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Consumption of dietary folate estimates and its implication for reproductive outcome among women of reproductive age in Kersa: cross-sectional survey

BMC Nutrition volume 7, Article number: 69 (2021) Cite this article

Abstract

Background

Dietary folate inadequacy is one the most common micronutrient deficiencies that cause neural tube defect (NTD) among infants in Sub-Saharan African countries. This study aims to determine the dietary intake of folate among women of reproductive age (WRA) of Kersa, Eastern Ethiopia.

Methods

A cross-sectional study took place among voluntary women that were selected from 1140 random households. Using a validated Food Frequency Questionnaire, participant’s weekly dietary intake history of Ethiopian foods and dietary folate intake was worked out. Statistical analysis was done at a 95% confidence interval. Modified Poisson regression was used to identify factors associated with dietary folate consumption.

Result

The estimated median usual intake of folate was 170 μg/d (IQR: 118.3; 252.2) and about 33% of WRA had low folate intake and 73.9% were at risk for folate inadequacy. From the reported food groups, Beans and Peas, Starchy staples, and Vitamin-A rich dark-green leafy vegetables were the top three ranked foods that contributed much of the dietary folate. The following conditions were statistically related to dietary folate inadequacy; women’s age, being in poor wealth index, low dietary diversity, having seasonal employment, and reliance on market food sources.

Conclusions

We found that women’s dietary intake of folate in Kersa is very low and cannot protect their offspring from the risk of having NTD. They could also potentially be predisposed to poor health outcomes. Diversifying and fortification of Ethiopian wheats and salts could decrease the burden of folate deficiency in the country.

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Background

Folate is one of the naturally occurring essential micronutrients found in food [1]. Dietary sources of folate include green leafy vegetables, legumes, egg yolks, liver, and citrus fruits [2]. Folic acid is the synthetic form of the micronutrient and is found in dietary supplements, enriched foods, and pharmaceutical vitamins [3, 4].

Folate deficiency is however a severe public health problem, especially among disadvantaged groups in developing countries [5, 6]. It has been linked to various complications during pregnancy. These include increased risk of maternal anemia, hypertensive disorder, abortion, bleeding, and cardiovascular disease [7, 8]. Folate deficiency has also been commonly cited as a significant risk factor for developing neural tube defects (NTD) in the fetus; affecting more than 300,000 babies worldwide, and 65 infants out of 10,000 births in Ethiopia [9,10,11,12].

Folate intakes are often low among women in SSA because access to micronutrient-rich foods and fortified foods is limited, and these foods are expensive, locally unavailable, or unacceptable for cultural or religious reasons [13]. Given that inadequate dietary folate consumption is one of the primary causes of folate deficiency, the World Health Organization (WHO) recommends supplementation with 400 μg of folic acid before pregnancy to decrease the incidence of NTD [14, 15]. Since the development of the central nervous system in the embryo occurs as early as 9 weeks after fertilization, an increment in pre-pregnancy folate levels is the crucial and most appropriate method of reducing NTD and other pregnancy complications due to folate deficiency [16].

Population-wise increment of folate consumption status by fortification of wheat and cereals and availing affordable nutrient-rich food alternatives and eliminating hunger have shown significantly in improving nutritional and the health status of women and their offspring [17, 18]. However, there are no folate fortified foods or enriched food products available in Ethiopia [19].

There is limited information available on the dietary intake of folate among WRA in Ethiopia. This study aims to evaluate dietary folate consumption among WRA in Kersa district of Oromia region, eastern Ethiopia. Further, the study evaluates dietary diversity and other factors associated with folate consumption.

Methods

Study design and settings

This study was conducted in the Kersa Health and Demographic Surveillance System (KHDSS) field site in Oromia region in eastern Ethiopia. The HDSS covers 24 kebeles (the lowest administrative unit in Ethiopia) three of which are urban, out of the 38 kebeles in the district. The 2016 national census reported that Kersa had the third-largest in Oromia region with a total population of 350,064, and a population density of 36.8 persons per square kilometers [20].

We conducted a cross-sectional survey among 1200 households in the KHDSS from September to August 2019 [21]. Study participants were selected using proportional allocation to the population size of the study kebeles, followed by random selection of households based on data from the KHDSS database. Eligibility criteria for the study included households with at least one married woman, who was of reproductive age (15–49 years old) and was not pregnant at study recruitment. If more than one woman of reproductive age lived in the household and was present at the time of the interview, a lottery method was used to select one woman for the interview.

Data collection tool

The participants responded to the questionnaire; which had five sections, including information on socio-demographic characteristics, health information, food choices, and cooking practices, food security, food expenditures, homestead food production, and dietary intake. Data were collected via interviewer-administered tablet-based questionnaires, using an Open Data Kit (ODK) platform.

