Authors: Nathan A. Shlobin
Worldwide, spina bifida and anencephaly (SBA) are common pediatric neurosurgical conditions leading to substantial morbidity and mortality. Level 1 evidence has existed for more than 3 decades that dietary folic acid fortification profoundly reduces the incidence of SBA, yet only about 23% of preventable SBA is currently being prevented globally. We provide a bibliometric analysis of folic acid supplementation and fortification.Methods: Articles retrieved from Scopus were screened. Inclusion criteria were focusing on arguments for, outcomes, or challenges of folic acid fortification / supplementation. Articles mentioning these strategies cursorily were excluded. Bibliographic and bibliometric data were extracted from the top 100 most cited articles.
Articles were published between 1980 and 2017. Forty-six articles discussed supplementation, 38 fortification, and 16 both. Forty-two articles were clinical, 41 policy, and 17 translational. Eighty-five discussed efficacy, 9 safety, and 6 both. Fifty-two articles originated from the United States, 16 from Canada, and 14 from the United Kingdom. Countries of origin were mainly (95.8%, 161/168) from the World Health Organization Region of the Americans or European Region and were primarily (93.5%, 157/168) high-income countries. Median total number of citations was 185.5 (range: 97 3,254). Median number of citations per year was 12.1 (range: 4.7 - 108.5). The most cited article was the seminal Medical Research Council Vitamin Study demonstrating prevention of neural tube defects with adequate folic acid supplementation. Folic acid fortification was consistently associated with reduced prevalence of SBA, while supplementation was inconsistently associated due to frequent lack of user knowledge and inconsistent use. Criticisms to increasing folic acid intake, including increased rates of cancer or autism and masking of B12 deficiency, were unsupported.
Mandatory food fortification with folic acid is well-supported, while supplementation may provide a useful adjunct. Neurosurgeons may potentially play an important role in advancing these efforts.