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Spina bifida folate fortification in Brazil, update 2022: a cross-sectional study

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Abstract

Introduction

Despite improving maternal-child indicators in Brazil, congenital malformations are still the second cause of mortality in the first years of life. This work aims to compare statistical data before and after flour fortification with folic acid (FA) in Brazil.

Methods

A cross-sectional Brazilian-population-based study compares the spina bifida (SB) rates pre- and post-fortification of the flour with folate. Data collected from the public database of the Live Birth Information System (SINASC/SUS) was performed. The period 1999–2004 (pre-fortification) was compared with 2005–2010 (post-maize and wheat fortification with FA), and another analysis comparing 2005–2010 and 2011–2020 (cassava flour fortification) was performed. The estimator was the prevalence ratio (PRR); the confidence interval selected was 95%. We used a random effects analysis model and inverse variance.

Results

The review showed a tendency to decrease the PRR after flour fortification; however, there is no statistical significance between studies. DATASUS data analysis comparing 5 years before and 5 years after mandatory maize and wheat flour fortification demonstrated a rate ratio of 1.05 (95% CI 0.99–1.1; p = 0.075). Furthermore, comparing 10 years after additional cassava flour folate fortification, the rate ratio increased to 1.4 (95% CI 1.34–1.45; p < 0.01).

Conclusion

This study demonstrated an increase in SB after FA fortification. Possible explanations rely on national registry improvement, not fortified staple food, or further unidentified causes. Moreover, suggestions can be made for creating a mandatory registry for malformations, inspecting the concentrations of FA in the flour, and fortifying all food.

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Data availability

Data from this manuscript are available upon reasonable request. WHA 63. https://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R17-en.pdf

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Acknowledgements

To AXIS Scientific Company and Dr. João Paulo Mota Telles for the contribution to the statistical analysis. Francisco Salomão for the revision.

Author information

Authors and Affiliations

  1. Department of Neurology and Neurosurgery, School of Medicine, Universidade Federal de São Paulo São Paulo, São Paulo, Brazil

    Nelci Zanon & Francisco Salomão

  2. Centro de Neurocirurgia Pediátrica, CENEPE, São Paulo, Brazil

    Nelci Zanon, Iracema Estevão & Victor Hugo da Costa Benalia

  3. Catholic University of Pernambuco, UNICAP, Recife, Brazil

    Rhuann Pontes dos Santos Silva

  4. Escola Bahiana de Medicina e Saúde Pública, EBMSP, Bahia, Brazil

    Eduardo Varjão Vieira

  5. Universidad Peruana Cayetano Heredia, Lima, Perú

    Milagros Niquen-Jimenez

  6. Department of Neurosurgery, Santa Paula Hospital, São Paulo, Brazil

    Iracema Estevão

  7. Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA

    Victor Hugo da Costa Benalia

  8. EDUCSIM Institute, São Paulo, Brazil

    Giselle Coelho

  9. Division of Neurosurgery, Department of Neurology, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil

    Giselle Coelho

  10. Hospital Infantil Sabará, São Paulo, Brazil

    Giselle Coelho

  11. Hospital Santa Casa de Misericórdia, São Paulo, Brazil

    Giselle Coelho

Authors
  1. Nelci Zanon
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  2. Rhuann Pontes dos Santos Silva
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  3. Eduardo Varjão Vieira
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  4. Milagros Niquen-Jimenez
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  6. Victor Hugo da Costa Benalia
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  7. Giselle Coelho
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  8. Francisco Salomão
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Contributions

Nelci Zanon, Giselle Coelho, Francisco Salomão: neurosurgical expert, manuscript draft, final writing, and review. Rhuann Pontes dos Santos Silva, Eduardo Varjão Vieira, Milagros Niquen-Jimenez, Iracema Estevão: statistical analysis, manuscript draft, final writing, and review. Victor Hugo da Costa Benalia: English language review. All authors reviewed all versions of the manuscript.

Corresponding author

Correspondence to Nelci Zanon.

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Competing interests

The authors declare no competing interests.

Ethics

This study is per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE and Robins 1).

Consent

Non-applicable.

Conflict of interest

NZ has nothing to declare. RPPS has nothing to declare. EVV has nothing to declare. MNJ has nothing to declare. IE has nothing to declare. VHCB has nothing to declare. GC has nothing to declare. FS has nothing to declare.

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Zanon, N., dos Santos Silva, R.P., Varjão Vieira, E. et al. Spina bifida folate fortification in Brazil, update 2022: a cross-sectional study. Childs Nerv Syst 39, 1765–1771 (2023). https://doi.org/10.1007/s00381-022-05771-6

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