Transcription:
The Relationship of Folic Acid and Birth Defects

Cori Cross, MD: Welcome to Peds Cast, a podcast brought to you by Children's Alabama I'm pediatrician, Dr. Cori Cross. Today, we'll be speaking with Dr. Jeffrey Blount, who is not only a pediatric neurosurgeon, but a professor and the Raymond Harbert Chair of Pediatric Neurosurgery at Children's of Alabama Dr. Blount participates in the full spectrum of pediatric neurosurgery, but his particular academic interest is in the surgical treatment of epilepsy in children and spinal bifida. Today, we'll be discussing the relationship of folic acid and birth defects. Dr. Blount, thank you for joining us.

Jeffrey Blount, MD: It's a pleasure and thanks for the opportunity.

Cori Cross, MD: So, Dr. Blount, tell us about folic acid. It's extremely important to the developing fetus. Can you tell us a little bit about why this is, its function, its importance in pregnancy?

Jeffrey Blount, MD: Folic acid is one of the building blocks of what are called nucleotides. And nucleotides are the building blocks, if you will, of DNA and RNA. So, it is an extraordinarily important vitamin. It's one of the B vitamins. It's really important that people get it in their nutrition, and particularly women of childbearing age. Because if women don't get enough folic acid, then that can increase their risks for getting a disease that we look after at Children's of Alabama called spina bifida.

Now, it's really important to emphasize that in North America, in the United States, in Canada and I'm not sure Mexico, but North America, United States and Canada for sure, Food and Drug Administration has already embraced the concept of fortification. So when we eat certain foods, grains and things of this nature, women here are getting folic acid. So, it's super important, whenever I talk about folic acid, that I make it really clear that I don't want anybody who hears this, who has spina bifida to think that, "Oh, if I'd just eaten more vitamins, that my child would not have this." This is much more of a global effort, particularly in parts of the world that don't fortify. And one would think that since the connection is so clear between this devastating problem, this birth defect and nutrition, one would think that it would be universal and worldwide. But unfortunately, it's not.

Cori Cross, MD: I'm in Los Angeles and there's a lot of people here who are on different restrictive diets. And so if you were on just a plant-based diet where you weren't getting anything that was maybe processed and fortified, this would be something you would need to think about.

Jeffrey Blount, MD: Yeah, that's true. And so, anybody that's actively avoiding any sort of processed foods is one area. And then, the evolution by which we came to fortification has been a gradual one. So, it started with grains and it's only been, unfortunately, relatively recently that it's turned to more corn-based products as vehicles as well. So that for a long time, like people in the Hispanic community that were using more of a corn-based basis for some of their carbohydrate and things like that, there wasn't as much fortification that was getting to them. So, the issue of disparities in public health is always one that we have to be aware of. And both in the United States and outside, we have to be particularly aware of that, and that's one of the things that has led to an active search for new vehicles, vehicle just being the food that the vitamin rides along with.

And one of the ones that's kind of quite promising, and I don't want to get ahead of myself too much, but it's is the notion of using salt. When people put iodide in salt years ago, it pretty much got rid of the disease of goiter. It's extraordinarily uncommon outside of low and middle income countries now to see people that have goiter, and that's largely because of iodized salt. Well, folic acid, thankfully, is a tough little molecule and it merges well with other foods. And as a result, you know, it can be put into things like salt. So, nobody's advocating for more salt. Salt has lots of adverse health effects. But in a real world, it's a practical reality that a population uses a certain amount of salt. And it's just one example of another vehicle that fortifiers are looking at as a potential source to get folic acid into the population.

Cori Cross, MD: No. I mean, to your point, whenever I try to have a dinner party and people tell me what they can't eat, it's they're dairy-free, they're gluten-free, they're whatever it is. But they generally don't tell me they're salt-free. So, I hear your point. As much as we try to be salt conscious, we seem to all use it.

Jeffrey Blount, MD: Absolutely true. And too much salt probably hurts more people on a purely public health basis than are affected by spina bifida. However, it is a practical reality that humanity has an appetite for salt on food and that it's regardless of the health thing, that there's going to be a certain consumption of salt, so why not try and take advantage of that. Not encouraging people to use more, but potentially investigating it as a very useful vehicle.

