Georgia Epidemiology Report The Georgia Epidemiology Report is a publication of the Epidemiology Section of the Epidemiology and Prevention Branch, Division of Public Health, Department of Human Resources December 1996 Volume 12 Number 12 Knowledge About Folic Acid and Use of Multivitamins Containing Folic Acid Among Reproductive-Aged Women http://www.ph.dhr.state.ga.us Division Of Public Health Patrick J. Meehan, M.D. - Director Epidemiology and Prevention Branch State Epidemiologist Kathleen E. Toomey, M.D., M.P.H.- Director Epidemiology Section Paul A. Blake, M.D., M.P.H.-Chief Notifiable Diseases Jeffrey D. Berschling, M.P.H.; Karen R. Horvat, M.P.H. ; Amri B. Johnson, M.P.H. ; Jane E. Koehler, D.V.M, M.P.H.; Preeti Pathela, M.P.H.; Sabrina Walton, M.S.P.H. Chronic Disease Nancy E. Stroup, Ph.D.-Program Manager Patricia M. Fox, M.P.H.; David M. Homa, Ph.D., M.P.H.; Edward E. Pledger, M.P.A. Tuberculosis Naomi Bock, M.D., M.S. HIV/AIDS/Sexually Transmitted Diseases Kim Cook, M.D., M.S.P.H.-Program Manager Stephanie Bock, M.P.H.; Mary Lynn Gaffield, M.P.H.; Awal D. Khan, Ph.D., M.A.; Andrew Margolis, M.P.H. Office of Perinatal Epidemiology Roger W. Rochat, M.D. - Program Manager Mary D. Brantley, M.P.H.; Raymond E. Gangarosa, M.D., M.P.H.; Mary P. Mathis, Ph.D., M.P.H.; Florina Serbanescu, M.D. Preventive Medicine Residents Hussain R. Yusuf, M.B.B.S., M.P.H.; E. Anne Peterson, M.D. EIS Officer Michael S. Friedman, M.D. Georgia Epidemiology Report Editorial Board Editorial Executive Committee Paul A. Blake, M.D., M.P.H.- Editor Kathleen E. Toomey, M.D., M.P.H. Mary D. Brantley, M.P.H. Jeffrey D. Berschling, M.P.H. Mailing List Edward E. Pledger, M.P.A. Adapted from Centers for Disease Control and Prevention (CDC),Morbidity and Mortality Weekly Report (MMWR), 1996 45(37):793-795. Neural tube defects (NTDs) are serious birth defects that affect an estimated 4000 pregnancies each year in the United States1. However, women can substan- tially decrease the risk for this birth defect by consuming 400mg (0.4 mg) of folic acid per day before conception and during early pregnancy. In September 1992, the Public Health Service (PHS) recommended that all women of childbearing age who are capable of becoming pregnant consume 400mg of folic acid daily2. To characterize knowledge about the benefits of folic acid and use of multivitamins containing folic acid among Georgia women, the Division of Public Health, Georgia Department of Human Resources (GDHR), analyzed data from the 1995 Georgia Women's Health Survey (GWHS)--a comprehensive study of women's health that included questions about folic acid. This report summarizes the survey findings regarding knowledge and use of folic acid, which indicate that only 20% of Georgia women aged 1544 years consumed a multivitamin containing >400mg of folic acid per day, and 71% did not know that folic acid can prevent some birth defects. GDHR conducted the GWHS during JanuaryJuly 1995. It was the first statewide probability survey of women's health conducted in a Southeastern state and the fifth state survey carried out nationwide. GWHS was a random digit dialed telephone survey of a probability sample of 4005 Georgia women aged 15 44 years; 3130 (78%) women responded3. Data for households with more than one eligible woman or multiple residential phone numbers were weighted to adjust for the unequal probability of selection. The sample was highly representative of all childbearing-aged women in Georgia3. Survey respondents were asked, "During the past 30 days, how often have you taken multivitamins?"; responses were "every day," "several times a week," "once a week," "less than once a week," and "don't know." Respondents also Epidemiology Section, Epidemiology & Prevention Branch, Two Peachtree St., N.W., Atlanta, GA 30303-3186 Phone: (404) 657-2588 FAX: (404) 657-2586 were asked "What brand of multivitamins do you or did you take most often?" and "Have you heard or read that taking a vitamin called folic acid can help prevent some birth defects?" The amount of folic acid women consumed was estimated based on the amount in the multivitamin brand they reported using. Overall, 20% of respondents reported consuming a multivitamin containing >400mg of folic acid per day, 5% reported consuming a multivitamin containing >400mg of folic acid several times a week (Figure 1). common among whites (22%) than among blacks (15%), and increased directly by educational and income levels. Women with higher educational levels were more likely to consume a multivitamin containing >400mg of folic acid per day than were less educated women (some high school education [10%], high school diploma [20%], some college education [23%], and college or postgraduate degree [27%]). Women with incomes above 150% of poverty level were more likely than women with incomes below 150% of poverty level (22% versus 14%). Figure 1. Self-reported folic acid consumption among women by dose and frequency of use Figure 2. Self-reported folic acid consumption among women by level of knowledge of the health benefits of folic acid and regimen Overall, 29% of respondents have heard about the health benefits of folic acid in preventing birth defects, and 71% had no knowledge about this issue (Figure 2). Of those who had heard folic acid can help prevent some birth de- fects, 30% reported consuming a multivitamin containing >400mg of folic acid per day, and 6% reported consuming a multivitamin containing >400mg of folic acid several times a week. Of the 71% who had not heard about folic acid, 16% reported consuming a multivitamin containing >400mg of folic acid per day, and 4% reported consuming a multivita- min containing >400mg of folic acid several times a week. For each educational level, women who reported knowledge of folic acid were more likely to have consumed a multivitamin containing >400mg of folic acid per day than women who had not heard about folic acid. Among women who had heard about folic acid, the prevalence of consum- ing a multivitamin containing >400mg per day was 16% for those with some high school education, 32% with a high school diploma, 32% with some college education, and 29% with a college degree. Prevalence of knowledge about folic acid was higher for white women than for black women (33% versus 19%) and varied directly by respondents' educational and income levels. Women with a college degree were more likely to have heard about folic acid than were those with only some high school (45% versus 12%), and women with incomes above 150% of poverty level were more likely than women with incomes below 150% of poverty level (31% versus 18%)*. Consuming 400mg of folic acid per day was more Editorial Note The findings in this report are subject to at least two limitations. First, folic acid consumption in the GWHS was * Poverty statistics are based on a definition originated by the Social Security Administration in 1964, that was subsequently modified by federal interagency committees in 1969 and 1980, and prescribed by the Office of Management and Budget as the standard to be used by federal agencies for statistical purposes. In 1994, the federal poverty level was equivalent to a total annual income of 14,800 for a family of four. - 2 - measured on the basis of reported use of multivitamins only; no information was obtained about consumption of folic acid tablets or foods fortified with folic acid. Second, 22% of the sample did not participate in the survey, and the survey excluded households without telephones; therefore, prevalences of knowledge and use of folic acid may be overestimated. However, when data were adjusted with poststratification weights** applied to account for nonresponse and the omission of non-telephone households, the overall knowledge and use of folic acid were lower only by 2 percentage points and 1 percentage point, respectively. acid are more likely to consume daily a multivitamin con- taining 400mg of folic acid, the design and implementation of health education programs for women of childbearing age will be important in educating them about these benefits at the earliest possible time before they become pregnant. More information about GWHS may be obtained from Roger Rochat, MD, at the Office of Perinatal Epidemiology (404) 657-6452. Questions on folic acid and nutrition may be directed to Cathy McCarroll, MPH, RDLD, at the Office of Nutrition (404) 657-2884. In 1986 and 1995, nationwide surveys estimated that 20% and 25% of U.S. women, respectively, reported con- suming a multivitamin containing >400mg of folic acid per day4,5. These studies and the GWHS findings underscore that 75%88% of the 60 million women of reproductive age in the United States may not obtain the amount of folic acid recommended by PHS to reduce the risk for spina bifida and other NTDs. In addition, GWHS and a recent survey by the March of Dimes5 indicate a substantial percentage of reproductive-aged women remain unaware of the potential benefits of folic acid despite publication of the PHS recommendation in 1992. The results of the survey in Georgia underscore the need for continuing efforts to increase consumption of and awareness about the benefits of folic acid among women of childbearing age. Convenient approaches for ensuring that women obtain adequate amounts of folic acid to reduce the risk for NTDs include daily consumption of either a