturation factors when identifying appropriate interventions.

Assessing the association between natural food folate intake and blood folate concentrations: a systematic review and Bayesian meta-analysis of trials and observational studies.

Folate is found naturally in foods or as synthetic folic acid in dietary supplements and fortified foods. Adequate periconceptional folic acid intake can prevent neural tube defects. Folate intake impacts blood folate concentration; however, the dose-response between natural food folate and blood folate concentrations has not been well described. We estimated this association among healthy females. A systematic literature review identified studies (1 1992-3 2014) with both natural food folate intake alone and blood folate concentration among females aged 12-49 years. Bayesian methods were used to estimate regression model parameters describing the association between natural food folate intake and subsequent blood folate concentration. Seven controlled trials and 29 observational studies met the inclusion criteria. For the six studies using microbiologic assay (MA) included in the meta-analysis, we estimate that a 6% (95% Credible Interval (CrI): 4%, 9%) increase in red blood cell (RBC) folate concentration and a 7% (95% CrI: 1%, 12%) increase in serum/plasma folate concentration can occur for every 10% increase in natural food folate intake. Using modeled results, we estimate that a natural food folate intake of ≥ 450 µg dietary folate equivalents (DFE)/day could achieve the lower bound of an RBC folate concentration (~ 1050 nmol/L) associated with the lowest risk of a neural tube defect. Natural food folate intake affects blood folate concentration and adequate intakes could help women achieve a RBC folate concentration associated with a risk of 6 neural tube defects/10,000 live births.

Folate status and concentrations of serum folate forms in the US population: National Health and Nutrition Examination Survey 2011-2.

Serum and erythrocyte (RBC) total folate are indicators of folate status. No nationally representative population data exist for folate forms. We measured the serum folate forms (5-methyltetrahydrofolate (5-methylTHF), unmetabolised folic acid (UMFA), non-methyl folate (sum of tetrahydrofolate (THF), 5-formyltetrahydrofolate (5-formylTHF), 5,10-methenyltetrahydrofolate (5,10-methenylTHF)) and MeFox (5-methylTHF oxidation product)) by HPLC-MS/MS and RBC total folate by microbiologic assay in US population ≥ 1 year (n approximately 7500) participating in the National Health and Nutrition Examination Survey 2011-2. Data analysis for serum total folate was conducted including and excluding MeFox. Concentrations (geometric mean; detection rate) of 5-methylTHF (37·5 nmol/l; 100 %), UMFA (1·21 nmol/l; 99·9 %), MeFox (1·53 nmol/l; 98·8 %), and THF (1·01 nmol/l; 85·2 %) were mostly detectable. 5-FormylTHF (3·6 %) and 5,10-methenylTHF (4·4 %) were rarely detected. The biggest contributor to serum total folate was 5-methylTHF (86·7 %); UMFA (4·0 %), non-methyl folate (4·7 %) and MeFox (4·5 %) contributed smaller amounts. Age was positively related to MeFox, but showed a U-shaped pattern for other folates. We generally noted sex and race/ethnic biomarker differences and weak (Spearman's r< 0·4) but significant (P< 0·05) correlations with physiological and lifestyle variables. Fasting, kidney function, smoking and alcohol intake showed negative associations. BMI and body surface area showed positive associations with MeFox but negative associations with other folates. All biomarkers showed significantly higher concentrations with recent folic acid-containing dietary supplement use. These first-time population data for serum folate forms generally show similar associations with demographic, physiological and lifestyle variables as serum total folate. Patterns observed for MeFox may suggest altered folate metabolism dependent on biological characteristics.

U.S. women of childbearing age who are at possible increased risk of a neural tube defect-affected pregnancy due to suboptimal red blood cell folate concentrations, National Health and Nutrition Examination Survey 2007 to 2012.

BACKGROUND: Red blood cell (RBC) folate concentrations are a potential biomarker of folate-sensitive neural tube defect (NTD) risk in the population. The purpose of this analysis was to describe women in the U.S. population with RBC folate concentrations below those associated with optimal NTD prevention. METHODS: We used data from the 2007 to 2012 National Health and Nutrition Examination Survey (NHANES) to assess the RBC folate status of U.S. women of childbearing age relative to risk categories for NTD risk based on RBC folate concentrations. We defined suboptimal RBC folate concentrations as those associated with a prevalence of ≥9 NTDs per 10,000 live births. RESULTS: Among nonpregnant women age 12 to 49 years, 22.8% (95% Confidence Interval: 21.1, 24.6) had suboptimal RBC folate concentrations. Women had greater odds of having a suboptimal RBC folate concentration if they did not use dietary supplements containing folic acid; had mandatorily fortified enriched cereal grain products as their only source of folic acid; were non-Hispanic black or Hispanic; or were current smokers. CONCLUSION: Based on RBC folate concentrations, we would predict that the majority of U.S. women of reproductive age are not at increased risk for folate sensitive NTDs in the presence of mandatory folic acid fortification. Prevention policies and programs can be aimed at population subgroups identified as having higher predicted risk for folate-sensitive NTDs based on RBC folate concentrations.

