Public Health Nutrition

Research Paper

A cost-effectiveness analysis of folic acid fortification policy in the United States

Tanya GK Bentleya1 p1 c1, Milton C Weinsteina2, Walter C Willetta3 and Karen M Kuntza2

a1 The Faculty of Arts and Sciences, Harvard University Ph.D. Program in Health Policy, 79 John F. Kennedy Street, Cambridge, MA, USA

a2 The Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA

a3 The Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, MA, USA


Objective To quantify the health and economic outcomes associated with changes in folic acid consumption following the fortification of enriched grain products in the USA.

Design Cost-effectiveness analysis.

Setting Annual burden of disease, quality-adjusted life years (QALY) and costs were projected for four steady-state strategies: no fortification, or fortifying with 140, 350 or 700 μg folic acid per 100 g enriched grain. The analysis considered four health outcomes: neural tube defects (NTD), myocardial infarctions (MI), colon cancers and B12 deficiency maskings.

Subjects The US adult population subgroups defined by age, gender and race/ethnicity, with folate intake distributions from the National Health and Nutrition Examination Surveys (1988–1992 and 1999–2000), and reference sources for disease incidence, utility and economic estimates.

Results The greatest benefits from fortification were predicted in MI prevention, with 16 862 and 88 172 cases averted per year in steady state for the 140 and 700 μg fortification levels, respectively. These projections were between 6261 and 38 805 for colon cancer and 182 and 1423 for NTD, while 15–820 additional B12 cases were predicted. Compared with no fortification, all post-fortification strategies provided QALY gains and cost savings for all subgroups, with predicted population benefits of 266 649 QALY gained and $3·6 billion saved in the long run by changing the fortification level from 140 μg/100 g enriched grain to 700 μg/100 g.

Conclusions The present study indicates that the health and economic gains of folic acid fortification far outweigh the losses for the US population, and that increasing the level of fortification deserves further consideration to maximise net gains.

(Received May 14 2007)

(Accepted April 03 2008)


c1 Corresponding author: Email:

p1 Correspondence address: RAND Corporation, 1776 Main Street, PO Box 2138, Santa Monica, CA 90407-2138, USA.