Beginning in January 1998, all enriched grains, rice, cornmeal, macaroni and noodle products will be fortified with folic acid before it's sold for use by consumers.
The new fortification rule, a result of heavy lobbying by women's health advocates at the March of Dimes, will provide a quarter of the normal daily recommended dosage and about an eighth of that suggested for pregnant women.
Experts said a supplement still will be necessary to achieve the prenatal health benefits, but fortifying certain foods will help a lot.
Folic acid is a basic B vitamin found in green leafy vegetables, beans, peas, nuts, liver and some fruits. It is known to prevent crippling neural defects such as spina bifida, which is an exposed spine, and anencephaly, which stops part or all of the brain or spinal cord from forming.
"We try to get women to take folic acid before they're pregnant. This is important because the neural tube is made at three weeks. A lot of people at that time are rarely even aware that they're pregnant," said Verna Raynor, a nurse midwife with Mid-Atlantic Women's Health Center in Hagerstown.
Dr. Eva Olah, a physician with Mid-Atlantic, said even though there is some disagreement over dosage - ranging from 0.4 milligrams per day to a full milligram per day - experts agree that folic acid prevents spinal cord defects.
Information about folic acid is reliable and has been around for years, according to Raynor and Olah. They said it is the first thing Mid-Atlantic prescribes to pregnant women or those wishing to become pregnant.
"This is an easy issue for us. It's just something you know," Raynor said.
But it wasn't easy for the federal government to build consensus on the folic acid fortification mandate.
"Adding it to the diets of 250 million people was controversial," said Judith Foulke, a spokeswoman for U.S. Food and Drug Administration. She said FDA accepted the health claims of folic acid, also known as folate, in 1993. But it took until 1996 to convince other sectors of the public health community.
"It's a very complicated issue. There's a considerable amount of science in a health claim," Foulke said.
For example, folic acid can mask symptoms of vitamin B-12 deficiencies, which causes a type of nerve-damaging anemia that is particularly dangerous to the elderly.
Consequently, FDA is requiring that fortified grain products contain less folic acid than women's health experts initially called for.
Dona Dei, who runs the March of Dimes folic acid project, said it's difficult to convince women that they need to take vitamins or eat foods rich in folic acid.
"Getting people to change their behavior is difficult, and that's a big behavioral change," she said.
A recent March of Dimes survey found women are more aware of the need to supplement their diet with folic acid, but still are not taking the vitamin or know what foods contain folic acid.
Morbidity data at Centers for Disease Control and Prevention count roughly 4,000 cases of neural tube birth defects every year.
In addition to folic acid, health experts recommend that pregnant women take vitamin B-12, extra iron, extra calcium and 60 grams of protein per day - versus the usual 45 grams. Pregnant women also should be careful not to overeat. Only an extra 300 calories per day is necessary, they said.
0.5 milligrams per serving:
0.15 to 0.5 milligrams per serving:
oranges and orange juice
pineapples and pineapple juice
wheat and white bread
some fortified breakfast cereals
*Association of Spina Bifida and Hydrocephalus of Great Britain does not recommend liver for prenatal care because it contains high levels of vitamin A, which is harmful to the fetus.
- Sources: FDA and March of Dimes. Dosages are from the Association of Spina Bifida and Hydrocephalus of Great Britain.