One other point, if I may, that I think is really important in terms of understanding folic acid, because when I mentioned it as a vitamin, people would say, "Well, okay..." But people who are conscious about their health, some people take vitamin supplements and supplement strategies could work instead of fortification. Fortification is when you take a food or take a vitamin and you put it into a food supply, so that people unconsciously are getting it, people are getting it when they eat grain, when they eat bread.

Cori Cross, MD: Right. We already do that with, as you said, iodine and fluoride.

Jeffrey Blount, MD: Correct. Exactly. So, those are excellent examples of things that are out there, and folic acid being one in North America. So, some people say, "Well, don't take the choice away from me. Let me decide." But the problem is, particularly with folic acid, is that for populations that are particularly aware of the problem and particularly dedicated, then those strategies might work. But most people are thinking of all the things of leading their life, they're not necessarily thinking of these things, so that compliance tends to suffer. And what's really important with folic acid is that, for women of childbearing age, it needs to be in the woman's system before they even realize they're pregnant, right? This problem of spina bifida occurs so early on in development that the problem has already occurred before most women even realize they're pregnant. So, it's not like they can realize they're pregnant, change their nutritional strategy and put up an effective barrier for this problem. Once they realize they're pregnant, if they have the problem, it's already occurred. So, it's very important from a public health perspective to have idealized folic acid levels in women of childbearing age. And time and again, across time and across different geography, fortification strategies are the only ones that really attain that very important goal.

Cori Cross, MD: Yeah. And to just emphasize the point that a lot of women, you know, when they get pregnant, it's a happy surprise. It's just not necessarily something they planned for months in advance and started taking vitamins for. So, to that point, something that you really have to be doing in advance. So, you were the co-founder of GAPSBiF. Is this what you work on with that organization?

Jeffrey Blount, MD: Yeah. So, this is an organization. So, just by way of a little bit of background, Children's of Alabama and our partner in healthcare with UAB, we see a lot of kids in our facility, in our medical center that have spina bifida. And again, to emphasize, in North America, these families are not people that are necessarily folate deficient. Most people in North America have sufficient folic acid. What we're talking about here is predominantly a global-oriented strategy to help other parts of the world that don't do this because there's a tremendous preventable burden of this very challenging disease kind of out there in other places. So, we see lots and lots of kids that have this problem, and we're working on strategies to help these kids and these families optimally manage the problems that come with that. So, we kind of have a front-row seat to see the struggles that occur.

But since about a few years ago, a couple years ago, there was a major sort of public health report that came out by the Lancet. Lancet's a very famous publication in healthcare. And it has tremendous public health impact. And what the Lancet did is they pulled together a commission to look at the impact of surgery in public health, because public health is traditionally always kind of focused on infectious disease and things of that nature, and surgery is always thought too expensive. Surgical disciplines were looked at and studied, and it was found that they are very important in terms of the public health of the world. Five billion people are without sufficient surgical basic support.

So, that really energized the whole surgical world to become much more interested and involved in global public health. And it gave birth to this sort of concept of global surgery. Well, those of us that are interested and attuned to these things, that was an impetus to action. And we sort of said, "Well, what are the apparent things that we in surgery need to pay attention to?" And in neurosurgery, particularly neurosurgery of children, the burden of spina bifida to the world is very significant. There's 300,000 cases annually, and most of that is preventable. We know that if we can get folic acid into population food supplies, that up to 90%, 92% of that can be reduced and can be in fact eliminated.

And we're talking about the simple difference between a child that's affected or not affected, okay? Different parts of the world get into other strategies of dealing with this problem and that they try and detect the problem in the mom, and some places are very aggressive at terminating those pregnancies, which of course is a very difficult, very challenging, whole approach to problems, but it's surprisingly widespread. And we sort of say, "Well, let's prevent it. Let's not terminate. Let's prevent it. Let's keep these little kids from getting this terrible problem because it's lifelong."

