Methods: We estimated quality-adjusted-life-years (QALYs) gained and costs incurred as a result of changes in annual disease incidence after folic acid fortification for four scenarios: no fortification, or fortifying with 140, 350, or 700 micrograms (mcg) of folic acid per 100 grams (g) of enriched grain. For each scenario, we calculated results based on predicted age-, gender-, race-, and folate-specific annual incidence of NTDs, MIs, colon cancer, and B-12 masking. Estimates were calculated for a one-year steady state among the U.S. population of non-institutionalized, non-Hispanic white (“white”), non-Hispanic black (“black”), and Mexican-American adults aged 15 or older.
Results: Compared with no fortification, all post-fortification strategies were projected to provide QALY gains and cost savings both at the population level as well as for all age, gender, and race/ethnicity-specific subgroups. These projected benefits were substantially greater for whites than for blacks and Mexican-Americans, with Mexican-Americans benefiting the least for all age and genders except for among women of childbearing age, for whom blacks benefited the least. For all subgroups, fortifying at 700 mcg/100 g enriched grain product was predicted to strongly dominate all other scenarios, with total population benefits of 322,940 QALYs gained and $4.4 billion saved. At the current fortification level, the greatest projected declines in NTD incidence were among Mexican-Americans, while those for MI and colon cancer incidence were for whites.
Conclusions: We project that the health and economic gains of folic acid fortification will far outweigh the losses for the U.S. population as a whole. An increase in the level of fortification deserves further consideration in order to maximize net gains among all age, gender, and race/ethnicity-specific subgroups. This knowledge can help policymakers – both in the U.S. and in other countries – who continue to debate the risks and benefits of fortification.