BMC Nutrition Volume 7, Article Number: 69 (2021) Cite this article
Dietary folic acid deficiency is one of the most common micronutrient deficiencies that cause neural tube defects (NTD) in infants in sub-Saharan African countries. The purpose of this study was to determine the dietary folic acid intake of Kersa women of childbearing age (WRA) in eastern Ethiopia.
A cross-sectional study was conducted on voluntary women selected from 1,140 random households. Using a validated food frequency questionnaire, the participants’ weekly Ethiopian food intake history and dietary folic acid intake were calculated. Perform statistical analysis with 95% confidence interval. Modified Poisson regression is used to determine factors related to dietary folic acid consumption.
The estimated median folic acid intake is 170 μg/d (IQR: 118.3; 252.2). About 33% of WRAs have low folic acid intake, and 73.9% are at risk of folic acid deficiency. Among the reported food groups, beans and peas, starchy staple foods, and dark green leafy vegetables rich in vitamin A are the top three foods, and they contribute a lot to dietary folic acid. The following conditions are statistically related to dietary folic acid deficiency; women are older, have a low wealth index, have low dietary diversity, seasonal employment, and rely on market food sources.
We found that the dietary folic acid intake of Kersa women is very low and cannot protect their offspring from the risk of NTD. They can also easily lead to poor health outcomes. The diversification and fortification of Ethiopian wheat and salt can alleviate the burden of folate deficiency in the country.
Folic acid is one of the essential micronutrients naturally present in food [1]. Dietary sources of folic acid include green leafy vegetables, beans, egg yolks, liver and citrus fruits [2]. Folic acid is a synthetic form of micronutrients, found in dietary supplements, fortified foods and medicinal vitamins [3, 4].
However, folic acid deficiency is a serious public health problem, especially among disadvantaged groups in developing countries [5, 6]. It is related to various complications during pregnancy. These include increased maternal anemia, hypertensive disease, miscarriage, bleeding and cardiovascular disease risk [7, 8]. Folic acid deficiency is also widely regarded as an important risk factor for fetal neural tube defects (NTD). More than 300,000 babies are affected worldwide, and 65 out of 10,000 babies in Ethiopia are affected [9,10,11,12].
SSA women generally have lower folate intake because of limited access to micronutrient-rich foods and fortified foods, and these foods are expensive, not available locally, or unacceptable due to cultural or religious reasons [13]. Given that insufficient dietary folic acid intake is one of the main causes of folic acid deficiency, the World Health Organization (WHO) recommends supplementing with 400 μg folic acid before pregnancy to reduce the incidence of NTD [14, 15]. Since the development of the embryonic central nervous system first occurs 9 weeks after fertilization, increasing the pre-pregnancy folate level is the key and most suitable method to reduce NTD and other pregnancy complications caused by folate deficiency [16].
By fortifying wheat and grains and providing affordable nutrient-rich food substitutes and eliminating hunger, population growth in folic acid consumption has significantly improved the nutrition and health status of women and their offspring [17, 18]. However, Ethiopia does not have folic acid fortified foods or fortified foods [19].
There is limited information on the dietary folic acid intake of the WRA in Ethiopia. The purpose of this study was to evaluate the dietary folic acid consumption of WRA in the Kersa region of Oromia region in eastern Ethiopia. In addition, the study also assessed dietary diversity and other factors related to folic acid intake.
The study was conducted on-site at the Kersa Health and Population Surveillance System (KHDSS) in the Oromia region of eastern Ethiopia. HDSS covers 24 kebeles (the lowest administrative unit in Ethiopia), of which 38 kebeles are located in cities among the 38 kebeles in the region. According to the 2016 National Census Report, Kersa ranked third in Oromia, with a total population of 350,064 people and a population density of 36.8 people per square kilometer [20].
We conducted a cross-sectional survey of 1,200 households in KHDSS from September to August 2019 [21]. Participants in the study were selected according to the population size of the study kebeles, and then families were randomly selected based on the data in the KHDSS database. The eligibility criteria for the study included families with at least one married woman who were of childbearing age (15-49 years) and were not pregnant at the time of study recruitment. If there is more than one woman of childbearing age living in the household and is present during the interview, a lottery is used to select a woman for the interview.
Participants answered the questionnaire; it has five parts, including sociodemographic information, health information, food choices and cooking methods, food safety, food expenditure, homestead food production and diet intake. Data is collected through a tablet-based questionnaire managed by interviewers, using the Open Data Toolkit (ODK) platform.
Since the research environment is rural, we categorize women’s employment as full employment, seasonal and part-time employment according to the definition of the Ethiopian Demographic and Health Survey [22]. The fully employed person had a skilled and stable job within 7 days prior to the survey. Based on the time and experience before the survey, hard labor and agricultural employment are classified as partial and seasonal employment. Household wealth is defined using a wealth index, which is constructed using principal component analysis (PCA). The index contains 10 items describing household asset ownership, housing quality, overcrowding, and water and sanitation facilities. The wealth index is divided into population tertiles (poor, medium and rich) [23].