Assessing the association between the methylenetetrahydrofolate reductase (MTHFR) 677C>T polymorphism and blood folate concentrations: a systematic review and meta-analysis of trials and observational studies.

BACKGROUND: The methylenetetrahydrofolate reductase (MTHFR) 677C>T polymorphism is a risk factor for neural tube defects. The T allele produces an enzyme with reduced folate-processing capacity, which has been associated with lower blood folate concentrations. OBJECTIVE: We assessed the association between MTHFR C677T genotypes and blood folate concentrations among healthy women aged 12-49 y. DESIGN: We conducted a systematic review of the literature published from January 1992 to March 2014 to identify trials and observational studies that reported serum, plasma, or red blood cell (RBC) folate concentrations and MTHFR C677T genotype. We conducted a meta-analysis for estimates of percentage differences in blood folate concentrations between genotypes. RESULTS: Forty studies met the inclusion criteria. Of the 6 studies that used the microbiologic assay (MA) to measure serum or plasma (S/P) and RBC folate concentrations, the percentage difference between genotypes showed a clear pattern of CC > CT > TT. The percentage difference was greatest for CC > TT [S/P: 13%; 95% credible interval (CrI): 7%, 18%; RBC: 16%; 95% CrI: 12%, 20%] followed by CC > CT (S/P: 7%; 95% CrI: 1%, 12%; RBC: 8%; 95% CrI: 4%, 12%) and CT > TT (S/P: 6%; 95% CrI: 1%, 11%; RBC: 9%; 95% CrI: 5%, 13%). S/P folate concentrations measured by using protein-binding assays (PBAs) also showed this pattern but to a greater extent (e.g., CC > TT: 20%; 95% CrI: 17%, 22%). In contrast, RBC folate concentrations measured by using PBAs did not show the same pattern and are presented in the Supplemental Material only. CONCLUSIONS: Meta-analysis results (limited to the MA, the recommended population assessment method) indicated a consistent percentage difference in S/P and RBC folate concentrations across MTHFR C677T genotypes. Lower blood folate concentrations associated with this polymorphism could have implications for a population-level risk of neural tube defects.

Fortification of corn masa flour with folic acid in the United States: an overview of the evidence.

Corn masa flour, used to make products such as corn tortillas, is a staple food for Hispanic populations residing in the United States, particularly among Mexican Americans and Central Americans. Research has indicated that Hispanic women in the United States continue to be at a higher risk of having a neural tube defect-affected pregnancy than women of other races/ethnicities, even after the introduction of folic acid fortification of cereal grain products labeled as "enriched." Corn masa flour has, therefore, been suggested as a potential food vehicle for folic acid in the United States. This paper explores the potential impact that folic acid fortification of corn masa flour could have on the Hispanic population in the United States.

The prevalence of low serum vitamin B-12 status in the absence of anemia or macrocytosis did not increase among older U.S. adults after mandatory folic acid fortification.

