Editing Folate (section)

===United States===
[[File:GrainProducts.jpg|right|thumb|In the United States and many other countries, wheat flour is fortified with folic acid; some countries also fortify maize flour and rice.<ref name=Map/>]]

In 1996, the United States [[Food and Drug Administration]] (FDA) published regulations requiring the addition of folic acid to enriched breads, cereals, flours, corn meals, pastas, rice, and other grain products.<ref>{{cite web |url=https://www.govinfo.gov/content/pkg/FR-1996-03-05/pdf/96-5014.pdf |title=Food and Drug Administration. Food standards: amendment of standards of identity for enriched grain products to require addition of folic acid. Final Rule. 21 CFR Parts 136, 137, and 139. |date=March 1996 |volume=61 |issue=44 |pages=8781–89 |website=Federal Register |access-date=6 October 2019 |archive-date=6 October 2019 |archive-url=https://web.archive.org/web/20191006122713/https://www.govinfo.gov/content/pkg/FR-1996-03-05/pdf/96-5014.pdf |url-status=live }}</ref> This ruling took effect on 1 January 1998, and was specifically targeted to reduce the risk of neural tube birth defects in newborns.<ref name=Crandall1998>{{cite journal|vauthors=Crandall BF, Corson VL, Evans MI, Goldberg JD, Knight G, Salafsky IS|title=American College of Medical Genetics statement on folic acid: fortification and supplementation|journal=American Journal of Medical Genetics|volume=78|issue=4|page=381|date=July 1998|pmid=9714444|doi=10.1002/(SICI)1096-8628(19980724)78:4<381::AID-AJMG16>3.0.CO;2-E}}</ref> There were concerns expressed that the amount of folate added was insufficient.<ref>{{cite news|url=http://www.boston.com/yourlife/health/women/articles/2004/01/06/fda_muffed_chance_to_prevent_birth_defects/?pages=full|title=FDA muffed chance to reduce birth defects|newspaper=Boston Globe|date=6 January 2004|url-status=live|archive-url=https://web.archive.org/web/20070313013804/http://www.boston.com/yourlife/health/women/articles/2004/01/06/fda_muffed_chance_to_prevent_birth_defects/?pages=full|archive-date=13 March 2007}}</ref>

The fortification program was expected to raise a person's folic acid intake level by 70–130&nbsp;μg/day;<ref name=Choumenkovitch2002>{{cite journal|vauthors=Choumenkovitch SF, Selhub J, Wilson PW, Rader JI, Rosenberg IH, Jacques PF|title=Folic acid intake from fortification in United States exceeds predictions|journal=The Journal of Nutrition|volume=132|issue=9|pages=2792–8|date=September 2002|pmid=12221247|doi=10.1093/jn/132.9.2792|doi-access=free}}</ref> however, an increase of almost double that amount was actually observed.<ref name="Quinlivan">{{cite journal|vauthors=Quinlivan EP, Gregory JF|title=Effect of food fortification on folic acid intake in the United States|journal=The American Journal of Clinical Nutrition|volume=77|issue=1|pages=221–5|date=January 2003|pmid=12499345|doi=10.1093/ajcn/77.1.221|doi-access=free}}</ref> This could be from the fact that many foods are fortified by 160–175% over the required amount.<ref name="Quinlivan"/> Much of the elder population take [[dietary supplement|supplements]] that add 400&nbsp;μg to their daily folic acid intake. This is a concern because 70–80% of the population have detectable levels of unmetabolized folic acid in their [[blood]], a consequence of folic acid supplementation and fortification.<ref name=Chustecka2009/> However, at blood concentrations achieved via food fortification, folic acid has no known cofactor function that would increase the likelihood of a causal role for free folic acid in disease development.<ref name=Obeid2012/>

The U.S. National Center for Health Statistics conducts the biannual National Health and Nutrition Examination Survey (NHANES) to assess the health and nutritional status of adults and children in the United States. Some results are reported as What We Eat In America. The 2013–2014 survey reported that for adults ages 20 years and older, men consumed an average of 249&nbsp;μg/day folate from food plus 207&nbsp;μg/day of folic acid from consumption of fortified foods, for a combined total of 601&nbsp;μg/day of dietary folate equivalents (DFEs because each microgram of folic acid counts as 1.7&nbsp;μg of food folate). For women, the values are 199, 153 and 459&nbsp;μg/day, respectively. This means that fortification led to a bigger increase in folic acid intake than first projected, and that more than half the adults are consuming more than the RDA of 400&nbsp;μg (as DFEs). Even so, fewer than half of pregnant women are exceeding the pregnancy RDA of 600&nbsp;μg/day.<ref>{{cite web|url=https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/1314/Table_1_NIN_GEN_13.pdf|title=TABLE 1: Nutrient Intakes from Food and Beverages|website=What We Eat In America, NHANES 2012–2014 (2016)|access-date=12 October 2018|archive-date=24 February 2017|archive-url=https://web.archive.org/web/20170224042515/https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/1314/Table_1_NIN_GEN_13.pdf|url-status=live}}</ref>

Before folic acid fortification, about 4,100 pregnancies were affected by a neural tube defect each year in the United States. The [[Centers for Disease Control and Prevention]] reported in 2015 that since the addition of folic acid in grain-based foods as mandated by the FDA, the rate of neural tube defects dropped by 35%. This translates to an annual saving in total direct costs of approximately $508 million for the NTD-affected births that were prevented.<ref>{{cite journal|title=Updated Estimates of Neural Tube Defects Prevented by Mandatory Folic Acid Fortification — United States, 1995–2011|journal=MMWR. Morbidity and Mortality Weekly Report|volume=64|issue=1|pages=1–5|date=16 January 2015|pmid=25590678|pmc=4584791|url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6401a2.htm|author=Centers for Disease Control Prevention (CDC)|access-date=15 September 2019|archive-date=31 July 2020|archive-url=https://web.archive.org/web/20200731174802/https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6401a2.htm|url-status=live}}</ref><ref name="cdc.gov">{{Cite web|title=Birth Defects COUNT {{!}} Folic Acid {{!}} NCBDDD {{!}} CDC|url=https://www.cdc.gov/ncbddd/folicacid/global.html#1|website=www.cdc.gov|access-date=16 November 2015|url-status=live|archive-url=https://web.archive.org/web/20151113191745/http://www.cdc.gov/ncbddd/folicacid/global.html#1|archive-date=13 November 2015}}</ref>