Use rangefinders and standard clinical scales [24] to measure the height and weight of WRA in the nearest centimeter (cm) and kilogram (kg). Body mass index (BMI) is calculated as weight (kg) divided by height (m) squared. Based on BMI, use standard cut-off values to classify individuals as underweight (< 18.5 kg/m2), normal weight (18.5–24.9 kg/m2), or overweight/obese (≥ 25 kg/m2). Overweight is classified as a BMI of 25–29.9 kg/m2, and obesity BMI ≥30 kg/m2 [25].
The result of interest is the dietary folate intake of women. The non-quantitative food frequency questionnaire (FFQ) was used to assess the diet of women, which was adapted from the semi-quantitative FFQ locally and was verified to be used for urban adults in Tanzania [26]. Participants were asked if they had eaten 69 different foods in the past 7 days, and how often they had eaten them (in days). The weekly reported food consumption is converted to daily consumption by dividing by 7. The FFQ includes common foods available locally and options for specifying other foods. Part of the size information was not collected in this study. We used the serving size of each food used in a recent national survey [27].
We used the Minimum Dietary Diversity for Women (MDD-W) indicator [28] to assess the dietary diversity of women. We divide the food consumed by women into ten non-overlapping food groups. The 10 food groups are 1) starchy staple food, 2) legumes, 3) nuts and seeds, 4) dairy products, 5) meat, 6) eggs, 7) dark green leafy vegetables, 8) fruits and vegetables rich in vitamin A, 9) other vegetables , And 10) other fruits[29]. Foods made from grains, cereals, rhizomes and tubers are classified as staple foods containing starch. Poultry and all meat products are classified as meat [30].
If the participant eats at least one food containing the food group every day, the participant is counted as eating the food group. We summarize the food groups consumed by women as a dietary diversity score (DDS-W, range 0-10). If women eat at least 5 food groups per day (DDS ≥ 5), we classify them as meeting minimum dietary diversity (MDD). MDD-W can be used as a surrogate indicator of micronutrient adequacy [31].
We estimate women’s daily folic acid consumption by multiplying the average serving size and folic acid content of each reported food with their daily consumption. We summarized women’s total folate intake based on individual foods reported in the FFQ. The cut-off value for insufficient folic acid intake is defined as the estimated average requirement (EAR) for folic acid intake for a specific age and sex that consumes less than WRA <250 μg/d [32]. We calculated the binary index (yes/no) for adequate folic acid intake. We also divided the total distribution of folic acid intake into tertiles, and divided them into low, medium, and high folic acid intakes.
Use STATA 16 to analyze the data. Mean and Standard Deviation (SD) are used to describe continuous variables and medians and interquartile ranges for variables that are not normally distributed. Counts and percentages are used to describe categorical variables. Data points with more than 50% missing data and abnormal numbers (outliers) were removed from the analysis. Using modified Poisson regression [33, 34] for bivariate analysis to examine independent predictors of insufficient folate intake (0 = adequate intake, 1 = insufficient intake) and crude prevalence (CPR) and 95% Confidence interval (CI) estimate. Include significant variables in the univariate analysis (p <0.2) to control the confounding of the final model. We calculate the adjusted prevalence (APR) by combining variables that are significant or assumed to be confounders. The statistical association level was p <0.05 to identify independent variables related to insufficient folate intake.
We analyzed the data of 1,134 WRA families that participated in the study. Thirty-nine families refused to participate in the study, and 27 participants with missing or abnormal data were excluded from the analysis. The average age of women is 31.1 (± 6.2) years, and half of women have never attended school. Most of the participants are Muslims and housewives. At least 67.5% of WRA work full-time and 56.2% fall into the poverty index category. The median weight and height of WRA were 51.0 kg (IQR: 48.0; 56.0) and 157.0 cm (IQR: 154.5; 161.1) (Table 1).
Many participants reported that they used their food production as their main food source and had to travel more than half a kilometer to reach that source. The median dietary diversity score was 4.0 (IQR: 3.0; 5.0), and 35.4% of people had the best dietary diversity (eating 5 or more food groups per day). Most of the study participants’ families had children under 5 years of age, with an average age of 36 months (IQR: 23.0; 48.0). The maximum number of previous pregnancies reported was 13 (Table 1).
