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Department of Biochemistry, Midwestern University, Downers Grove IL 60515
1To whom correspondence should be addressed. E-mail: slynch{at}midwestern.edu
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONAPPENDIX 1LITERATURE CITED |
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KEY WORDS: • folic acid • neural tube defects • pharmacists • education • humans
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONAPPENDIX 1LITERATURE CITED |
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). These birth defects, which include spina bifida and anencephaly, result from failure of the neural tube to close properly during wk 4 of gestation (2
). Thus, NTD often occur in the developing embryo at a time before a woman may even know she is pregnant. Furthermore, it should be noted that almost one-half of all pregnancies in the United States are unplanned (3
). For these reasons, the U.S. Public Health Service recommends that all women of childbearing age consume 400 µg of folic acid/d for the prevention of NTD (4
). Similarly, the Institute of Medicine’s Food and Nutrition Board recommends that women capable of becoming pregnant should consume this same amount of (synthetic) folic acid daily from fortified foods and/or supplements (5
). It is estimated that optimal periconceptional intake of folic acid could reduce the incidence of NTD by at least 50% in the United States (4
). However, although folic acid is clearly important for the prevention of NTD and despite Food and Drug Administration-mandated fortification of certain food staples with folic acid (6
,7
), many women consume less than the recommended amount (8
). Furthermore, a survey of 1100 women performed in 1998 (9
) found that only 13% were aware that folic acid could prevent birth defects, and even fewer (7%) were aware that it should be taken before pregnancy. In three surveys performed over the last 6 y (9
–11
), 
30% of nonpregnant women reported consuming a daily folic acid-containing supplement. It is clear that most women are neither aware of current recommendations regarding folic acid nor consume adequate amounts of this vitamin for optimal prevention of NTD.
Healthcare providers, including pharmacists, can perform an important public health service by educating their female patients about the role of folic acid in promoting optimal pregnancy outcome. A role for pharmacists in preventive health education is well-recognized [see (12
–14
), for example], and the efficacy of pharmacists in promoting various preventive activities is documented [see (15
–17
), for example]. Such activity is consistent with the "Health Promotion and Disease Prevention" domain of the Pharmacist Practice Activity Classification (18
) developed by the American Pharmaceutical Association, the largest professional association of pharmacists in the United States (19
). Furthermore, the American Pharmaceutical Association is also a Steering Committee Member of the National Council on Folic Acid whose stated mission is: "to reduce birth defects by promoting the consumption of folic acid among reproductive-age women" (20
). Although no studies have been performed in the United States, evidence from Australia indicates that pharmacists can be an important source of information for women concerning folic acid and prevention of NTD (21
,22
). Currently, only approximately one-fifth of American women (19%) report that they learned about folic from a healthcare provider (9
). Some evidence suggests that gaps in knowledge concerning folic acid may be at least one factor limiting the ability of some healthcare providers to counsel women about prevention of NTD (9
). The aim of this study was to determine whether student pharmacists in the final year of a professional degree program are sufficiently knowledgeable about folic acid to effectively counsel women regarding its ability to prevent birth defects in their future clinical practices.