Sociodemographic assessment

As the study setting was rural, we classified women’s employment according to the Ethiopian Demographic and health survey definition, as fully-employed, and seasonal and part-time employment [22]. Those who were fully employed had a skilled and stable job working in the 7 days preceding the survey. Hard labor and agricultural employment were categorized as partial and seasonal based on time and experience before the survey. Household wealth was defined using a wealth index, constructed using principal component analysis (PCA) of 10 items describing the household’s asset ownership, housing quality, crowding, and water and sanitation facilities. The wealth index was divided into population tertiles (poor, middle, and rich) [23].

Anthropometric assessment

Height and weight of WRA were measured in the nearest centimeters (cm) and kilograms (kg) using a stadiometer and standard clinical scale [24].. Body mass index (BMI) was computed as weight in kilograms divided by height in meters squared. Based on BMI, individuals were classified using standard cutoffs as underweight (< 18.5 kg/m2), normal weight (18.5–24.9 kg/m2), or overweight/obese (≥ 25 kg/m2). Overweight was classified as BMI 25–29.9 kg/m2, and obesity BMI ≥30 kg/m2 [25].

Dietary assessment

The outcome of interest was women’s dietary folate intake. Women’s diets were assessed using a non-quantitative food frequency questionnaire (FFQ), locally adapted from a semi-quantitative FFQ validated for use among urban Tanzanian adults [26]. The participants were asked if they consumed 69 different foods items in the past 7 days and the frequency of their consumption in terms of days. The weekly reported consumption of the food items was converted into daily consumption by dividing by seven. The FFQ included locally available common foods and an option to specify other foods. Portion size information was not collected in the current study. We used portion sizes for each food item that were adopted from a recent national survey [27].

We assessed women’s dietary diversity using the Minimum Dietary Diversity for Women (MDD-W) indicator [28]. We grouped foods consumed by women into ten non-overlapping food groups. The 10 food groups are 1) starchy staples, 2) pulses 3) nuts and seeds 4) dairy products 5) flesh foods 6) eggs 7) dark green leafy vegetables 8) vitamin-a rich fruits and vegetables 9) other vegetables, and 10) other fruits [29]. Foods made from grains, cereals, roots, and tubers are grouped into starchy staples. Poultry and all meat products were categorized as flesh foods [30].

A participant was scored as consuming a food group if they ate at least one type of food item comprising that food group daily. We summed up the food groups consumed by women into a dietary diversity score (DDS-W, range 0–10). We categorized women as meeting minimum dietary diversity (MDD) if they consumed at least 5 food groups (DDS ≥5) daily. MDD-W serves as a proxy for micronutrient adequacy [31].

We estimated women’s daily folate consumption by multiplying the mean portion size and folate composition for each reported food item with its daily consumption. We summed up women’s total folate intake based on the reported individual foods in the FFQ. The cutoffs for inadequate folate intake were defined as consuming less than the age- and sex-specific Estimated Average Requirement (EAR) of folate intake of WRA < 250 μg/d [32]. We calculated a binary indicator for adequate folate intake (yes/no). We have also divided the total distribution of folate intake into tertiles and categorized them into low, middle, and high folate intake, respectively.

Data processing and analysis

Data was analyzed using STATA 16. Means and standard deviations (SDs) were used to describe continuous variables and medians and interquartile ranges for variables that were not normally distributed. Counts and percentages were used to describe categorical variables. Data points with more than 50% missing data and with un-usual amounts (outliers) were removed from the analysis. Bivariate analysis using Modified Poisson regression [33, 34] was undertaken to examine the independent predictors of inadequate folate intake (0 = adequate consumption, 1 = inadequate consumption) and Crude Prevalence Ratios (CPR) and 95% Confidence Interval (CI) estimated. Variables that were significant in the univariate analysis (p < 0.2) were included to control for confounding for the final model. We computed Adjusted Prevalence Ratio (APR) by incorporating variables that are significant or assumed to be a confounder. The statistical association level was p < 0.05 to identify independent variables associated with inadequate folate consumption.

Result

We analyzed data from 1134 WRA households that participated in the study. Thirty-nine households refused to participate in the study and 27 participants with missing and outlier data were excluded from the analysis. The mean age of women was 31.1 (± 6.2) years and half of the women had never attended school. Most participants were Muslims and housewives. At least 67.5% of WRA worked full time and 56.2% were in the poor wealth index category. The median weight and height of WRA was 51.0 kg (IQR: 48.0; 56.0) and 157.0 cm (IQR: 154.5; 161.1), respectively (Table 1).