We also talked to our colleagues that do neurosurgery in other countries and a big part of their life and their world is taken up caring for these kids. And it prevents them from being able to do other things, like take care of people with strokes, take care of people with trauma, things like that. So, it overloads an already challenged workforce. In the United States, for example for about every a hundred thousand people of population, there's a neurosurgeon to meet their needs. Many places in Africa, many places in Asia, you'll have two, five, eight million people for every neurosurgeon. So, the available resources to support those people's needs for other important problems gets taxed and stressed. So, there's this tremendous demand on the already low infrastructure and, much more importantly, all the suffering that is entirely preventable by a relatively simple and very safe, time-proven fortification strategy.

So, we saw this, we came together as a group and we said, "Neurosurgery sees this. Neurosurgery knows this disease. We have a front-row seat to all these problems. So, why don't we try to organize in such a way that we work with other agencies to try and attain this goal of universal fortification?"

Cori Cross, MD: That makes sense. And just as a pediatrician here in the United States where we have access to great healthcare and neurosurgeons, the prognosis, it's a spectrum. And so, you know, not everyone with a neural tube defect or with spina bifida, we have better care and a better prognosis than in the rest of the world.

Jeffrey Blount, MD: That's a really important thing to stress. We've had tremendous advances in standards for people around the world in spina bifida but, particularly, in resource-rich countries, that there are many things that can be done now to help support and we're understanding these problems more. And the quality of life, the duration of life markedly increased.

We at UAB have a large adult program for folks that now transition from pediatric care to adult care and this is a major initiative. We're getting ready to get organized for the World Congress of Spina Bifida here coming up in March out in Arizona. So, there's tremendous interest in this problem, for looking after people who have it, for developing better protocols, paradigms for treatment, for understanding the basic pathophysiology, for all of these things, and it's a multidisciplinary thing. Neurosurgery is just a limited part of it. Urology plays a big deal. Developmental pediatric, physical medicine and rehabilitation, orthopedics, across the board, nutrition, many different disciplines contribute substantially, and there really has been tremendous progress. So, fortification is an important part of our initiative, but that's aimed out there, that's aimed sort of at global surgery and reaching beyond Birmingham, beyond the United States and trying to, you know, use what we've learned here and our expertise and our experience to try and favorably impact a problem that affects hundreds of thousands of people.

Cori Cross, MD: Absolutely. And getting back just to the folic acid, so obviously fortification is important. You touched on vitamin supplementation. And I have just a couple of questions being a mom myself. And for me, when I got married and I realized like we were going to have children, I didn't just rely on the fortification. I decided I was going to take supplements as well. And I knew that basically we say sexually active women of reproductive age should take 400 micrograms of folic acid daily. And I know that you were saying that there are other factors in play that affect whether or not a developing fetus ends up having a neural tube defect. And I was wondering, is it maternal or paternal age? Do those play factors? What are other factors? Is it genetic? What are the other things?

Jeffrey Blount, MD: That's a great question. The predominant one that eclipses all the others is folic acid. So, people that know they're trying to have children, the notion of a good multivitamin is a great concept because it picks up folic acid and some of the other important micronutrients, zinc, iron, things of this nature all in one.

There are other modification factors. Obesity, smoking, those are all important ones. Prior family history, if there's an immediate relative who was affected, then the dose goes from 400 micrograms to four milligrams. So, it's a larger dose of folic acid that's recommended, and that's been demonstrated to be an effective strategy in prevention. Certainly, a family where a mom has had one child who's affected, they're recommended to go to that higher level as well. And that should be done in conjunction with healthcare providers, right? Because those are higher levels. But those are the predominant ones.

There have been some observations about extended exposure to particularly warm things, I think those are mostly anecdotal observations, warm things like hot tubs and things like that. I really don't think the evidence for things like that are very, very good, and I wouldn't encourage listeners to be particularly concerned about that.

To me, the most important thing that families can do is maintain a general good body weight, level of fitness in the sense of regular activity, healthy diet, and proper nutrition, which if you're trying to have a family, if you're trying to get pregnant, certainly the notion of a good multivitamin is a safe and effective strategy.

