A recent peer-reviewed study conducted in Ethiopia has shown that iodized table salt fortified with folic acid can significantly improve folate status among non-pregnant women of reproductive age, paving the way for one of the world’s first nationwide double-fortified salt programs aimed at preventing neural tube defects (NTDs).
The community-based, household-randomized trial followed Ethiopian women aged 18–49 who received iodized salt with different levels of added folic acid over a 26-week period. Results indicate that daily consumption of double-fortified salt with iodine and folic acid (DFS-IoFa) substantially reduced folate insufficiency, without compromising iodine status, underscoring the safety and scalability of this intervention.
Ethiopia carries one of the highest documented burdens of neural tube defects globally, with population-based studies reporting rates ranging from about 60 to more than 160 cases per 10,000 births—far above the global average. Nearly 85 percent of women of reproductive age in the country have been found to have low folate levels, which sharply increases the risk of NTDs such as spina bifida and anencephaly, as well as stillbirths and low-birth-weight deliveries.
Because the neural tube closes in the first four to six weeks of pregnancy—often before many women even know they are pregnant—routine supplementation alone cannot reach all at-risk pregnancies. Public-health experts argue that reaching women earlier in the life course, through a staple food such as salt, is therefore critical to reducing NTDs at scale.
The new trial builds on Ethiopia’s long-running universal salt iodization program, which already reaches over 90 percent of households. By adding folic acid to the existing iodized salt supply, the government, the Ethiopian Public Health Institute (EPHI), Nutrition International and partners are converting a widespread condiment into a preventive tool for both iodine deficiency disorders and NTDs.
Technical studies show that folic acid can be stably combined with iodine in the same salt-fortification process, with the nutrients remaining detectable for at least 12 months when properly packaged. Pilot work and acceptability surveys in both rural and urban Ethiopian settings suggest that double-fortified salt does not alter taste or cooking behavior, smoothing the path toward nationwide rollout.
On the back of this evidence, the Ethiopian government, in collaboration with Nutrition International and international research partners, has charted a national roadmap to introduce double-fortified salt with iodine and folic acid at scale. The initiative is being framed as a global first, aligning with Ethiopia’s National Food and Nutrition Policy, the Seqota Declaration targets, and the Sustainable Development Goals.
Officials and researchers emphasize that mandatory fortification of both coarse and fine salt, coupled with robust quality-control and monitoring systems, will be essential to maintain iodine and folic acid levels in the market. Cost-effectiveness analyses suggest that integrating folic acid into the existing iodization platform is a low-cost way to expand protection, especially where large-scale wheat-flour fortification remains limited.
Public-health leaders and nutrition advocates describe double-fortified salt as a “game-changing” intervention for Ethiopia, capable of averting thousands of preventable birth defects and stillbirths over time. By embedding folic acid into a product already used by the vast majority of households, the program shifts the focus from individual behavior change to structural food-system reform—an approach that could inspire similar policies in other high-burden countries.
For women and future parents, the implications are concrete: the same salt used to season meals may soon also help protect a baby from devastating congenital abnormalities. As Ethiopia moves from evidence to implementation, the double-fortified salt program is poised to become a landmark case study in how innovation, research, and policy can converge to improve maternal and child health on a national scale.
