Should Folic Acid Be Added To Table Salt?

The importance of women having enough folic acid before and during pregnancy to prevent permanent and life-threatening birth defects has been known for decades, and recommendations have been established. Additionally, in 2023 the World Health Assembly adopted a resolution prompting food fortification with folic acid to the slow pace of prevention of birth defects associated with low maternal folate levels during pregnancy. 

Folic acid has been added via mandatory staple grain food fortification in around 65 countries, which includes America, but over 100 countries have yet to implement fortification due to challenges that include the limited capacity for large-scale fortification of staple grains in their regions or the lack of political will. 

This study showed that a solution to this problem is possible via a product that many people already have in their cupboards and on their kitchen tables. The clinical trial showed that mixing folic acid with commercially available iodized table salt increased serum folate levels among the participants to meet the levels that are required for the prevention of spina bifida and anencephaly, according to the researchers. They found the increase was significant enough to create a 3.7-fold improvement before and after a four-month period using the study salt with iodine and folic acid. 

"We proved that folic acid can get into the blood through salt. Hopefully, countries that have not already implemented fortification programs can now look at their infrastructures and realize that salt fortification is cheap and it's really easy to add in the amount of folic acid needed to save lives," says Jogi Pattisapu, MD, the study's lead author and a neurosurgeon from UCF's College of Medicine. "It might just turn the salt a little yellow, but the participants did not mind and we know it works. What we need now is action."

The team believes that the impact of this study should be felt globally in countries with successful salt iodization programs. At least 50% of the current global spina bifida cases could be prevented if the major pre-existing iodized salt programs began adding folic acid to the mixture. 

"We now know folic acid fortification of iodized salt can prevent folate deficiency that causes spina bifida," says Godfrey Oakley Jr., MD, director of the Center for Spina Bifida Prevention at Rollins. "The stage is now set for a rapid acceleration of prevention of these birth defects in many countries"

India has a high prevalence of spina bifida and anencephaly. Pattisapu credits the study's successful outcome to the collaborative nature of the research team, specifically the efforts and expertise of researchers from Emory University's Rollins School of Public Health and colleagues from multiple institutions in India, who co-led the study, and recruited/monitored the 83 non-pregnant women between the ages of 18-45, from four different villages in southern India, who consumed the folic acid-fortified salt as part of their regular diet during four months in 2022. 

"Work was done there, by the Indian team, for their cause," Pattisapu says. "That was very important, and it is a powerful message."

"This is a global goodwill involving the health of mothers and babies. We are making sure we apply the knowledge we have," says Vijaya Kancherla, an associate professor in the Department of Epidemiology at Rollins. "These are preventable birth defects and once it happens, you cannot cure it. Surgeries and clinical care are expensive and largely not available in low- and middle-income countries. Due to that, most babies with spina bifida die globally. So, it is a human rights issue that everyone should be worried about and should strive to find alternate solutions that prevent these conditions from occurring in the first place, no matter where one is born. We show that salt has the potential to close the prevention gap now."

It is important to note that this study does not promote salt intake, rather adding the necessary amount of folic acid to table salt that residents of these regions are already consuming to help prevent birth defects. If the average daily salt intake has been reduced in these regions, the concentrations of folic acid added would merely need to be increased to meet the needs. This type of approach is already being used in the grain fortification programs.