Michael Feldman, M.D., a pediatric neurosurgery fellow in the University of Alabama at Birmingham Department of Neurosurgery Division of Pediatric Neurosurgery, is leading efforts to reduce spina bifida rates in Alabama's Hispanic community through folic acid fortification of corn masa flour.

Spina bifida, a neural tube defect (NTD) that affects the spinal cord, can lead to significant disabilities, paralysis and even infant mortality. An estimated 50% to 70% of NTDs are folic acid sensitive, meaning that adequate maternal folic acid intake before and during early pregnancy can have a significant impact in decreasing the occurrence of these defects, including spina bifida.

Since the FDA mandated folic acid fortification for enriched cereal grains in the late 1990s, the incidence of spina bifida has declined in populations consuming these grains. However, corn masa flour, a staple in the Hispanic diet, was excluded from this mandate, leaving a significant gap in preventive health measures for the Hispanic community.

The lack of mandated fortification leads to devastating consequences for affected families, including a 30% higher rate of divorce and underemployment among parents of children with spina bifida, according to Feldman.Michael Feldman, M.D.

To address this disparity, Feldman has collaborated with various organizations, including the March of Dimes, the Hispanic and Immigrant Center of Alabama (¡HICA!), and Alabama Arise, to form action groups advocating for legislative change. These groups are working diligently to draft and promote bills that would mandate the fortification of corn masa flour in Alabama.

Efforts are not limited to state-level actions. Feldman is working with UnidosUS, the nation’s largest Latino nonprofit advocacy organization, and Alabama Senators Katie Britt and Tommy Tuberville to advocate for federal policies. Feldman has also met with Secretary Xavier Becerra of the Department of Health and Human Services (HHS) to discuss the implementation of an FDA citizen petition that would require all corn masa products to be labeled if they are not fortified with folic acid.

Despite minimal industry resistance, concerns about product labeling timelines persist with manufacturers, such as Gruma, the largest manufacturer of corn tortilla products, advocating for a two-year implementation period to ensure all new labels would indicate fortification.

The potential impact of these legislative efforts, that could be implemented within two to five years, is profound. Mandating folic acid fortification in corn masa flour could prevent 30 to 120 cases of spina bifida annually in the Hispanic community, saving millions in healthcare costs and improving quality of life for affected families.

In 2016, the FDA permitted voluntary folic acid fortification of corn masa flour, but, despite the low cost of fortification—estimated at around $1 per metric ton of corn masa flour—only a small percentage of manufacturers currently add folic acid to their products.

“Fortification is a cost-effective and straightforward solution that can save lives and reduce healthcare expenses,” said Feldman. “It’s a public health measure that has proven successful with other staple grains, and there’s no reason why it shouldn’t be applied to corn masa flour as well.”

Feldman’s dedication to this cause is rooted in his extensive training and advocacy experience. He also credits his interest in folic acid as an actionable cause to Jeffrey P. Blount, M.D., MPH, an international NTD prevention advocate, professor in the Department of Neurosurgery and director of the Division of Pediatric Neurosurgery.

Before training at UAB, Feldman completed his residency and an endovascular neurosurgery fellowship at Vanderbilt University, along with fellowships in socioeconomic and legislative advocacy through the American Association of Neurological Surgeons and Congress of Neurological Surgeons. His work underscores the critical role that medical professionals play in patient advocacy, particularly in underserved communities.

"Neurosurgeons can leverage their expertise to influence policy and advocate for patient needs," Feldman emphasized. "Engagement from both the medical community and legislators is essential to drive this initiative forward."

As Feldman transitions to the University of Oklahoma this September, he plans to continue his advocacy efforts, aiming to replicate and expand these initiatives in other states. In Alabama, Regan Gaskin, MPA, a clinical research coordinator II in the Division of Pediatric Neurosurgery, will coordinate in-state research in place of Feldman. The ultimate goal is to achieve nationwide mandatory folic acid fortification of corn masa flour, ensuring equitable health benefits for all communities.