They found that adding folic acid – known to play a key role in foetal growth and development – to commercially available iodised table salt led to a 3.7-fold increase in participants’ serum folate levels after four months, taking them to the levels needed to prevent spina bifida and anencephaly.
“We proved that folic acid can get into the blood through salt. Hopefully countries that have not already implemented fortification programmes can now look at their infrastructures and realise that salt fortification is cheap and it’s really easy to add in the amount of folic acid needed to save lives,” said lead author Jogi Pattisapu, a neurosurgeon from the University of Central Florida’s College of Medicine.
“It might just turn the salt a little yellow, but the participants did not mind and we know it works. What we need now is action.”
Folic acid: An essential nutrient before and during pregnancy
The importance of folic acid intake among mothers-to-be before and during pregnancy to prevent birth defects has been known for decades. The World Health Organization recommends that women are supplemented with 400 µg of folic acid daily from the moment they begin attempting to conceive and throughout the first three months of pregnancy.
Mandatory food fortification with folic acid is a cost-effective, safe, and equitable way to address the risk. In May 2023, the World Health Assembly adopted a resolution promoting food fortification with folic acid to accelerate the slow pace of prevention of spina bifida and other birth defects associated with low maternal folate levels during early pregnancy.
However, approximately 260,000 births worldwide – about 20 per every 10,000 births – are still affected by spina bifida and anencephaly.
While folic acid is a focus for mandatory staple grain food fortification in 65 countries worldwide, more than 100 countries – including India, where the recent research was undertaken – have yet to implement such programmes, contributing to a high number of stillbirths, elective pregnancy terminations, and deaths of infants and young children.
Fortified salt programmes hold potential ‘to close prevention gap now’
The study, published in JAMA Network Open, found that adding folic acid to iodised salt resulted in a significant increase in serum folate levels: a 3.7-fold improvement before and after a four-month period of using the salt.
Participants included 83 non-pregnant women aged 18 to 45 years, from four different villages in southern India, who consumed the folic acid-fortified salt as part of their regular diet during a four-month period in 2022. India has a high prevalence of spina bifida and anencephaly.
The team behind the research hope it could have a global impact, highlighting that at least 50% of current global spina bifida cases would be prevented if all major existing iodised salt programmes took the simple step of adding folic acid.
“These are preventable birth defects and once it happens, you cannot cure it,” said Vijaya Kancherla, an associate professor in epidemiology at Emory University’s Rollins School of Public Health. “Surgeries and clinical care are expensive and largely not available in low- and middle-income countries. Due to that, most babies with spina bifida die globally.
“So, it is a human rights issue that everyone should be worried about and should strive to find alternate solutions that prevent these conditions from occurring in the first place, no matter where one is born.
“We show that salt has the potential to close the prevention gap now.”
Stage ‘is now set’ for widespread acceleration of prevention of birth defects
Pattisapu credited the study’s success to the collaborative nature of the research team, specifically the efforts of Rollins researchers and colleagues from multiple institutions in India, who co-led the study and recruited and monitored participants.
The researchers emphasised that the study is not intended to promote salt intake; the necessary amount of folic acid should be added to the table salt that residents of these regions are already consuming. If average daily salt consumption were to reduce in these regions, the concentration of folic acid could simply be increased to meet the need – an approach already used in grain fortification programmes.
“We now know folic acid fortification of iodised salt can prevent folate deficiency that causes spina bifida,” said Godfrey Oakley Jnr, director of the Center for Spina Bifida Prevention at Rollins. “The stage is now set for a rapid acceleration of prevention of these birth defects in many countries.”
