A team of international researchers — including a professor at UCF’s College of Medicine — has proven for the first time in a field study that a specific type of salt can prevent spina bifida and anencephaly, severe birth defects that cause death or permanent neurologic disability.
Jogi Pattisapu, a retired Orlando pediatric neurosurgeon who helped create UCF’s medical school, is the lead author of a study published online this week by the Journal of the American Medical Association’s Network Open publication that showed the success of folic-acid fortified table salt.
The study was a collaboration between physicians, scientists and health officials across the United States, Canada and India. The team included Pattisapu, M.V. Vijayashekar and Anil Kumar from Andhra Medical College/King George Hospital in Visakhapatnam, India, and Vijaya Kancherla and Godfrey Oakley of Emory University.
For over 30 years research has shown that women need enough folic acid in their bodies before and during pregnancy to prevent spina bifida and anencephaly (SBA). The defect occurs when the fetus’ neural tube doesn’t fold completely — about 28 days after conception and before many women even know they are pregnant. For that reason, many grains, cereals and flours sold in the U.S. are fortified with folic acid and most U.S. vitamins contain it, according to the CDC. Women of child-bearing age who are thinking of becoming pregnant are urged to take 400 micrograms of folic acid daily for several months before trying to conceive and during early stages of pregnancy.
“You have to prevent a brain injury before it happens,” says Pattisapu of spina bifida and anencephaly. “I can’t count the thousands of times I have held a parent’s hand as they cried, ‘How did this happen? Why did this happen to my baby?’”
However, only about 25% of the world’s countries have mandatory folic acid policies. And while SBA occurs in about 20 out of 10,000 births worldwide (about 260,000 births), in India it happens at twice that rate (about 40 out of 10,000 births). The South Asian region accounts for a disproportionately high level of the birth defect worldwide.
To combat the problem, researchers worked with a manufacturer to create iodized salt fortified with folic acid. An army of researchers and volunteers then went into four rural Indian villages with an educational campaign and recruited volunteers to participate in the study. Heathcare teams held town halls and went home-to-home to discuss the importance of using the salt and follow-up with residents.
After the initial discussions, women of childbearing age (18-45 years) were recruited by surveys and stringent criteria. They agreed to be interviewed, undergo a screening examination and to eat only the fortified salt during the study. They also agreed to remain in the village and not travel and to give blood samples, before and during the study.
The team replaced each community’s salt supply with the fortified variety. They delivered the study salt to each villager and replaced the salt sold at the few stores where the villagers shopped. That gave them a control sample — even if a villager borrowed salt from a neighbor, it was fortified. And because villagers hardly if ever left their community, they were not exposed to another region’s salt.
Villagers ate the salt as part of their regular diet from July 1 to Nov. 30, 2022. The researchers tested 83 women and found a statistically significant 3.7-fold increase in their serum folic acid levels.
The study found the use of folic acid-fortified salt was associated with increased serum folic concentrations in women of reproductive age, providing evidence that can inform public health policy to accelerate SBA prevention. An increase in blood folate levels is known to prevent 80% of SBA, which hasn’t changed or reverted the strategies of the over 65 countries worldwide that have initiated mandatory folic acid fortification policies.
Vijayashekar says the study shows how women in remote areas can benefit from coordinated medical support.
“These are women who do not have medical care,” he says. “Through this study we’ve shown how we can protect them from having babies with spina bifida.”
Kumar, who managed the project, says the villagers’ response was so positive that other rural areas asked to participate in the project. It expanded into other areas and residents reported they felt better and had more energy using salt fortified with folic acid, which is a form of vitamin B. Researchers said they hope news of their study will encourage more countries around the world to initiate folic acid policies and practices.
“This is a global goodwill involving the health of mothers and babies. We are making sure we apply the knowledge we have,” Kancherla says. “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.”
A pediatric neurosurgeon who practiced for more than 30 years, Pattisapu has a long history of support to UCF, including helping to create its innovative curriculum.