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SUBJECTS AND METHODS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONAPPENDIX 1LITERATURE CITED |
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Over a 3-y period (1998–2000), groups (n = 32, 36 and 30 in 1998, 1999 and 2000, respectively; overall, n = 98) of students enrolled in the PharmD degree program at Midwestern University’s Chicago College of Pharmacy (23
) were administered a survey consisting of five multiple-choice questions concerning folic acid and prevention of NTD (see Appendix)
. The survey questions were included within a 50-item questionnaire as a required educational component of an elective course on the role of nutrition in promoting optimal health. The questionnaire was administered during the first class session (i.e., before any teaching on course subject matter) with the overall aim of assessing students’ general nutrition knowledge. Students were informed of the purpose of the questionnaire and that their individual responses to questions would remain anonymous with data being analyzed in aggregate form only. Survey questions were designed to determine whether students knew that folic acid prevents NTD (question 1), when this vitamin should be consumed for optimal benefit (question 2), and the recommended amount that should be consumed (question 3). Students’ ability to identify good dietary sources of folic acid (question 4) and food items fortified with folic acid (question 5) were also assessed. The surveyed students represented a subgroup of those in the final (fourth) professional year of the PharmD degree program and were selected as a convenience sample to assess student pharmacists’ knowledge concerning folic acid and prevention of NTD. These students had successfully completed 2 y of prepharmacy course work and three years of professional course work (including general and pharmaceutical sciences, and pharmacy practice) and clinical practice experience rotations. During their previous 3 y of professional course work, students had taken courses that included nutrition-related topics (e.g., coenzyme activities of vitamins in biochemistry courses) but had not taken a specific nutrition course. After completion of the survey, students enrolled in this elective course attended 10 lectures (corresponding to 10 contact hours) covering various aspects of nutrition with an emphasis on promoting optimal health. Major topics covered during the course included the role of nutrition in obesity (one contact hour), cardiovascular disease (two contact hours), cancer (two contact hours), pregnancy (one contact hour; included a short (
15 min; i.e., 3% of total contact hours) presentation on the role of folic acid in NTD prevention), and osteoporosis (one contact hour), and health effects of non-nutrient (phytochemical) components of foods (one contact hour). The remaining two contact hours were divided equally between an introductory lecture and a final overview/summary lecture. Immediately after completing the course, the questionnaire (containing the same survey questions) was readministered to assess student learning.
Statistical analysis.
Statistical comparison of the proportion of students correctly answering each question before and after the educational intervention was performed by Fisher’s exact test (GraphPad Prism, Version 3.00 for Windows 95; GraphPad Software, San Diego, CA).
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RESULTS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONAPPENDIX 1LITERATURE CITED |
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) of the student pharmacists surveyed in this study knew that folic acid can prevent NTD from occurring during pregnancy (question 1). Of the six student pharmacists who did not select folic acid as the nutrient capable of preventing NTD, five selected iron and one chose zinc. Of those student pharmacists who knew that folic acid can prevent NTD (n = 92), many (68 of 92; 73.9%; Table 1
) also knew that supplementation should begin before pregnancy for optimal benefits (question 2). However, approximately one in four (24 of 92; 26.1%) did not. Among these individuals, most (21 of 24; 87.5%) instead selected "after a positive pregnancy test."
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. Most who did not select this amount (41 of 92; 44.6%) chose either 0.4 µg/d (16 of 41; 39.0%) or 40 µg/d (14 of 41; 34.1%); seven selected 4 µg/d and four selected 4000 µg/d.
Among student pharmacists who knew that folic acid prevents NTD, approximately two-thirds (60 of 92; 65.2%; Table 1
) were able to correctly identify four good dietary sources of folic acid (orange juice, a multivitamin supplement, green leafy vegetables, and fortified breakfast cereals; question 4). Student pharmacists who did not recognize all four dietary items in question 4 as good sources of folic acid (32 of 92; 34.8%) mostly chose green leafy vegetables (16 of 32; 50%); fewer selected either a multivitamin supplement (9 of 32; 28.1%), fortified breakfast cereals (5 of 32; 15.6%), or orange juice (2 of 32; 6.3%). The proportion of student pharmacists who knew that folic acid could prevent NTD and could correctly identify four dietary staples currently fortified with folic acid was similarly relatively low (53 of 92; 57.6%; question 5). Student pharmacists who failed to recognize that all of the listed food staples are currently fortified with folic acid mostly selected flour (24 of 39; 61.5%) as a fortified item; nine (of 24; 23.1%) selected rice, while two (of 24; 5.1%) and four (of 24; 10.3%) selected corn meal, and macaroni and noodles, respectively.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONAPPENDIX 1LITERATURE CITED |
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indicates a high level of awareness of this important public health message among this group. Indeed, this level of awareness compares favorably with that observed in a recent survey of 488 obstetrician-gynecologists among whom 96.5% were aware that preconceptual folic acid supplementation protects against NTD (24
). In contrast to these results, a survey of U.S. women of childbearing age found that only 13% knew that folic acid can prevent NTD (9
). Thus, the data reported here clearly, but perhaps not surprisingly, indicate that student pharmacists, like obstetrician-gynecologists, are much better informed than the general public about the ability of folic acid to prevent NTD. Whether this level of awareness among student pharmacists is indicative of what can be expected among practicing pharmacists is presently unknown as, to the best of the author’s knowledge, this has not yet been assessed in the United States. However, although it is clear that most student pharmacists know that folic acid can prevent NTD, the results presented here indicate that many lack the more specific knowledge, such as when and how much folic acid should be consumed, necessary to effectively counsel women in future clinical practice. A large proportion of student pharmacists (26.1–44.6%) who knew that folic acid prevents NTD were unable to correctly identify the optimal time for supplementation with folic acid, the amount recommended for prevention of NTD, or good dietary sources/fortified food items (Table 1)
.
