{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,18]],"date-time":"2026-03-18T04:46:47Z","timestamp":1773809207691,"version":"3.50.1"},"reference-count":36,"publisher":"Cambridge University Press (CUP)","issue":"1","license":[{"start":{"date-parts":[[2024,11,29]],"date-time":"2024-11-29T00:00:00Z","timestamp":1732838400000},"content-version":"unspecified","delay-in-days":333,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["cambridge.org"],"crossmark-restriction":true},"short-container-title":["Public Health Nutr."],"published-print":{"date-parts":[[2024]]},"abstract":"<jats:title>Abstract<\/jats:title>\n\t  <jats:sec id=\"S1368980024002271_as1\">\n\t    <jats:title>Objective:<\/jats:title>\n\t    <jats:p>Neural tube defects (NTD) are serious, life-threatening birth defects. Staple food fortification with folic acid (vitamin B<jats:sub>9<\/jats:sub>) is a proven, effective intervention to reduce NTD birth prevalence. Mandatory food fortification with folic acid was implemented in South Africa (SA) in 2003. This article provides an overview of NTD birth prevalence in SA, pre- and post-fortification, and evaluates current folic acid fortification regulations.<\/jats:p>\n\t  <\/jats:sec>\n\t  <jats:sec id=\"S1368980024002271_as2\">\n\t    <jats:title>Design:<\/jats:title>\n\t    <jats:p>Fortification effectiveness data in SA were reviewed using published studies and national reports on NTD birth prevalence pre- and post-folic acid fortification. Current folic acid fortification regulations in SA were evaluated by experts.<\/jats:p>\n\t  <\/jats:sec>\n\t  <jats:sec id=\"S1368980024002271_as3\">\n\t    <jats:title>Setting:<\/jats:title>\n\t    <jats:p>Regulations were assessed using national health guidelines, legislation and regulations. NTD birth prevalence data were sourced from the published literature.<\/jats:p>\n\t  <\/jats:sec>\n\t  <jats:sec id=\"S1368980024002271_as4\">\n\t    <jats:title>Participants:<\/jats:title>\n\t    <jats:p>None.<\/jats:p>\n\t  <\/jats:sec>\n\t  <jats:sec id=\"S1368980024002271_as5\">\n\t    <jats:title>Results:<\/jats:title>\n\t    <jats:p>Significant reductions in the birth prevalence of spina bifida and anencephaly and improved maternal folate levels have been achieved following the introduction of folic acid fortification in SA. However, there is poor overall regulatory compliance in some instances and a gap in current regulations that excludes the fortification of cake flour in SA.<\/jats:p>\n\t  <\/jats:sec>\n\t  <jats:sec id=\"S1368980024002271_as6\">\n\t    <jats:title>Conclusions:<\/jats:title>\n\t    <jats:p>While the SA NTD birth prevalence has decreased by 30% post-fortification, the regulatory exclusion of cake flour fortification is a significant and growing issue. Proposed 2016 regulatory amendments to address this gap urgently require finalisation and enactment by government to prevent negating benefits achieved to date and to ensure continued improvement. Fortification monitoring requires strengthening to ensure widespread compliance with policies, particularly in underserved areas.<\/jats:p>\n\t  <\/jats:sec>","DOI":"10.1017\/s1368980024002271","type":"journal-article","created":{"date-parts":[[2024,11,29]],"date-time":"2024-11-29T04:08:50Z","timestamp":1732853330000},"update-policy":"https:\/\/doi.org\/10.1017\/policypage","source":"Crossref","is-referenced-by-count":1,"title":["Status of prevention of neural tube defects post-folic acid fortification of cereal grains in South Africa"],"prefix":"10.1017","volume":"27","author":[{"given":"Vijaya","family":"Kancherla","sequence":"first","affiliation":[{"name":"Emory University"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Phillip","family":"Randall","sequence":"additional","affiliation":[{"name":"P Cubed"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Arnold L","family":"Christianson","sequence":"additional","affiliation":[{"name":"University of the Witwatersrand"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9566-6248","authenticated-orcid":false,"given":"Helen