FOLIC ACID SUPPLEMENTATION IN SOUTH CAROLINA COULD SAVE $ 10- 20 MIL.

FOLIC ACID SUPPLEMENTATION IN SOUTH CAROLINA COULD SAVE $ 10- 20 MIL. in health care costs by preventing neural tube defects in new- borns, Roger Stevenson, MD, director of South Carolina's Neural Tube Defects Prevention Initiative, estimated in a Sept. 20 presentation at the Council for Responsible Nutrition's annual meeting. "In South Carolina," Stevenson said, "we anticipate with the prevention of even half of the cases [of NTDs] with folate supplementation that we would have [significant] health cost savings . . . and we have one-eightieth of the population of the U.S. We are obviously talking about large figures." Calling South Carolina the "epicenter" for NTDs in the southeastern U.S., Stevenson reported that the prevalence of NTDs in his state is twice the balance of NTD rates for the nation. The state has not identified the specific cause of the high NTD rate. As part of the state's NTD prevention program, the South Carolina health department has issued a "physicians alert" document that explains the beneficial effects of folic acid, Stevenson noted. Personal letters have also been sent to all medical professionals who have contact with pregnant women including family practitioners, internists and obstetricians. In addition, the state has distributed a series of newsletters to doctors accompanied by patient brochures. Stevenson stressed the need to reach consumers with the message that women of child-bearing age should be taking .4 mg of folic acid a day. "About 40% of women who become pregnant," he explained, "become so without anticipating it and . . . [are] not taking vitamins in preparation for the pregnancy." The South Carolina NTD Prevention Initiative has launched a public education program that includes an 11-minute "educational television documentary of the folic acid prevention story," as well as newspaper articles and brochures that can be picked up from health agencies. Scott Simpson, MD, director of Maternal Health and Family Planning at the Texas Department of Health, described a similar NTD prevention program in the southern part of Texas. Simpson noted that an unusually high number of reported cases of anencephaly, the most severe form of NTDs, in Cameron County prompted the state health department and the U.S. Centers for Disease Control and Prevention to investigate the NTD incidence rate along the Texas/Mexico border. The investigation found that the NTD rates in Cameron and Hidalgo counties are higher than those for the rest of the country, ranging from 16 cases in 1981 to 38 cases in 1991, Simpson explained. After adjusting the incidence rates to account for early pregnancy terminations and the counties' predominantly Hispanic population (Hispanic women have a higher statistical expectation of NTD births), Simpson pointed out that the incidence rate in the two Texas counties is still higher than the average rate of six to eight cases per 10,000 in the U.S. The Texas Department of Health decided in October 1992 to support CDC's health recommendations and began an educational campaign in Cameron County that included press conferences to educate the public, articles published in Texas journals and letters sent to all physicians in the 14 counties along the Texas/Mexico border. In addition, the Texas prevention program initiated a folic acid distribution program, which dispenses free vitamins that include folic acid to women of child-bearing age. The vitamins, contributed by various sources including Lederle, Food Hold USA and Pharmavite, are made available through public health agencies and are advertised through radio and television ads and via posters and pamphlets. The Texas Department of Health "distributed about 4 mil. tablets . . . to about 45,000 women" between October 1992 and July of this year, Simpson announced. CDC and Texas have also established an active surveillance system that tracks the incidence of NTDs in the 14 counties along the Texas/Mexico border, according to Simpson. As part of this surveillance system, he reported, women who are identified as high risk (having one child with an NTD) are given folic acid and followed for four to five years through any subsequent pregnancies. The program will also conduct a case control study "where women are evaluated with a fairly extensive questionnaire and with various laboratory studies," Simpson maintained. In April 1993, the Folic Acid Subcommittee voted 6-4 to recommend that a folic acid health claim to prevent neural tube defects be allowed by FDA. The subcommittee also reiterated a recommendation made at a November 1992 meeting of the subcommittee to fortify the food supply with folic acid. At the April meeting, the subcommittee voted overwhelmingly in favor of the establishment of a folic acid adverse effects surveillance system ("The Tan Sheet" April 19, pp. 3-6). Since that meeting, CDC has worked on various options for a surveillance system ("The Tan Sheet" Aug. 23, p. 8). FDA is expected within the next month to issue a proposal on folic acid fortification. Commenting on FDA's handling of the folic acid issue, Stevenson asserted that "even if the FDA . . . allows or recommends fortification at that level [140 mcg/100 g of flour], we will still be faced with the need in a substantial portion of the reproducing population to use supplements in order to reach that .4 mg/day intake." CRN ran a full-page ad in the Sept. 20 issue of Roll Call appealing to FDA to change its "policy and help women prevent a common and severe birth defect." In the ad, CRN quotes several physicians endorsing a folic acid health claim.