Although many of the student pharmacists (73.9%) who knew that folic acid can prevent NTD also knew that it should be consumed before pregnancy for optimal benefit (Table 1)
, approximately one in four (26.1%) did not. Most of the students who did not select before pregnancy as the optimal time for supplementation with folic acid selected after a positive pregnancy test. Because closure of the neural tube occurs during wk 4 of gestation (2
), supplementation with folic acid only after a positive pregnancy test may be too late for prevention of NTD in many women. However, although incorrect, selection of this alternative answer would seem to indicate recognition among student pharmacists that optimal folic acid nutrition is important during the early stages of pregnancy.
Also, it is apparent that a significant proportion of student pharmacists are uninformed concerning the amount of folic acid recommended for prevention of NTD (Table 1)
. Only slightly more than one-half of surveyed student pharmacists (55.4%) could identify 400 µg/d as the amount recommended for prevention of NTD. One possible reason for this may be confusion among student pharmacists regarding the actual recommendation. Thus, whereas the actual U.S. Public Health Service recommendation states: "All women of childbearing age in the United States should consume 0.4 mg of folic acid per day..." (4
), most educational materials intended for either the public or healthcare professionals [see (25
), for example] convert the recommendation from 0.4 mg/d to the corresponding amount in micrograms per day (i.e., 400 µg/d). For this reason, it was assumed that student pharmacists would likely be more familiar with the recommendation in the micrograms per day format and question 3 was formatted with 400 µg/d as the correct answer. However, it may be that some student pharmacists were confused by the inclusion of 0.4 µg/d as a possible alternative answer and selected this instead. However, in the unlikely event that this was true even for all those selecting 0.4 µg/d as a possible alternative answer, it is still clear that many student pharmacists did not know the amount of folic acid recommended for prevention of NTD.
When asked to identify good dietary sources of folic acid approximately two-thirds (Table 1)
of student pharmacists surveyed recognized that all of the dietary items listed in question 4 (i.e., orange juice, a daily multivitamin supplement, green leafy vegetables, and fortified breakfast cereals) can contribute significantly to folic acid intake. According to data collected in the Second National Health and Nutrition Examination Study (conducted from 1976 to 1980), orange juice was the single most important contributor to daily folic acid intake; other major food sources of folic acid identified included green salad and ready-to-eat breakfast cereals (26
). In a more recent study performed among elderly participants in the Framingham Heart Study (27
), orange juice was also identified as a major dietary source of folic acid; cold breakfast cereals and multivitamins were the other major sources. Leafy green vegetables, such as spinach, although rich in folic acid, and, thus, a potentially good source of folic acid, tend not to be consumed as frequently as orange juice, fortified cereals and multivitamin supplements (26
). The reason why approximately one-third of student pharmacists surveyed did not recognize all four of the dietary items listed in question 4 as good sources of folic acid is uncertain. Although most student pharmacists who knew that folic acid can prevent NTD identified leafy green vegetables as a good source of folic acid (either alone or in combination with other sources of the vitamin), fewer identified multivitamin supplements, fortified breakfast cereals or orange juice (i.e., the most common and convenient sources of folic acid in the diet) as such. Many student pharmacists were also relatively uninformed concerning which dietary staples are currently fortified with folic acid. Thus, whereas most of those who knew that folic acid can prevent NTD were aware that flour is fortified, fewer also knew that corn meal, rice, and macaroni and noodles are also fortified.