Louise","family":"Malherbe","sequence":"additional","affiliation":[{"name":"North-West University"},{"name":"Rare Diseases South Africa NPC"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"56","published-online":{"date-parts":[[2024,11,29]]},"reference":[{"key":"S1368980024002271_ref18","volume-title":"Clinical Guidelines for Genetic Services","year":"2021"},{"key":"#cr-split#-S1368980024002271_ref29.1","unstructured":"29. Government Gazette (2016) Republic of South Africa Foodstuffs, Cosmetics and Disinfectants Act 1972. Regulations Relating to the Fortification of Certain Foodstuffs. Government Gazette No. 39776, 3 March 2016"},{"key":"#cr-split#-S1368980024002271_ref29.2","unstructured":"available at https:\/\/archive.opengazettes.org.za\/archive\/ZA\/2016\/government-gazette-ZA-vol-609-no-39776-dated-2016-03-03.pdf (accessed October 2024)."},{"key":"S1368980024002271_ref2","doi-asserted-by":"publisher","DOI":"10.1016\/j.urology.2022.11.025"},{"key":"S1368980024002271_ref30","volume-title":"Wheaten Products Manufactured (Monthly and Yearly)","year":"2024"},{"key":"S1368980024002271_ref31","first-page":"89","article-title":"Folate and iron status of South African non-pregnant rural women of childbearing age, before and after fortification of foods","volume":"20","author":"Modjadji","year":"2007","journal-title":"S Afr J Clin Nutr"},{"key":"S1368980024002271_ref9","unstructured":"9. World Health Assembly (2023) Seventy-sixth World Health Assembly Resolution 76.19. Accelerating efforts for preventing micronutrient deficiencies and their consequences, including spina bifida and other neural tube defects, through safe and effective food fortification; available at https:\/\/apps.who.int\/gb\/ebwha\/pdf_files\/WHA76\/A76_R19-en.pdf (accessed July 2024)."},{"key":"#cr-split#-S1368980024002271_ref24.1","unstructured":"24. Government Gazette (2003) Republic of South Africa Foodstuffs, Cosmetics and Disinfectants Act 1972. Regulations Relating to the Fortification of Certain Foodstuffs. Government Gazette No. 24715, 7 April 2003"},{"key":"#cr-split#-S1368980024002271_ref24.2","unstructured":"available at https:\/\/archive.gazettes.africa\/archive\/za\/2003\/za-government-gazette-regulation-gazette-dated-2003-04-07-no-24715.pdf (accessed October 2024)."},{"key":"S1368980024002271_ref17","volume-title":"Guidelines for Maternity Care in South Africa. A Manual for Clinics, Community Health Centres and District Hospitals","year":"2016"},{"key":"S1368980024002271_ref21","doi-asserted-by":"publisher","DOI":"10.7196\/SAMJ.2016.v106i10.11314"},{"key":"S1368980024002271_ref23","volume-title":"South African Maternal, Perinatal and Neonatal Health Policy","year":"2021"},{"key":"S1368980024002271_ref10","doi-asserted-by":"publisher","DOI":"10.1111\/nyas.13548"},{"key":"S1368980024002271_ref32","doi-asserted-by":"publisher","DOI":"10.1002\/bdra.20442"},{"key":"#cr-split#-S1368980024002271_ref26.1","unstructured":"26. Government Gazette (2008) Republic of South Africa Foodstuffs, Cosmetics and Disinfectants Act 1972. Amendment of Regulations Relating to the Fortification of Certain Foodstuffs. Government Gazette No. 31584, 14 November 2008"},{"key":"#cr-split#-S1368980024002271_ref26.2","unstructured":"available at https:\/\/archive.opengazettes.org.za\/archive\/ZA\/2008\/government-gazette-ZA-vol-521-no-31584-dated-2008-11-14.pdf (accessed October 2024)."},{"key":"S1368980024002271_ref8","volume-title":"Monitoring Flour Fortification to Maximize Health Benefits: A Manual for Millers, Regulators and Programme Managers","year":"2021"},{"key":"S1368980024002271_ref7","doi-asserted-by":"publisher","DOI":"10.1111\/nyas.13601"},{"key":"S1368980024002271_ref27","volume-title":"A Reflection of the South African Maize Meal and Wheat Flour Fortification Programme (2004 to 2007)","year":"2008"},{"key":"S1368980024002271_ref4","first-page":"569","article-title":"Spina bifida care, education, and research: a multidisciplinary community in a global context","volume":"14","author":"Castillo","year":"2021","journal-title":"J Pediatr Rehabil