vitamin supplement or a fortified breakfast cereal containing 400mg of folic acid. In March 1996, the Food and Drug Administration (FDA) required many enriched foods (e.g., most flours, corn meals, pasta, and rice) to be fortified with 140mg of folic acid per 100g of cereal grains by January 1, 19986; this mandate will increase daily consumption of folic acid on average by 100 mg. FDA also issued a regulation that permits the labels of products containing sufficient amounts of folate to claim the products may reduce the risk for having a pregnancy with NTDs7. The use of health claims on folic acid-containing products and folate-rich foods (e.g., orange juice and green leafy vegetables) will assist in increasing awareness about the benefits of folic acid. Because women who know about the benefits of folic ** These adjustments were calculated by weighting to 1990 US Bureau of Census counts of Georgia population by sex, age, race, education level, and telephone coverage. They will be used in analyses for the survey final report. References 1. CDC. Surveillance for anencephaly and spina bifida and the impact of prenatal diagnosis-- United States, 19851994. In: CDC surveillance summaries (August 25). MMWR 1995;44 (no. SS-4). 2. CDC. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR 1992;41(no. RR-14). 3. Serbanescu F, Rochat R. Georgia Women's Health Survey, 1995: Preliminary Report, October 1996. Atlanta, Georgia: Georgia Department of Human Resources, Division of Public Health, Epidemiology and Prevention Branch, Office of Perinatal Epidemiology. 4. Moss AJ, Levy AS, Kim I, Park YK. Use of vitamin and mineral supplements in the United States: current users, types of products, and nutrients. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, National Center for Health Statistics, 1989. 5. CDC. Knowledge and use of folic acid by women of childbearing age--United States, 1995. MMWR 1995;44:7168. 6. Food and Drug Administration. Food standards: amendment of standards of identity for enriched grain products to require addition of folic acid. Federal Register 1996;61:878197. 7. Food and Drug Administration. Food labeling: health claims and label statements--folate and neural tube defects. Federal Register 1996;61:875280. Vol. 45 / No. 37 MMWR 795 This report was contributed by Florina Serbanescu, MD, Roger Rochat, MD, Office of Perinatal Epidemiology, Epidemiology and Prevention Branch; Virginia Floyd, MD, Family Health Br, Kathleen Toomey, MD, State Epidemiologist, Div of Public Health, Georgia Dept of Human Resources; Drew Posey, MPH and Joe Mulinare, MD, Birth Defects and Genetic Diseases Branch, Division of Birth Defects and Developmental Disabilities, National Center for Environmental Health; Pregnancy and Infant Health Branch, and Behavioral Epidemiology and Demographic Research Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. - 3 - The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186 December 1996 Volume 12 Number 12 Selected Notifiable Diseases Reported Cases of Selected Notifiable Diseases in Georgia Profile for September 1996 Total Reported for September 1996 Previous 3 Months Total Ending in September 1994 1995 1996 Previous 12 Months Total Ending in September 1994 1995 1996 Campylobacteriosis Chlamydia genital infection Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilis influenzae (invasive) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other Syphilis - Congenital Tuberculosis 27 1280 8 3 73 1598 1 0 0 7 0 0 0 125 52 20 37 95 57 2 30 389 343 183 NA 3130 3491 NA NA 23 9 10 15 127 193 244 NA 4749 5456 10 1 2 25 0 0 35 4 0 12 16 21 4 2 1 13 15 1 0 0 0 620 660 439 554 331 226 60 75 59 144 172 125 402 406 308 190 326 215 11 15 2 179 217 135 895 NA NA 15 435 NA 63 106 112 71 14 31 7 1403 1344 244 625 1813 773 55 787 1104 8794 NA 33 537 15042 40 30 29 86 12 33 0 1593 1782 265 599 1716 1041 53 779 756 12640 54 38 673 22199 41 5 1 154 6 22 0 1444 683 239 536 1340 931 52 717 The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office; and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia. Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis. Report Period Last 12 Mos 12/95 to 11/96 5 Yrs Ago 12/90 to 11/91 Cumulative 01/80 to 11/96 Total Cases Reported * 2464 1404 16826 Percent Female 18.9 12.2 14.3 AIDS Profile Update MSM Risk Group Distribution (%) IDU MSM&IDU HS Blood Unknown Race Distribution (%) White Black Other 43.2 16.9 4.2 15.5 1.5 18.7 33.0 64.4 2.5 58.2 20.3 5.5 9.2 1.7 5.1 46.3 52.1 1.5 52.2 19.0 6.0 10.7 2.1 10.0 40.9 57.1 2.0 MSM - Men having sex with men * Case totals are accumulated by date of report to the Epidemiology Section IDU - Injection drug users HS - Heterosexual - 4-