Table 1 Sociodemographic, reproductive, and Food intake characteristics of women of reproductive age in Kersa, Eastern Ethiopia, 2019
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Many of the participants reported using their food production as a primary source of food and travel more than half a kilometer for reaching the source. The median dietary diversity score was 4.0 (IQR: 3.0; 5.0) and 35.4% of had optimum dietary diversity (consumed 5 or more food groups daily). Most study participants had under-five children in their household with a median age of 36 months (IQR: 23.0; 48.0). The highest number of previous pregnancies reported was thirteen (Table 1).

Food frequency distribution and food ranking

Table 2 shows the ranking and contribution of food groups to the dietary intake of folate. Almost all participants reported consuming starchy staples and other vegetables but these groups ranked 2nd and 5th in contributing to daily dietary folate intake. Even though less than half of the study participants reported intake of beans and peas, they were ranked the 1st in contributing dietary folate with a median of 101.7 μg/d (IQR: 73.7; 178.3). The least consumed food group was flesh foods and it is also contributed least to folate intake. The median folate consumption in this study was 170.2 μg/day (IQR: 118.3; 252.2): 95% CI (164.3–176.1). The distribution of folate intake was positively skewed and 73.9% were at risk for dietary folate inadequacy based on a cut-off of 250 μg/day (Figs. 1 and 2). About 33% of WRA had low folate intake.

Table 2 Food frequency with Mean Folate dietary intake of women of reproductive age in Kersa, Eastern Ethiopia, 2019
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Fig. 1
figure 1

Usual dietary Folate consumption among women of reproductive age, Kersa, Eastern Ethiopia, 2019

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Fig. 2
figure 2

Total Dietary Folate Consumption by Minimum Dietary Diversity among women of reproductive age, Kersa, Eastern Ethiopia, 2019

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Factors associated with dietary folate inadequacy

Table 3 shows the factors associated with inadequate dietary folate consumption. We found that wealth index, seasonal employment, and low women’s nutritional diversity were associated with inadequate folate intake defined as intake of below EAR of folate, which is below 250 μg/day in a population in univariate models. In adjusted models, seasonal employment, food source, being in the lowest and middle wealth index category, and low women’s nutritional diversity were associated with dietary folate inadequacy. Women with low dietary diversity intake were twice as likely (APR 1.9; 95% CI 1.7–2.2) to have inadequate folate intake compared to women who met the criteria for minimum dietary diversity. Women who were involved in seasonal agricultural employments were more likely (APR 1.1; 95% CI 1.1–1.2) to have inadequate folate intake compared to women with full-time employment. Compared to women in the wealthiest households, women from poor and middle wealth tertile were 1.1 times (95% CI 1.0–1.3) and 1.2 times (95% CI 1.1–1.4) more likely to have dietary folate inadequacy, respectively. Women aged 15–25 years were 10% less likely to be at risk for folate inadequacy compared to those aged 36 years or older.

Table 3 Factors associated with inadequate dietary folate consumptiona among women of reproductive age in Kersa, eastern Ethiopia, 2019
Full size table

Discussion

This study assessed dietary folate intake among women of reproductive age in Kersa, Eastern Ethiopia. The food groups least consumed were fish, eggs, fleshy foods, and fruits. The majority of women had folate intake which was insufficient and far less than the recommended standard of 250 μg/d [32]. We found that women that had low dietary diversity, in poorer households, seasonal employment, and market purchases of food were at higher risk of dietary folate inadequacy. Older women were also more like to have inadequate dietary folate intake.

The magnitude of the folate inadequacy in this study was higher compared to Tanzania which was 33.8%, but comparable with the low intake of folate, which was 33% [35]. It was also higher than in the Nigerian study, where 47% had inadequate intake but lower than in the South African report of 98% [6]. The difference could be related to the difference in utilizing different methodologies, food stability, and security in those different countries.

The high magnitude of dietary folate inadequacy is expected and could be related to the characteristics of the study area. With reliance on supplementation of folic acid in pregnancy, WRA would be at risk for folate deficiency. It is also one of drought-prone, with poor living standards and difficulty in accessing affordable folate-rich foods and poor place in Ethiopia. Most of the dietary system is mainly based on traditional farming in unsuitable places, with poor support from the agriculture system. As a result, most of the residents are supported through the safety-net program [36].

In contrast, the developed counties had decreased folate deficiency and the incidence of NTD by fortifying primary foods that would typically have no or little folate [9, 35, 37] In those countries not only mandatory folate fortification policies are in place, but also improving in dietary diversity, gender equity and equality [4, 38, 39] unlike Ethiopia, explaining the higher folate deficiency in our population. It is estimated that mandatory fortification in Ethiopia will reduce NTD by 85% annually if fully implemented [40]. Although effective, the policy has not been endorsed and developed in Ethiopia [41].