Med"},{"key":"S1368980024002271_ref16","volume-title":"March of Dimes: Global Report on Birth Defects, the Hidden Toll of Dying and Disabled Children","author":"Christianson","year":"2006"},{"key":"S1368980024002271_ref14","volume-title":"Statistical Release P0302. Mid-Year Population Estimates 2024","year":"2024"},{"key":"S1368980024002271_ref12","volume-title":"Statistical Release P0305. Recorded Live Births 2022","year":"2023"},{"key":"S1368980024002271_ref5","doi-asserted-by":"publisher","DOI":"10.1016\/j.dhjo.2019.100883"},{"key":"S1368980024002271_ref20","first-page":"75","article-title":"Limited obstetrics ultrasound by midwifes in Gauteng, South Africa: benefit of service-oriented competency development in primary healthcare delivery: a pilot study","volume":"10","author":"Mashamba","year":"2022","journal-title":"Int J Gynaecol Obstet"},{"key":"S1368980024002271_ref3","first-page":"S1","article-title":"International collaborations on advocacy, education, and research: broad-spectrum thematic diversity catalyzes multidisciplinary spina bifida care","volume":"16","author":"Castillo","year":"2023","journal-title":"J Pediatr Rehabil Med"},{"key":"S1368980024002271_ref19","doi-asserted-by":"publisher","DOI":"10.7196\/SAMJ.2016.v106i7.10813"},{"key":"S1368980024002271_ref1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199911113412006"},{"key":"S1368980024002271_ref11","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.2015.302902"},{"key":"S1368980024002271_ref28","unstructured":"28. Global Fortification Data Exchange (2024) South Africa Fortification Dashboard; available at https:\/\/fortificationdata.org\/country-fortification-dashboard\/?alpha3_code=ZAF&lang=en (accessed July 2024)."},{"key":"S1368980024002271_ref15","doi-asserted-by":"publisher","DOI":"10.1046\/j.1365-2788.2002.00390.x"},{"key":"S1368980024002271_ref22","doi-asserted-by":"publisher","DOI":"10.1002\/bdr2.1898"},{"key":"S1368980024002271_ref25","first-page":"928","article-title":"Neural tube defects and folic acid-a South African perspective","volume":"87","author":"Robertson","year":"1997","journal-title":"S Afr Med J"},{"key":"S1368980024002271_ref6","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2017-3730"},{"key":"S1368980024002271_ref13","doi-asserted-by":"publisher","DOI":"10.7196\/SAMJ.2019.v109i9.13863"},{"key":"S1368980024002271_ref33","unstructured":"33. National Chamber of Milling South Africa (2024) Registered Fortification Mix Manufacturers\/Suppliers\/Importers (24 July 2024 update); available at www.grainmilling.org.za\/technical\/ (accessed October 2024)."}],"container-title":["Public Health Nutrition"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.cambridge.org\/core\/services\/aop-cambridge-core\/content\/view\/S1368980024002271","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,7]],"date-time":"2025-10-07T14:34:56Z","timestamp":1759847696000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.cambridge.org\/core\/product\/identifier\/S1368980024002271\/type\/journal_article"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024]]},"references-count":36,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2024]]}},"alternative-id":["S1368980024002271"],"URL":"https:\/\/doi.org\/10.1017\/s1368980024002271","relation":{},"ISSN":["1368-9800","1475-2727"],"issn-type":[{"value":"1368-9800","type":"print"},{"value":"1475-2727","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024]]},"assertion":[{"value":"\u00a9 The Author(s), 2024. Published by Cambridge University Press on behalf of The Nutrition Society","name":"copyright","label":"Copyright","group":{"name":"copyright_and_licensing","label":"Copyright and Licensing"}},{"value":"This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (https:\/\/creativecommons.org\/licenses\/by\/4.0\/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.","name":"license","label":"License","group":{"name":"copyright_and_licensing","label":"Copyright and Licensing"}},{"value":"This content has been made available to all.","name":"free","label":"Free to read"}],"article-number":"e258"}}