Table 2 shows the ranking and contribution of food groups to the dietary intake of folic acid. Almost all participants reported eating starchy staple foods and other vegetables, but these groups ranked 2nd and 5th in terms of daily dietary folic acid intake. Although less than half of the study participants reported consuming beans and peas, they ranked first in the contribution of dietary folic acid, with a median of 101.7 micrograms/day (IQR: 73.7; 178.3). The food group that consumes the least is meat, which contributes the least to folic acid intake. The median folic acid intake in this study was 170.2 micrograms/day (IQR: 118.3; 252.2): 95% CI (164.3-176.1). The distribution of folic acid intake is positively skewed. According to the cut-off value of 250 μg/day, 73.9% of people are at risk of insufficient dietary folic acid (Figure 1 and Figure 2). Approximately 33% of WRAs have low folate intake.
The usual dietary folic acid intake of women of childbearing age, Kersa, Eastern Ethiopia, 2019
Total dietary folic acid consumption for women of childbearing age with minimum dietary diversity, Kersa, Eastern Ethiopia, 2019
Table 3 shows the factors associated with insufficient dietary folic acid intake. We found that wealth index, seasonal employment, and low female nutritional diversity are related to insufficient folic acid intake. Folic acid intake is defined as folic acid intake below EAR, and the population in the univariate model is below 250 μg/day. In the adjusted model, seasonal employment, food sources, being in the lowest and middle wealth index categories, and low nutritional diversity among women are associated with insufficient dietary folic acid. Compared with women who met the minimum dietary diversity criteria, women with low dietary diversity intake were twice as likely to have insufficient folate intake (APR 1.9; 95% CI 1.7-2.2). Compared with full-time women, women in seasonal agricultural employment are more likely (APR 1.1; 95% CI 1.1-1.2) to have insufficient folate intake. Compared with women from the wealthiest households, women from poor and middle wealth tertiles are 1.1 times more likely (95% CI 1.0-1.3) and 1.2 times (95% CI 1.1-1.4) to have insufficient dietary folic acid, respectively . Compared with women 36 years of age or older, women aged 15-25 are 10% less likely to be at risk for folate insufficiency.
This study evaluated the dietary folic acid intake of women of childbearing age in Kersa in eastern Ethiopia. The food groups that consume the least are fish, eggs, meat, and fruits. Most women have insufficient folic acid intake, which is far below the recommended standard of 250 μg/d [32]. We found that women with low dietary diversity, poor families, seasonal employment, and market-buying food are at higher risk of insufficient folate in their diets. Older women also prefer insufficient folic acid intake in their diet.
The degree of folic acid deficiency in this study is higher than Tanzania's 33.8%, but it is comparable to the low folic acid intake of 33% [35]. It is also higher than the Nigerian study, in which 47% of people had insufficient intake, but lower than the 98% reported in South Africa [6]. This difference may be related to the differences in the use of different methods, food stability and safety in these different countries.
It is expected that the severity of dietary folic acid deficiency may be related to the characteristics of the study area. Due to the dependence on folic acid supplementation during pregnancy, WRA will face the risk of folic acid deficiency. It is also one of the areas susceptible to drought, the standard of living is low, it is difficult to obtain affordable foods rich in folic acid, and the poor areas of Ethiopia. Most diet systems are mainly based on traditional agriculture in unsuitable areas, and the agricultural system is insufficiently supported. Therefore, most residents are supported by the safety net program [36].
In contrast, developed countries reduce the incidence of folic acid deficiency and NTD by fortifying primary foods that usually contain no or almost no folic acid[9, 35, 37] In these countries, not only are mandatory folic acid fortification policies in place, And it is also improving in terms of dietary diversity, gender equity and equality [4, 38, 39], which is different from Ethiopia, which explains the folic acid deficiency in our population. It is estimated that if fully implemented, Ethiopia’s mandatory fortifications will reduce NTD by 85% every year [40]. Although effective, this policy has not yet been recognized and formulated by Ethiopia [41].
We found that as women get older, they are more likely to be deficient in dietary folic acid. Another cross-sectional FFQ study reported that young women are more likely to have folic acid deficiency than older women [7]. This difference can be explained by the higher family members and the children that older women expect to feed [7]. Research results may also be limited by the potential introduction of recall bias, and participants may overreport consumption of certain foods.
Seasonal agricultural employment and being in poverty and middle wealth categories are also related to insufficient dietary folic acid intake. This finding is expected, because if harvest or dry seasons are difficult, women's seasonal agricultural employment may lead to family hunger, food shortages and insecurity due to lack of other options [42]. In addition, seasonal agricultural employment can also lead to poverty, which in turn makes it difficult to buy enough nutritious food for the family [43]. Compared with women, women with low dietary diversity have a two-fold increase in the risk of folic acid insufficiency. This finding can be attributed to the fact that low dietary diversity can lead to unhealthy and unbalanced diet patterns and micronutrient deficiencies [44]. Ethiopia’s WRA eats relatively little due to food shortages, physical discomfort, unpleasant monotony of food, and less variety [45]. This puts them at greater risk of any micronutrient deficiency in the family. Other studies in Ethiopia have also reported that dietary diversity is a strong predictor of micronutrient adequacy and is directly related to food safety, household income, and the health of the community [46, 47].