We found that with an increase in women’s age was more likely to have inadequacy of dietary folate. Another cross-sectional FFQ study reported younger women were more likely to have folate inadequacy than advanced-aged women [7]. This difference could be respectively be explained by the higher household family member and children the older women expected to feed [7]. The study finding could also be limited by the potential introduction of recall bias and participants could over-report the consumption of specific food items.

Seasonal agricultural employment and being in a poor and middle category of wealth were also associated with dietary folate intake insufficiency. This finding is expected because women’s seasonal dependent agricultural employment could have a potential for hunger and food scarcity and insecurity for families due to lack of other options if difficulties arise for harvest or drought seasons [42]. Besides, seasonal agricultural employment also leads to poverty, which in-turn poses makes it difficult to purchase adequate nutrient-rich food for the family [43]. The risk of folate dietary inadequacy increased twice in women who had low dietary diversity compared to their counterparts. This finding can be attributed to the fact that having low dietary diversity leads to unhealthy and unbalanced diet patterns as well as micronutrient deficiencies [44]. WRA in Ethiopia relatively eat less because of food shortage, physical discomfort, and unpleasant monotonous food with less variety [45]. This puts them at increased risk for any micronutrient deficiency in a household. Other studies in Ethiopia have also reported dietary diversity was a strong predictor of micronutrient adequacies with a direct relationship with food security, household income, and health access of a community [46, 47].

Ethiopia is one the highest NTD burdened country, with a prevalence rate ranging from 0.23–40.3% [48, 49]. For pregnant women, reports indicate 12% folate deficiency in Ethiopia, 3% in Kenya, and 4% in Nigeria [6]. Low levels of folate consumption reported in this study can affect nutrition and health for WRA. Given that low folate intake can affect cell growth and duplication [50]. Low intake among WRA prior to and during pregnancy could lead to irreversible damage to the nerve system of the conceived fetus [51]. The nerve damage to the baby ranges from a complete loss of fetal brain to some defects in the brain, spinal cord, and associated structures [52]. In any case of these, the outcome is clear, either the fetus will die or be born with permanent neural damage leading to a lifelong disability affecting growth, development, and failure to thrive [53].

To correct the problem, in the routine health system, pregnant women are given a capsule that contains iron and folic acid for ninety days. Yet, it is reported that only as few as 5 % of the women complete the full doses, and the remaining more than 95% leave their fetus to the mercy of dietary folate consumption [54, 55]. In addition, the widely available foods in Ethiopia have low bioavailable folate. Even though it is planned in introducing Folic Acid intervention program in our national document like a fortification, it is not implemented [27].

Some of the strength of this study is utilizing the first community-based FFQ with adequate sample size and training data collectors for quality control. The utilization of FFQ is a quick and efficient way of identifying and assessing micronutrient inadequacy. A past-week FFQ can provide a better assessment of the usual intake of micronutrient intake compared to 24- h recall [56]. However, it has also several limitations. FFQ usually overestimates micronutrient intake which made it difficult to accurately capturing absolute micronutrient value. Also, the serum level of folate and serving size of the food intake was not measured, which introduces with and between variation errors [57]. To reduce this we have seen the folate intake distribution using two different cut-offs, the EAR(< 250 μg/d) and tertiles. Other factors that may affect folate absorption, seasonal dietary changes, knowledge, and awareness towards folate were not considered in this study.

Conclusion

The study found that folate intake is low and that folate inadequacy is a major public health problem in Kersa, Eastern Oromia. Diversifying diets, and daily consumption of folate-rich foods like beans and liver, and mandatory fortification of wheat or salt are highly recommended to increase folate adequacy and decrease the risk of folate deficiency among WRA. National FFQ coupled with plasma folate levels is recommended for accurate identification of folate inadequacy and deficiency as well as for monitoring of micronutrient deficiencies.

Availability of data and materials

The datasets used and analyzed during this study are available from the corresponding author on reasonable request.

Abbreviations

DDS:

Dietary diversity score

FFQ:

Food frequency questionnaire

IFA:

Iron and folic acid

MDD:

Minimum dietary diversity

NTD:

Neural tube defect

PCA:

Principal component analysis

SSA:

Sub-Saharan Africa

WRA:

Women of reproductive age

References

  1. Gazzali AM, Lobry M, Colombeau L, Acherar S, Azais H, Mordon S, et al. Stability of folic acid under several parameters. Eur J Pharm Sci. 2016;93:419–30. https://doi.org/10.1016/j.ejps.2016.08.045.

