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Purpose: For countries deciding on folic acid fortification policies, the tradeoff of focus has been on benefits for neural tube defects (NTDs) versus risk of masking B-12 deficiency. However, folate consumption is also associated with reduced risks of cardiovascular disease and colon cancer. We used a decision-analytic model to quantify the projected health outcomes associated with changes in folic acid consumption following the 1998 mandate to fortify enriched grain products with folic acid in the US.
Methods: We developed a Markov model to simulate the effect of changes in folate consumption on disease incidence, comparing pre-fortification vs. post-fortification levels. The starting folate distributions before and after fortification were based on separate analyses of two National Health and Nutrition Examination Surveys (1988-1994 and 1999-2000). We analyzed cohorts by age, sex, and race (non-Hispanic white, non-Hispanic black, and Mexican-American). The model distributes a cohort of disease-free individuals into four folate intake states: <201; 201-300; 301-400; and >400 micrograms per day. In each one-year cycle, persons face gender, age, race, and folate-specific risks based on published associations of developing an NTD-affected pregnancy, myocardial infarction (MI), colon cancer, or masking of B-12 deficiency, with multiple events allowed.
Results: In a 25-year-old US cohort, the increase in folate intake after fortification was predicted to prevent the following disease burden over 10 years: 705 MIs, 74 NTDs, and 51 colon cancers; there is no risk of B-12 masking in the young cohorts. The greatest percent change was in Mexican-Americans, while the largest population-based benefits accrued in non-Hispanic whites. In a 65-year-old US cohort over a 10-year period, 85 individuals experienced neurological complications resulting from masked B-12 deficiency, but 9,462 MIs and 2,326 colon cancers were averted. In this age cohort, non-Hispanic whites received the greatest benefits for MIs and colon cancer, while also suffering the greatest burden from B-12 deficiency; Mexican-American males and non-Hispanic black females gained the least benefit from MI and colon cancer prevention.
Conclusions: The potential risks of a small number of cases of B-12 masking were weighed against a substantial predicted benefit of NTDs, MIs, and colon cancers prevented. This knowledge can help policymakers – both in the US and other countries – who continue to debate the risks and benefits of fortification.
See more of Oral Concurrent Session A - Simulation
See more of The 26th Annual Meeting of the Society for Medical Decision Making (October 17-20, 2004)