Whether folic acid fortification and supplementation at the population level have led to a higher prevalence of vitamin B-12 deficiency in the absence of anemia remains to be examined among a nationally representative sample of older U.S. adults. We assessed the prevalence of low vitamin B-12 status in the absence of anemia or macrocytosis before and after fortification among adults aged >50 y using cross-sectional data from the NHANES 1991-1994 (prefortification) and 2001-2006 (postfortification). We compared the prefortification and postfortification prevalence of multiple outcomes, including serum vitamin B-12 deficiency (<148 pmol/L) and marginal deficiency (148-258 pmol/L) with and without anemia (hemoglobin <130 g/L for men, <120 g/L for women) and with and without macrocytosis (mean cell volume >100 fL) using multinomial logistic regression, adjusting for age, sex, ethnicity, body mass index, C-reactive protein, and vitamin B-12 supplement use. Prefortification and postfortification serum vitamin B-12 deficiency without anemia [4.0 vs. 3.9%; adjusted prevalence ratio (aPR) (95% CI): 0.98 (0.67, 1.44)] or without macrocytosis [4.2 vs. 4.1%; aPR (95% CI): 0.96 (0.65, 1.43)] remained unchanged. Marginal deficiency without anemia [25.1 vs. 20.7%; aPR (95% CI): 0.82 (0.72, 0.95)] or without macrocytosis [25.9 vs. 21.3%; aPR (95% CI): 0.82 (0.72, 0.94)] were both significantly lower after fortification. After fortification, higher folic acid intake was associated with a lower prevalence of low serum B-12 status in the absence of anemia or macrocytosis. Results suggest that the prevalence of low serum B-12 status in the absence of anemia or macrocytosis among older U.S. adults did not increase after fortification. Thus, at the population level, we found no evidence to support concerns that folic acid adversely affected the clinical presentation of vitamin B-12 deficiency among older adults.

Estimate of the potential impact of folic acid fortification of corn masa flour on the prevention of neural tube defects.

BACKGROUND: Hispanics in the US have a higher prevalence of neural tube defect (NTD) -affected pregnancies than non-Hispanic whites, and lower median total folic acid (FA) intake. FA fortification of corn masa flour (CMF) is a policy-level intervention for NTD prevention; however, the impact on NTD prevalence has not been estimated. METHODS: We developed a model to estimate the percentage reduction in prevalence of spina bifida and anencephaly (NTDs) that could occur with FA fortification of CMF. Model inputs included estimates of the percentage reduction in United States NTD prevalence attributed to FA fortification of enriched cereal grain products (1995-1996 vs. 1998-2002), the increase in median FA intake after enriched cereal grain product fortification, and the estimated increase in median FA intake that could occur with CMF fortification at the same level as enriched cereal grain products (140 µg/100 g). We used Monte Carlo simulation to quantify uncertainty. We stratified analyses by racial/ethnic group and rounded results to the nearest 10. RESULTS: We estimated CMF fortification could prevent 30 Hispanic infants from having spina bifida (95% uncertainty interval: 0, 80) and 10 infants from having anencephaly (95% uncertainty interval: 0, 40) annually. The estimated impact among non-Hispanic whites and blacks was smaller. CONCLUSION: CMF fortification with FA could prevent from 0 to 120 infants, with the most likely value of approximately 40, from having spina bifida or anencephaly among Hispanics, the population most likely to benefit from the proposed intervention. While this estimated reduction is unlikely to be discernible using current birth defect surveillance methods, it still suggests an important benefit to the target population.

Modeling fortification of corn masa flour with folic acid: the potential impact on exceeding the tolerable upper intake level for folic acid, NHANES 2001-2008.

BACKGROUND: The Institute of Medicine set a tolerable upper intake level (UL) for usual daily total folic acid intake (1,000 µg). Less than 3% of US adults currently exceed the UL. OBJECTIVE: The objective of this study was to determine if folic acid fortification of corn masa flour would increase the percentage of the US population who exceed the UL. DESIGN: We used dietary intake data from NHANES 2001-2008 to estimate the percentage of adults and children who would exceed the UL if corn masa flour were fortified at 140 µg of folic acid/100 g. RESULTS: In 2001-2008, 2.5% of the US adult population (aged≥19 years) exceeded the UL, which could increase to 2.6% if fortification of corn masa flour occurred. With corn masa flour fortification, percentage point increases were small and not statistically significant for US adults exceeding the UL regardless of supplement use, sex, race/ethnicity, or age. Children aged 1-8 years, specifically supplement users, were the most likely to exceed their age-specific UL. With fortification of corn masa flour, there were no statistically significant increases in the percentage of US children who were exceeding their age-specific UL, and the percentage point increases were small. CONCLUSIONS: Our results suggest that fortification of corn masa flour would not significantly increase the percentage of individuals who would exceed the UL. Supplement use was the main factor related to exceeding the UL with or without fortification of corn masa flour and within all strata of sex, race/ethnicity, and age group.

Modelling fortification of corn masa flour with folic acid and the potential impact on Mexican-American women with lower acculturation.