    CAS  Article  PubMed  Google Scholar 

  2. Evans SE, Mygind VL, Peddie MC, Miller JC, Houghton LA. Effect of increasing voluntary folic acid food fortification on dietary folate intakes and adequacy of reproductive-age women in New Zealand. Public Health Nutr. 2014;17(7):1447–53. https://doi.org/10.1017/S1368980013001717.

    Article  PubMed  Google Scholar 

  3. van Gool JD, Hirche H, Lax H, De Schaepdrijver L. Folic acid and primary prevention of neural tube defects: a review. Reprod Toxicol. 2018;80:73–84. https://doi.org/10.1016/j.reprotox.2018.05.004.

    CAS  Article  PubMed  Google Scholar 

  4. Rogers LM, Cordero AM, Pfeiffer CM, Hausman DB, Tsang BL, De-Regil LM, et al. Global folate status in women of reproductive age: a systematic review with emphasis on methodological issues. Ann N Y Acad Sci. 2018;1431(1):35–57. https://doi.org/10.1111/nyas.13963.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. Nunn RL, Kehoe SH, Chopra H, Sahariah SA, Gandhi M, Di Gravio C, et al. Dietary micronutrient intakes among women of reproductive age in Mumbai slums. Eur J Clin Nutr. 2019;73(11):1536–45. https://doi.org/10.1038/s41430-019-0429-6.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  6. Harika R, Faber M, Samuel F, Kimiywe J, Mulugeta A, Eilander A. Micronutrient Status and Dietary Intake of Iron, Vitamin A, Iodine, Folate and Zinc in Women of Reproductive Age and Pregnant Women in Ethiopia, Kenya, Nigeria and South Africa: A Systematic Review of Data from 2005 to 2015. Nutrients. 2017(10):9. https://doi.org/10.3390/nu9101096.

  7. Rodrigues HG, Gubert MB, Santos LM. Folic acid intake by pregnant women from Vale do Jequitinhonha, Brazil, and the contribution of fortified foods. Arch Latinoam Nutr. 2015;65(1):27–35.

    CAS  PubMed  Google Scholar 

  8. Arias LD, Parra BE, Munoz AM, Cardenas DL, Duque TG, Manjarres LM. Study exploring the effects of daily supplementation with 400 mug of folic acid on the nutritional status of folate in women of reproductive age. Birth Defects Res. 2017;109(8):564–73. https://doi.org/10.1002/bdr2.1004.

    CAS  Article  PubMed  Google Scholar 

  9. Centeno Tablante E, Pachon H, Guetterman HM, Finkelstein JL. Fortification of wheat and maize flour with folic acid for population health outcomes. Cochrane Database Syst Rev. 2019;7:CD012150. https://doi.org/10.1002/14651858.CD012150.pub2.

    Article  PubMed  Google Scholar 

  10. Bulloch RE, McCowan LME, Thompson JMD, Houghton LA, Wall CR. Plasma folate and its association with folic acid supplementation, socio-demographic and lifestyle factors among New Zealand pregnant women. Br J Nutr. 2019;122(8):910–8. https://doi.org/10.1017/S0007114519001788.

    CAS  Article  PubMed  Google Scholar 

  11. McNulty H, Ward M, Hoey L, Hughes CF, Pentieva K. Addressing optimal folate and related B-vitamin status through the lifecycle: health impacts and challenges. Proc Nutr Soc. 2019;78(3):449–62. https://doi.org/10.1017/S0029665119000661.

    Article  PubMed  Google Scholar 

  12. Bitew ZW, Worku T, Alebel A, Alemu A. Magnitude and Associated Factors of Neural Tube Defects in Ethiopia: A Systematic Review and Meta-Analysis. Glob Pediatr Health. 2020;7:2333794X20939423.

    PubMed  PubMed Central  Google Scholar 

  13. Sayed AR, Bourne D, Pattinson R, Nixon J, Henderson B. Decline in the prevalence of neural tube defects following folic acid fortification and its cost-benefit in South Africa. Birth Defects Res A Clin Mol Teratol. 2008;82(4):211–6. https://doi.org/10.1002/bdra.20442.

    CAS  Article  PubMed  Google Scholar 

  14. Amoroso L. The second international conference on nutrition: implications for hidden hunger. World Rev Nutr Diet. 2016;115:142–52. https://doi.org/10.1159/000442100.

    Article  PubMed  Google Scholar 

  15. World Health Organization (WHO), Food and Agriculture Organization (FAO). Vitamin and mineral requirements in human nutrition. 2nd ed. Geneva: WHO; 2004.

    Google Scholar 

  16. Obeid R, Oexle K, Rissmann A, Pietrzik K, Koletzko B. Folate status and health: challenges and opportunities. J Perinat Med. 2016;44(3):261–8. https://doi.org/10.1515/jpm-2014-0346.

