Purpose: To quantify the health and economic outcomes associated with changes in folic acid consumption resulting from fortifying enriched grain products in the United States. We consider the folic acid fortification level of the 1998 U.S. mandate as well as higher levels, and evaluate the potential benefits for neural tube defects (NTDs), myocardial infarctions (MIs), and colon cancer versus the possible risks of masking B-12 deficiency.

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.