Ethiopia is one of the countries with the heaviest NTD burden, with a prevalence rate of 0.23-40.3% [48, 49]. For pregnant women, the report shows 12% of folic acid deficiency in Ethiopia, 3% in Kenya, and 4% in Nigeria [6]. The low-level folic acid consumption reported in this study can affect the nutrition and health of WRA. In view of the low folic acid intake will affect cell growth and replication [50]. Low WRA intake before and during pregnancy may cause irreversible damage to the nervous system of the pregnant fetus [51]. Infants’ nerve damage ranges from complete loss of the fetal brain to certain defects in the brain, spinal cord and related structures [52]. In either case, the result is clear, either the fetus will die, or there will be permanent nerve damage at birth, leading to lifelong disability, affecting growth, development and inability to thrive [53].
To correct this problem, in the regular health system, pregnant women take capsules containing iron and folic acid for 90 days. However, it is reported that only 5% of women complete the full dose, and more than 95% of women have their fetus affected by dietary folic acid intake [54, 55]. In addition, the bioavailability of foods widely used in Ethiopia is low in folic acid. Although it was planned to introduce the folic acid intervention program as an enhancement in our national document, it was not implemented [27].
Part of the advantage of this research lies in the use of the first community-based FFQ with sufficient sample size and training data collectors for quality control. The use of FFQ is a quick and effective way to identify and assess micronutrient deficiencies. Compared with 24-hour recall, the FFQ of the past week can better assess the usual micronutrient intake [56]. However, it also has several limitations. FFQ usually overestimates the intake of micronutrients, making it difficult to accurately capture absolute micronutrient values. In addition, serum folate levels and food intake were not measured, which would introduce variability errors [57]. To reduce this, we have seen the use of two different cut-off values, the EAR (< 250 μg/d) and the tertile folic acid intake distribution. This study did not consider other factors that may affect the absorption of folic acid, seasonal dietary changes, knowledge and understanding of folic acid.
Studies have found that low folic acid intake and insufficient folic acid are a major public health problem in Kersa, Eastern Oromia. It is strongly recommended to have a varied diet, consume foods rich in folic acid such as beans and liver, and fortify wheat or salt to increase the folate adequacy rate and reduce the risk of folic acid deficiency in WRA. It is recommended to combine the national FFQ with plasma folate levels to accurately identify folate deficiencies and deficiencies and monitor micronutrient deficiencies.
The data sets used and analyzed in this study can be obtained from the corresponding authors according to reasonable requirements.
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The author would like to thank Dr. Sabri Bromage for his valuable comments and suggestions, and the Harvard School of Public Health for help in data collection. The authors would like to thank study participants, local administrators and data collectors for facilitating data collection.
This work was supported by the Harvard TH Chan School of Public Health.
Nega Assefa and Yasir Y Abdullahi are the first authors
Faculty of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
Nega Assefa, Aklilu Abraham, Yadeta Dessie and Kedir Teji Roba
Department of Obstetrics and Gynecology, Jugal Hospital, Harar, Ethiopia
Department of Global Health and Population, Harvard University TH Chan School of Public Health, Boston, Massachusetts, USA
Elena C. Hemler, Isabel Madzorera and Wafaie W. Fawzi
Department of Nutrition, Harvard University, TH Chan School of Public Health, Boston, Massachusetts, USA
Elena C. Hemler, Isabel Madzorera and Wafaie W. Fawzi
Department of Epidemiology, TH Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
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Concept notes for NS, AAR, KTR, YD and WWF designs. NS, AAR, KTR and YD made proposals. NS, AAR, KTR and YD are engaged in data generation and field work. Statistical analysis was performed on NS, YYA, EC and IM. NS, YYA, EC, IM and WWF prepared manuscripts. All authors review, edit and approve the manuscript as the final manuscript.
Correspondence with Yasir Y. Abdullahi.
This study was ethically approved by the Institutional Health Research Ethics Review Committee of the School of Health and Medicine, and the reference number is SHE/S1M/14.4/708/19. The research procedure was also carried out in accordance with the Helensky Declaration. When interviewing the households, the interviewees have obtained written informed and voluntary consent.
The author declares that there is no conflict of interest.
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Assefa, N., Abdullahi, YY, Abraham, A. etc. Kersa estimated dietary folic acid consumption in women of childbearing age and its impact on reproductive outcomes: a cross-sectional survey. BMC Nutr 7, 69 (2021). https://doi.org/10.1186/s40795-021-00476-6
DOI: https://doi.org/10.1186/s40795-021-00476-6
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