    CAS  Article  PubMed  Google Scholar 

  17. Gaskins AJ, Mumford SL, Chavarro JE, Zhang C, Pollack AZ, Wactawski-Wende J, et al. The impact of dietary folate intake on reproductive function in premenopausal women: a prospective cohort study. PLoS One. 2012;7(9):e46276. https://doi.org/10.1371/journal.pone.0046276.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  18. Gaskins AJ, Minguez-Alarcon L, Fong KC, Abu Awad Y, Di Q, Chavarro JE, et al. Supplemental folate and the relationship between traffic-related air pollution and livebirth among women undergoing assisted reproduction. Am J Epidemiol. 2019;188(9):1595–604. https://doi.org/10.1093/aje/kwz151.

    Article  PubMed  PubMed Central  Google Scholar 

  19. USAID. Feed The Future: Ethiopia’s Growth through Nutrition project. In: The US Goverment's Global Hunger & Food Security Initiative; 2019.

    Google Scholar 

  20. Oromiya: Demography and Health [http://www.ethiodemographyandhealth.org/Oromia.html].

  21. Assefa N, Oljira L, Baraki N, Demena M, Zelalem D, Ashenafi W, et al. HDSS profile: the Kersa health and demographic surveillance system. Int J Epidemiol. 2016;45(1):94–101. https://doi.org/10.1093/ije/dyv284.

    Article  PubMed  Google Scholar 

  22. Central Statistical Agency (CSA), ICF. Ethiopia Demographic and Health Survey. Addis Ababa, Ethiopia and Rockville, Maryland, USA: CSA and ICF; 2016.

    Google Scholar 

  23. Rutstein SO, Johnson K. The DHS wealth index. In: DHS comparative reports no 6. Calverton: ORC Macro; 2004.

    Google Scholar 

  24. Bilukha O, Leidman E. Concordance between the estimates of wasting measured by weight-for-height and by mid-upper arm circumference for classification of severity of nutrition crisis: analysis of population-representative surveys from humanitarian settings. BMC Nutr. 2018;4(1):24. https://doi.org/10.1186/s40795-018-0232-0.

    Article  PubMed  PubMed Central  Google Scholar 

  25. WHO (World Health Organization): Body Mass Index - BMI. 2019.

    Google Scholar 

  26. Zack RM, Irema K, Kazonda P, Leyna GH, Liu E, Gilbert S, et al. Validity of an FFQ to measure nutrient and food intakes in Tanzania. Public Health Nutr. 2018;21(12):2211–20. https://doi.org/10.1017/S1368980018000848.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Ethiopian Public Health Institute. Ethiopian national food consumption survey. Addis Ababa; 2013.

  28. Wiesmann D, Arimond M, Loechi C. Dietary diversity as a measure of the micronutrient adequacy of women’s diets: Results from rural Mozambique site. In: Washington (DC): Food and Nutrition Technical Assistance II Project, FHI 360; 2009.

    Google Scholar 

  29. FAO, FHI. 360: minimum dietary diversity for women: a guide for measurement, vol. 82. Rome: FAO; 2016.

    Google Scholar 

  30. FAO. A resource guide to method selection and application in low resource settings. Rome; 2018. p. 152.

  31. Women's Dietary Diversity Project Study Group. Development of a dichotomous Indicator for population-level assessment of dietary diversity in women of reproductive age. Curr Dev Nutr. 2017;1(12). https://doi.org/10.3945/cdn.117.001701.

  32. Allen LH, Carriquiry AL, Murphy SP. Perspective: proposed harmonized nutrient reference values for populations. Adv Nutr. 2020;11(3):469–83. https://doi.org/10.1093/advances/nmz096.

    Article  PubMed  Google Scholar 

  33. Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702–6. https://doi.org/10.1093/aje/kwh090.

    Article  PubMed  Google Scholar 

  34. Yelland LN, Salter AB, Ryan P. Performance of the modified Poisson regression approach for estimating relative risks from clustered prospective data. Am J Epidemiol. 2011;174(8):984–92. https://doi.org/10.1093/aje/kwr183.

    Article  PubMed  Google Scholar 

  35. Noor RA, Abioye AI, Ulenga N, Msham S, Kaishozi G, Gunaratna NS, et al. Large -scale wheat flour folic acid fortification program increases plasma folate levels among women of reproductive age in urban Tanzania. PLoS One. 2017;12(8):e0182099. https://doi.org/10.1371/journal.pone.0182099.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  36. Miller BDD, Welch RM. Food system strategies for preventing micronutrient malnutrition. Food Policy. 2013;42:115–28. https://doi.org/10.1016/j.foodpol.2013.06.008.

