Adding Folic Acid to Iodized Salt

A team of international researchers—including experts from the University of Central Florida and Emory—has proven that folic acid–fortified iodized table salt can prevent multiple severe birth defects.

The importance of women having enough folic acid before and during pregnancy to prevent permanent, life-threatening birth defects such as spina bifida and anencephaly has been known for decades. The World Health Organization recommends all women take supplement pills with 400 micrograms of folic acid daily, from attempting to conceive through the first three months of pregnancy.

Mandatory staple food fortification with folic acid is a cost–effective, safe and equitable way to address the issue. In 2023, the World Health Assembly adopted a resolution promoting food fortification with folic acid.

Yet approximately 260,000 births worldwide—about 20 per 10,000 births—are still affected by spina bifida and anencephaly, contributing to a high number of stillbirths, pregnancy terminations, and deaths of infants and young children.

While folic acid has been added through mandatory staple grain food fortification in about 65 countries, including the United States, more than 100 countries have yet to implement fortification due to challenges including limited capacity for large-scale fortification or lack of political will.

A recent study in JAMA Network Open showed a convenient solution: adding folic acid to iodized table salt based on existing average consumption of salt. This increased serum folate levels among participants to levels needed for prevention of spina bifida and anencephaly in their infants. The increase was significant: a 3.7-fold improvement before and after a four-month period of using the study salt with iodine and folic acid.

Colleagues from multiple institutions in India co-led the study and recruited and monitored 83 non-pregnant women between 18 and 45 from four villages in southern India. They consumed the folic acid–fortified salt as part of their regular diet. India has a high prevalence of spina bifida and anencephaly.

“This is a global goodwill effort involving the health of mothers and babies. We are making sure we apply the knowledge we have,” says Vijaya Kancherla, associate professor of epidemiology at Rollins School of Public Health. At least 50 percent of current global spina bifida cases could be prevented if already existing iodized salt programs add folic acid, researchers say.

Godfrey Oakley Jr., director of the Center for Spina Bifida Prevention at Rollins, says, “The stage is now set for a rapid acceleration of prevention in many countries.”