OBJECTIVE: Hispanics with lower acculturation may be at higher risk for neural tube defects compared with those with higher acculturation due to lower total folic acid intake or other undetermined factors. Modelling has indicated that fortification of corn masa flour with folic acid could selectively target Mexican Americans more than other race/ethnicities. We assessed whether fortification of corn masa flour with folic acid could selectively increase folic acid intake among Mexican-American women with lower acculturation, as indicated by specific factors (language preference, country of origin, time living in the USA). DESIGN: We used dietary intake and dietary supplement data from the National Health and Nutrition Examination Survey 2001-2008, to estimate the amount of additional total folic acid that could be consumed if products considered to contain corn masa flour were fortified at 140 µg of folic acid per 100 g of corn masa flour. SETTING: USA. SUBJECTS: Non-pregnant women aged 15-44 years (n 5369). RESULTS: Mexican-American women who reported speaking Spanish had a relative percentage change in usual daily total folic acid intake of 30·5 (95 % CI 27·8, 33·4) %, compared with 8·3 (95 % CI 7·3, 9·4) % for Mexican-American women who reported speaking English. We observed similar results for other acculturation factors. An increase of 6·0 percentage points in the number of Mexican-American women who would achieve the recommended intake of ≥400 µg folic acid/d occurred with fortification of corn masa flour; compared with increases of 1·1 percentage points for non-Hispanic whites and 1·3 percentage points for non-Hispanic blacks. An even greater percentage point increase was observed among Mexican-American women who reported speaking Spanish (8·2). CONCLUSIONS: Fortification of corn masa flour could selectively increase total folic acid intake among Mexican-American women, especially targeting Mexican-American women with lower acculturation, and result in a decrease in the number of pregnancies affected by neural tube defects.

Does obesity modify the association of supplemental folic acid with folate status among nonpregnant women of childbearing age in the United States?

BACKGROUND: Obesity is associated with an increased risk of having a pregnancy affected by a neural tube defect (NTD). It is not clear whether the amount of folic acid required by obese women to protect against NTDs is the same as that for nonobese women. METHODS: We analyzed data from the National Health and Nutrition Examination Survey, representative of the noninstitutionalized civilian U.S. population, to assess whether body mass index (BMI; normal weight, overweight, and obese categories) modified the association between supplemental folic acid intake and folate status. We estimated the geometric mean concentration among nonpregnant women of childbearing age (15-44 years) during the postfortification period of: serum folate (2003-2008); red blood cell (RBC) folate (2007-2008); and plasma total homocysteine (tHcy; 2003-2006), adjusted for age, race and ethnicity, and total dietary folate expressed as dietary folate equivalents for strata of supplement use and BMI. RESULTS: BMI was inversely associated with serum folate among women who did not use supplements containing folic acid; no differences between women in different BMI categories were observed among supplement users. Regardless of supplement use, obese women had the highest RBC folate concentrations. There were no differences in tHcy by BMI, regardless of supplement use. CONCLUSIONS: These results do not support a straightforward modification of the relationship between supplemental folic acid intake and folate status by BMI. In this population, BMI may affect the body distribution of folate, as reflected by lower serum and higher RBC folate levels in obese women who do not use supplements.

Usual folic acid intakes: a modelling exercise assessing changes in the amount of folic acid in foods and supplements, National Health and Nutrition Examination Survey, 2003-2008.

OBJECTIVE: The USA currently fortifies enriched cereal grain products (ECGP) with folic acid at 140 µg/100 g. In addition, folic acid can be voluntarily added to ready-to-eat cereals (RTEC) up to 400 µg/serving and it is found in many dietary supplements, most often at a dose of 400 µg. We sought to model folic acid intake under various fortification and supplementation scenarios. DESIGN: The National Health and Nutrition Examination Survey is a population-based cross-sectional survey representative of the non-institutionalized, civilian US population. Information on folic acid intake is collected in two 24 h dietary recalls and survey questions on dietary supplement use, which allows estimation of usual total folic acid intake. We modelled five different levels of folic acid fortification in ECGP, while varying the amounts in RTEC and dietary supplements. SETTING: United States. SUBJECTS: US adults (n 14 353) aged ≥19 years; non-pregnant women of childbearing age (n 4272). RESULTS: The percentage of adults with usual daily folic acid intake above the tolerable upper intake level of 1000 µg was influenced more by the typical amount in supplements, while the median intake was influenced more by the ECGP fortification level. By manipulating the amount in at least two sources, it was possible to shift the distribution such that more women of childbearing age consumed the recommended intake of 400 µg of folic acid without increasing the percentage of adults with intake above the tolerable upper intake level. The results varied among population subgroups. CONCLUSIONS: Our results suggest that combined strategies are required to meet population recommendations for folic acid intake.