    Article  Google Scholar 

  37. Ferreira AF, Giugliani R. Consumption of folic acid-fortified flour and folate-rich foods among women at reproductive age in South Brazil. Community Genet. 2008;11(3):179–84. https://doi.org/10.1159/000113881.

    Article  PubMed  Google Scholar 

  38. Monteagudo C, Mariscal-Arcas M, Palacin A, Lopez M, Lorenzo ML, Olea-Serrano F. Estimation of dietary folic acid intake in three generations of females in southern Spain. Appetite. 2013;67:114–8. https://doi.org/10.1016/j.appet.2013.04.004.

    CAS  Article  PubMed  Google Scholar 

  39. Karacil Ermumcu MS, Mengi Celik O, Acar Tek N. An evaluation of awareness, knowledge, and use of folic acid and dietary folate intake among non-pregnant women of childbearing age and pregnant women: a cross-sectional study from Turkey. Ecol Food Nutr. 2020;60(1):1–15. https://doi.org/10.1080/03670244.2020.1807344.

    Article  Google Scholar 

  40. Kancherla V, Koning J, Biluts H, Woldemariam M, Kibruyisfaw Z, Belete A, et al. Projected impact of mandatory food fortification with folic acid on neurosurgical capacity needed for treating spina bifida in Ethiopia. Birth Defects Res. 2021;113(5):393–8. https://doi.org/10.1002/bdr2.1857.

    CAS  Article  PubMed  Google Scholar 

  41. Kancherla V, Chadha M, Rowe L, Thompson A, Jain S, Walters D, et al. Reducing the burden of Anemia and neural tube defects in low- and middle-income countries: an analysis to identify countries with an immediate potential to benefit from large-scale mandatory fortification of wheat flour and Rice. Nutrients. 2021;13(1):244. https://doi.org/10.3390/nu13010244.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  42. Belgnaoui S, Belahsen R. Nutrient intake and food consumption among pregnant women from an agricultural region of Morocco. Int J Food Sci Nutr. 2006;57(1-2):19–27. https://doi.org/10.1080/09637480500465261.

    CAS  Article  PubMed  Google Scholar 

  43. Maugeri A, Barchitta M, Agrifoglio O, Favara G, La Mastra C, La Rosa MC, et al. The impact of social determinants and lifestyles on dietary patterns during pregnancy: evidence from the "Mamma & Bambino" study. Ann Ig. 2019;31(2 Supple 1):81–9. https://doi.org/10.7416/ai.2019.2280.

    CAS  Article  PubMed  Google Scholar 

  44. Adubra L, Savy M, Fortin S, Kameli Y, Kodjo NE, Fainke K, et al. The Minimum Dietary Diversity for Women of Reproductive Age (MDD-W) Indicator Is Related to Household Food Insecurity and Farm Production Diversity: Evidence from Rural Mali. Curr Dev Nutr. 2019;3:nzz002.

    Article  Google Scholar 

  45. Asayehu TT, Lachat C, Henauw S, Gebreyesus SH. Dietary behaviour, food and nutrient intake of women do not change during pregnancy in southern Ethiopia. Matern Child Nutr. 2017;13(2):e12343. https://doi.org/10.1111/mcn.12343.

    Article  Google Scholar 

  46. Mekonnen DA, Talsma EF, Trijsburg L, Linderhof V, Achterbosch T, Nijhuis A, et al. Can household dietary diversity inform about nutrient adequacy? Lessons from a food systems analysis in Ethiopia. Food Security. 2020;12(6):1367–83. https://doi.org/10.1007/s12571-020-01056-5.

    Article  Google Scholar 

  47. Jemal K, Awol M. Minimum dietary diversity score and associated factors among pregnant women at Alamata general hospital, Raya Azebo zone, Tigray region, Ethiopia. J Nutr Metab. 2019;2019:8314359–6. https://doi.org/10.1155/2019/8314359.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Oumer M, Taye M, Aragie H, Tazebew A. Prevalence of spina bifida among newborns in Africa: a systematic review and Meta-analysis. Scientifica (Cairo). 2020;2020:4273510.

    Google Scholar 

  49. Tadesse AW, Kassa AM, Aychiluhm SB. Determinants of neural tube defects among newborns in Amhara region, Ethiopia: A Case-Control Study. Int J Pediatr. 2020;2020:5635267–9. https://doi.org/10.1155/2020/5635267.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Krishnaswamy K, Madhavan Nair K. Importance of folate in human nutrition. Br J Nutr. 2001;85(Suppl 2):S115–24. https://doi.org/10.1079/BJN2000303.