Cori Cross, MD: Yeah. And the good thing about folic acid is because it's water-soluble, should you take too much, you will just pee out the rest. So, it's not something you have to really worry about.

Jeffrey Blount, MD: Absolutely. That's correct. That's also true.

Cori Cross, MD: It's expensive urine, but you still just pee it out.

Jeffrey Blount, MD: It is. That's exactly right. I can't emphasize it enough though because the folks who have spina bifida already have enough to think about, that I don't want anything that I'm saying to be construed as, "Oh, if only I had taken more vitamins" or "If only I had then, my child wouldn't have this." If you live in North America, you are overwhelmingly likely. Because we live here, folic acid fortification in our grains is highly effective. So, there are different types of spina bifida, and that's why we call ourselves GAPSBiF. And that's sort of the designation between 90% of spina bifida that's responsive to folic acid and about the 10% that's not. I mean, 10% of folks have spina bifida whose moms and families had perfectly good folic acid levels, and that's most all the people in North America, right? So, it's exceptionally important that nobody either themselves consider themselves at fault or have guilt or blame their family member. Because if you live in North America, it's just not that way.

Now, some surprisingly sophisticated places around the world, think Western Europe, think some of the really sophisticated Asian countries, et cetera, have opted not to fortify, right? And the notion here is not to lay blame or point fingers or anything like that, but the simple assumption that it's simply really low and middle income countries that don't fortify, those are unequivocally disproportionately represented. There's tons of those that don't. But there are some very sophisticated places that have not chosen a fortification strategy either. And those are particularly ripe targets for us to look at and try and influence public policy in a more positive, favorable way.

Cori Cross, MD: That makes sense. I mean, to your point, if it's 90% preventable, you're definitely going to see the other 10% in the developing countries, and those are children then that we work towards having a better prognosis through the multidisciplinary approach that you were speaking about.

Jeffrey Blount, MD: That's right. Basically, the 10% is who's here, right? If you have spina bifida in North America, you probably don't have folic acid-dependent spina bifida because most populations are very successfully served by the fortification strategies that are already in place here right now.

Cori Cross, MD: Well, it's been such a pleasure to talk to you. In summary, is there anything else you want our listeners to know today?

Jeffrey Blount, MD: Well, it's just I think the essential thing is that we've had three decades of very good science-based evidence. We talk about medical evidence in terms of different classes. We have class 1 evidence and have for three decades that this fortification strategy is very safe, it's cost effective, it's very effective at reducing a very significant problem. And yet, there still are many places around the world that we're only preventing, the best estimate is about a quarter of the disease. This is a very easy, very high impact, very low cost public health initiative that we in global neurosurgery are trying to embrace science-based advocacy to exert an impact on this. And this is not an issue in the United States. But it's very much of a preventable issue in other places, and it's a big part of what we're doing at Children's of Alabama and UAB as part of our reach beyond just our area here in the local community.

Cori Cross, MD: And that's something to be really proud of. I mean, to not just be focused on Alabama, but as Children's of Alabama and UAB to be focused on globally what we can do because we know the difference that it can make and really, if we implement these things, how easy that change will be. I really applaud what you're doing, so thank you.

Jeffrey Blount, MD: Well, thank you very much for that. And we really very much appreciate opportunities to spread this word and to inform people because you never know, we've been very surprised. Opportunities like this to spread the word have resulted in people getting involved with it that have had surprising contacts and impact and things like that. So, we're very grateful for any good opportunity like this to share this word and share this information.

Cori Cross, MD: Thank you for joining us to contact Dr. Jeffrey Blount through the Global Alliance for Prevention of Spina Bifida. Please email G a P. SBF UAB edu. If you'd like more information or to refer patients to Children's of Alabama, please visit children's al.org.

That concludes this episode of Children's of Alabama Peds Cast. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for other topics that might be of interest to you. Please remember to subscribe, rate, and review this podcast.

Thanks for listening to this episode of Children's of Alabama Peds Cast. I'm your host, Dr. Corey Cross.