Running head: PREVALENCE OF SEVERE CONGENITAL HEART DISEASE

Prevalence of Severe Congenital Heart Disease

After Folic Acid Fortification of Grain Products: Time Trend Analysis in Quebec, Canada
A Review of the Literature
Jaleel Arnado, Boris Chang, Katherine Fajardo, Roberta Amie Howard, Andrea Idudhe
The University of San Francisco

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Abstract
After studies showed that folic acid intake around the time of conception reduces the risk of
neural tube defects in the newborn, the Canadian government decided to take action by targeting
all women of childbearing age. In December 1998, the Canadian government mandated the
fortification of grain products with folic acid. This paper examines Ionescu-Ittu, Marelli, Mackie
and Pilotes (2009) research investigating the impact of the fortification of foods with folic acid
on the prevalence of severe congenital heart defects.

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Prevalence of Severe Congenital Heart Disease
After Folic Acid Fortification of Grain Products: Time Trend Analysis in Quebec, Canada

A Review of the Literature

In December 1998, the Canadian government mandated the fortification of grain
products with folic acid. This study investigated the impact of the fortification of foods with
folic acid on the prevalence of severe congenital heart defects. The study was done in
Quebec, Canada and the research design was time trend analysis. Researchers investigated
infants born, live and stillborn, from 1990 to 2005 with severe congenital heart
defects. Data about these infants were collected from provincial administrative databases
that record all contacts between Quebec residents and the medical system.
In general, severe congenital heart defects are problems with the structure of the
heart present at birth (Congenital heart defects, n.d.). For this study, severe congenital
heart defects were diagnosed as one of the following defects: endocardial cushion defect,
tetralogy of Fallot, univentricular heart, transposition complex, or truncus arteriosus.
As a result of the study, the data showed that the average birth prevalence of severe
congenital heart defects in the 9 years before fortification (1.64/1000) was slightly higher
than the average birth prevalence in the period after fortification (1.47/1000).
Research Review
The sample size here consisted of 1,324,440 births in Quebec, Canada between 19902005, where 2,083 infants were born with severe congenital heart defects. This corresponds
to an average birth prevalence of 1.57/1000 births across 16 years of the study. Given the

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large sample size used in the study and the focus on one dependent variable (the introduction
of mandatory folic acid fortification), the study is considered valid to use as scientific
evidence to indicate a positive correlation between increased folic acid intake and diminished
severe congenital heart defects in newborns. An average 6.2% reduction in the birth
prevalence of severe congenital heart defects was observed after fortification. (Ionescu-Ittu
et al., 2009) The use of diagnostic and procedural codes from physicians claims and
hospital databases along with verification with death registry provided the evidence to assess
for changes in congenital heart defect prevalence.
How has the prevalence of severe congenital heart disease been affected by folic acid
fortification of grain products?
The purpose of the research was to determine if the 1998 government policy for
mandatory fortification of flour and pasta products with folate resulted in a decrease in the
prevalence of severe congenital heart disease. The study promptly described the problem of
severe congenital heart disease in Canada. This study is of great significance to the field of
nursing. Nurses are patient educator and should be well informed on maternal nutrition, so
they may pass on their knowledge to their patients. This paper explained the necessity and
significance of this study by discussing how prenatal supplements only target women at are
planning a pregnancy and fortification measures a larger scope and targets all women
(Ionescu-Ittu et al., 2009). The research variables were the measurements of the births of
infants with severe congenital birth defects before and after the fortification. With nonexperimental research design correlation does not imply causation. Therefore, it is not yet a
proven fact that folic acid fortification is the cause for the decrease in severe congenital heart

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disease in Canada. However, the research may be useful knowledge for further research is
completed.
Sampling
The target population is carefully identified to include both live births and stillbirths
in Quebec from 1990 to 2005 of infants with severe congenital heart defects. The sampling
method fits the research design and the sampling size is justified in that the research focused
on the effects of Canadas folic acid fortification policy and therefore all infants with severe
congenital heart defects would need to be identified and analyzed. The study population was
selected using three provincial administrative databases and the stillbirth population was
retrieved from Statistics Canada reports. The condition of severe congenital heart defects is
based on procedural and diagnosis codes. The study can be generalized to all women of
childbearing age that a diet adequate in folic acid at time of conception will reduce neural
tube defects during fetal development.
Detection bias in time trends was resolved by only using the Quebec death registry to
identify infant deaths due to severe congenital heart defects. Ascertainment bias is resolved
by not including mild congenital heart defects because severe defects have early clinical
symptoms that involve further review and are thus less likely to be affected by ascertainment
bias (Ionescu-Ittu, Marelli & Pilote, 2009).

Conclusions and Recommendations

The researchers concluded that the fortification of grain products with folic acid was
followed by a significant decrease in the prevalence of severe CHDs.

Although there is a

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clear association, it is difficult to conclude that the decrease is a definite result from the
fortification of flour and pasta. There is no information available on the exact consumption
of these grain products. Women may also have been continuing to take folic acid
supplements during the conception period and not relying solely on that found in grain
products. Despite the use of accurate databases that were used to obtain data on severe
CHDs, there is the possibility for inaccurate recording and misclassification.
As CNLs, we can promote the application of this research and its findings into
education to patients and their families. This is especially important because advancements
in technology and medical treatment have given patients and families access to information
that is not always reliable.

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References
Congenital Heart Defects. (2013). MedlinePlus. Retrieved from
http://www.nlm.nih.gov/medlineplus/congenitalheartdefects.html
Facts about Transposition of the Great Arteries. (2011). Centers for Disease Control and
Prevention. Retrieved from http://www.cdc.gov/ncbddd/heartdefects/tga.html
Frank, L., Dillman, J.R., Parish, V., Mueller, G.C., Kazerooni, E.A., Bell, A., Attili, A.K.
(2010). Cardiovascular MR imaging of conotruncal anomalies. Radiographics. 30(4),
1069-1094
Ionescu-Ittu R., Marelli A.J., Mackie A.S., Pilote L. (2009). Prevalence of severe congenital
heart disease after folic acid fortification of grain products: time trend analysis in Quebec,
Canada. British Medical Journal, 338 (b1673). doi:10.1136/bmj.b1673
Khairy, P., Poirier, N., & Mercier, L.D. (2007). Congenital heart disease for
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Schumacher, K.R. (2012). Endocardial cushion defect. MedlinePlus.
Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/007324.htm
Schumacher, K.R. (2011). Truncus arteriosus. MedlinePlus. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/001111.htm

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What is Tetralogy of Fallot? (2011). National Institutes of Health, National Heart, Lung
and Blood Institute. Retrieved from http://www.nhlbi.nih.gov/health/health-

topics/topics/tof/