    CAS  Article  PubMed  Google Scholar 

  51. Ohrvik VE, Witthoft CM. Human folate bioavailability. Nutrients. 2011;3(4):475–90. https://doi.org/10.3390/nu3040475.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  52. Gomes S, Lopes C, Pinto E. Folate and folic acid in the periconceptional period: recommendations from official health organizations in thirty-six countries worldwide and WHO. Public Health Nutr. 2016;19(1):176–89. https://doi.org/10.1017/S1368980015000555.

    Article  PubMed  Google Scholar 

  53. Gashu D, Stoecker BJ, Adish A, Haki GD, Bougma K, Marquis GS. Ethiopian pre-school children consuming a predominantly unrefined plant-based diet have low prevalence of iron-deficiency anaemia. Public Health Nutr. 2016;19(10):1834–41. https://doi.org/10.1017/S1368980015003626.

    Article  PubMed  Google Scholar 

  54. Tuokkola J, Luukkainen P, Kaila M, Takkinen HM, Niinisto S, Veijola R, et al. Maternal dietary folate, folic acid and vitamin D intakes during pregnancy and lactation and the risk of cows' milk allergy in the offspring. Br J Nutr. 2016;116(4):710–8. https://doi.org/10.1017/S0007114516002464.

    CAS  Article  PubMed  Google Scholar 

  55. Desta M, Kassie B, Chanie H, Mulugeta H, Yirga T, Temesgen H, et al. Adherence of iron and folic acid supplementation and determinants among pregnant women in Ethiopia: a systematic review and meta-analysis. Reprod Health. 2019;16(1):182. https://doi.org/10.1186/s12978-019-0848-9.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  56. Eck LH, Klesges RC, Hanson CL, Slawson D, Portis L, Lavasque ME. Measuring short-term dietary intake: development and testing of a 1-week food frequency questionnaire. J Am Diet Assoc. 1991;91(8):940–5. https://doi.org/10.1016/S0002-8223(21)01264-5.

    CAS  Article  PubMed  Google Scholar 

  57. Resnicow K, Odom E, Wang T, Dudley WN, Mitchell D, Vaughan R, et al. Validation of three food frequency questionnaires and 24-hour recalls with serum carotenoid levels in a sample of African-American adults. Am J Epidemiol. 2000;152(11):1072–80. https://doi.org/10.1093/aje/152.11.1072.

    CAS  Article  PubMed  Google Scholar 

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Acknowledgments

The authors wish to thank Dr. Sabri Bromage for his valuable comments and suggestions and Harvard school of public health for their assistance in data collection. The authors would like to thank study participants, local administrators, and data collectors for facilitating the data collection.

Funding

This work was supported by Harvard T.H. Chan School of Public Health, USA.

Author information

Author notes

  1. Nega Assefa and Yasir Y Abdullahi are First Authors

Affiliations

  1. College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia

    Nega Assefa, Aklilu Abraham, Yadeta Dessie & Kedir Teji Roba

  2. Jugal Hospital Department of Obstetrics and Gynecology, Harar, Ethiopia

    Yasir Y. Abdullahi

  3. Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA

    Elena C. Hemler, Isabel Madzorera & Wafaie W. Fawzi

  4. Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA

    Elena C. Hemler, Isabel Madzorera & Wafaie W. Fawzi

  5. Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA

    Wafaie W. Fawzi

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  1. Nega Assefa
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Contributions

NS, AAR, KTR, YD, and WWF designed concept note. NS, AAR, KTR, and YD developed proposal. NS, AAR, KTR, and YD worked on data generation and field work. NS, YYA, EC, and IM performed statistical analysis. NS, YYA, EC, IM, and WWF developed the manuscript. All authors reviewed, edited and approved manuscript the final manuscript.

Corresponding author

Correspondence to Yasir Y. Abdullahi.

Ethics declarations

Ethics approval and consent to participate

This study was ethically approved by the Institution Health Research Ethical Review Board of the College of Health and Medical Sciences with reference number SHE/S1M/14.4/708/19. The study procedures were also undertaken in accordance with the Helenski Declaration. At the time of visit to the household, written informed, voluntary consent was secured from respondents.

Consent for publication

Not Applicable.

Competing interests

The authors declare no conflicts of interest.

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Assefa, N., Abdullahi, Y.Y., Abraham, A. et al. Consumption of dietary folate estimates and its implication for reproductive outcome among women of reproductive age in Kersa: cross-sectional survey. BMC Nutr 7, 69 (2021). https://doi.org/10.1186/s40795-021-00476-6

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Keywords

  • Folate consumption
  • Dietary folate
  • Food diversity
  • Daily folate consumption

BMC Nutrition

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