The lack of knowledge concerning specific aspects of folic acid nutrition among student pharmacists reported here may not be remarkable. In the most recent survey of nutrition education in colleges of pharmacy (28
), it was reported that although 72% of surveyed colleges included a basic science course covering nutrient biochemistry and 46% offered elective nutrition courses, only 19% required a stand-alone nutrition course as part of the professional pharmacy curriculum. In common with students at most other colleges of pharmacy, those surveyed here did not take a formal nutrition course as part of their professional pharmacy curriculum; nutrition-related information was incorporated into courses where appropriate, and students had the option to enroll in elective nutrition courses (29
). However, although pharmacists’ nutrition education may be limited, it has been documented that, at least in some practice settings, many pharmacists are called upon to serve as sources of nutrition information for patients (30
). Given their often limited nutrition education, it is not surprising that only a minority of pharmacists report either that their nutrition preparation is (moderately/very) adequate or that they are very prepared to counsel patients regarding diet modification (30
,31
).
Although some student pharmacists lacked certain specific knowledge concerning folic acid and prevention of NTD, this could be easily rectified. After participating in a short nutrition course (ten 50-min lectures delivered over a 3-wk period), the same survey questions were readministered to the same student pharmacists. At this time, the proportion of student pharmacists who knew that folic acid can prevent NTD was found to have increased significantly (98 of 98; 100.0%; P = 0.0289 compared with before participation in the course by Fisher’s exact test). Significantly (P < 0.0001 by Fisher’s exact test) increased proportions of student pharmacists also knew when (96 of 98; 98.0%) and how much (93 of 98; 94.9%) of this vitamin is needed for optimal protection from NTD, and could correctly identify sources of folic acid (94–97 of 98; 95.9–99.0%). Providing increased education concerning folic acid and prevention of NTD to healthcare providers, such as (future) pharmacists, may, therefore, represent one potential mechanism to increase awareness of this important public health message and increase consumption of folic acid by women of reproductive age.
Although the results of this study are interesting, there are several important limitations that must be kept in mind when interpreting the data. First, the study was performed at a single site, and the results may not be representative of student pharmacists (or pharmacists) in general. Also, the large proportion of female students enrolled in this course (76 of 98 students were female during 1998–2000; 77.6%) may have skewed the results due, perhaps, to increased awareness of women’s health issues among female students. However, when survey data for the years 1999 and 2000 were segregated according to gender (information concerning gender-specific responses to survey questions was not collected for 1998), it was found that essentially the same proportion of male (16 of 17; 94.1%) and female (46 of 49; 93.9%) students knew that folic acid can prevent NTD. Similarly, gender had no effect on student pharmacists’ responses to other survey questions (data not shown).
In conclusion, the results of this study show that although an overwhelming majority of student pharmacists (93.9%) in the final year of a professional degree program know that folic acid can prevent NTD, some are uncertain of specific aspects, such as when and how much of this vitamin needs to be consumed, and what are good dietary sources. It is hoped that educating future pharmacists about folic acid will help prevent birth defects in the general population.
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APPENDIX 1 |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONAPPENDIX 1LITERATURE CITED |
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Manuscript received 18 May 2001.
Initial review completed 26 June 2001.
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LITERATURE CITED |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONAPPENDIX 1LITERATURE CITED |
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25. March of Dimes (2001) Folic Acid Fact Sheet 2001 Available at http//www.modimes.org/Programs2/FolicAcid/FASheet.htm. Accessed May 14, 2001. .
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29. Chicago College of Pharmacy (1999) Midwestern University Catalog 1999/2000 1999 Midwestern University Downers Grove, IL .
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