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Impact of Text Messaging and Availability of a Folic Acid-Containing Supplement on Folate / Folic Acid Knowledge and Behaviors in College Age Women

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Title:
Impact of Text Messaging and Availability of a Folic Acid-Containing Supplement on Folate / Folic Acid Knowledge and Behaviors in College Age Women
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Gruspe, Abigail
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English

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Educational evaluation ( jstor )
Food ( jstor )
Neural tube defects ( jstor )
Pregnancy ( jstor )
Questionnaires ( jstor )
Research studies ( jstor )
Text messages ( jstor )
Text messaging ( jstor )
Vitamins ( jstor )
Women ( jstor )
folate
folic acid
nutrition education
supplement
text message

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Abstract:
Folate is a water soluble B vitamin that plays a key role in one-carbon metabolism and is crucial for the prevention of neural tube defects (NTDs). Women able to become pregnant are recommended to consume 400 micrograms (mcg) of folic acid per day (i.e., the synthetic form of the vitamin) in order to prevent NTD-affected pregnancies. However, many women, especially those between the ages of 18 and 24, have limited knowledge, awareness, and intake of this vitamin. The purpose of this study was to identify whether intervention strategies such as text messaging and/or providing a folic acid supplement are effective in enhancing folate-related knowledge and improving health behaviors (i.e., increasing folate/folic acid intake) among college-age women who currently are not planning to become pregnant. Women between the ages of 18 and 24 years who met certain additional inclusion criteria participated in a randomized controlled intervention study in which they viewed an educational video and received educational materials related to folate/folic acid, after which they were randomly assigned to one of four study groups (i.e., control; text message only; supplement only; text message + supplement) for a six-week intervention period. Throughout the study, participants completed various quizzes, questionnaires, and dietary recalls. A significant increase in folaterelated knowledge was detected for all participants from baseline to post-study, and mean intake of total folate (micrograms/d and DFE/d) and folic acid were significantly higher at the mid- and post-study time points compared to baseline, with intake being higher in the combined supplement groups compared to the combined non-supplement groups. This thesis focuses specifically on the impact of our intervention strategies on knowledge and folate/folic acid intake. Our data suggest that folic acid education and the provision of a supply of a folic acid! containing supplement are effective intervention strategies for increasing folic acid knowledge and intake in our target population. ( en )

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! ! Impact of Text Messaging and Availability of a Folic Acid Containing Supplement on Folate/Folic Acid Knowledge and Behaviors in College Age Women By Abigail Frances Gruspe Department of Food Science and Human Nutrition Adviser: Dr. Gail P. A. Kauwell A Thesis Submitted to the College of Agricultural and Life Sciences for Fulfillment of University of Florida Honors, Summa Cum Laude University of Florida 2015

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! ! GRUSPE 2 ! ! ! ACKNOWLEDGEMENTS I would like to thank my faculty men tor, Dr. Kauwell, for all of her guid ance and encouragement throughout this entire research project. I am very grateful to have had the opportunity to work with her, and she has been an incredible source of knowledge and advice. I would also like to thank Gail Rampersaud for being a wonderful mentor and for helping me through the research process. Finally, I would like to thank my family and friends for their constant love and support throughout my undergraduate career, which has helped me to successfully complete this thesis.

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! ! GRUSPE 3 ! ! ! TABLE OF CONTENTS Acknowledgements............................................................................................................. ...........2 Abstract ..................................................................................................... ....... ...............................4 Introduction ..................................................................................................... ...............................6 Materials and Method s................................................. ................................. ..............................13 Results ............................................................................................................................. ..............17 Discussion ....................................................................................................... ..............................19 Limitations ...................................................................................................... ....... .......................22 Conclusion................................................................................................................... .................23 Literature Cited ..................................................................... ........................ ..............................24 Supporting Figures/Tables............................................................. .. ....................... . ........... . ..... ..29 Figure 1: Research Study Design....................................................................... . .......... ..29 Table 1: Participant Descriptive Statistics............................................................... .....30 Table 2: Temporal Changes for A ll Participants .................................................. .. ...... 33 Table 3: Group Evaluation Ð No Text Message versus Text Messag e................. .......34 Table 4: Group Evaluation Ð No Supplement versus Supplement.......................... ... . 35 Appendix ......................................................................................................... ..............................36

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! ! GRUSPE 4 ! ! ! ABSTRACT Folate is a water soluble B vitamin that plays a key role in one carbon metabolism and is crucial for the prevention of neural tube defects (NTDs). Women able to become pregnant are recommended to consume 400 micrograms (mcg) of folic acid per day (i.e., the synthetic form of the vitamin) in order to prevent NTD affected pregnancies . How ever, many women, especially those between the ages of 18 and 24, have limited knowledge, awareness, and intake of this vitamin. The purpose of this study was to identify whether intervention strategies such as text messaging and/ or providing a folic acid supplement are effective in enhancing folate related knowledge and improving health behaviors (i.e., increasing folate/folic acid intake) among college age women who currently are not planning to become pregnant. Women between the ages of 18 and 24 years w ho met certain additional inclusion criteria participated in a randomized controlled intervention study in which they view ed an educational video and received educational materials related to folate/folic acid, after which they were random ly assigned to on e of four study groups (i.e., control; text message only; supplement only; text message + supplement) for a six week intervention period. Throughout the study, participants completed various quizzes , questionnaires , and dietary recalls. A significant increase in folate related knowledge was detected for all participants from baseline to post study, and mean intake of total folate (micrograms/d and DFE/d) and folic acid were significantly higher at the mid and post study time points compa red to baseline, with intake being higher in the combined supplement groups compared to the combined non supplement groups. This thesis focuses specifically on the impact of our intervention strategies on knowledge and folate/folic acid intake. O ur data su ggest that folic acid education and the provision of a supply of a folic acid

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! ! GRUSPE 5 ! ! ! containing supplement are effective intervention strategies for increasing folic acid knowledge and intake in our target population.

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! ! GRUSPE 6 ! ! ! INTRODUCTION Folate/Folic Acid Folate is a water soluble B vitamin that functions in one carbon metabolism and exists in various forms. The term folate is used in a general sense to refer to all forms of this vitamin, including folic acid, the synthetic form of the vitamin found in supplements and fortified foods. It also is used to refer specifically to forms of this vitamin that are naturally present in food (i.e., food folate). Foods that are naturally high in folate include dark green leafy vegetables, broccoli, orange juice, strawberries, avoc ados, asparagus, peanuts, and dried peas and beans (1,2) . Because the bioavailability of folate differs depending on the form that is consumed, the recommended dietary allowance (RDA) for adults is expressed as micrograms (mcg) per day of dietary folate equivalents (DFEs). DFEs account for the fact that only 50 % of food folate is generally absorbed, while 100% of folic acid is absorbed when taken on an empty stomach. Folic acid present in fortified foods is approximately 85% bioavailable (1,3) . Folate functions in a variety of pathways and is specifically involved in the synthesis of purines and pyrimidines needed for DNA synthesis, as well as the remethylation of homocysteine to methionine. Methionine can be utilized in the formation of prot eins or can be converted to S adenosylmethionine, the body's principal methyl donor. Because of its importance in DNA synthesis, adequate amounts of folate are crucial during pregnancy for the healthy growth and development of the fetus (1) . Neural Tube Defects Neural tube defects (NTDs) are congenital deformities that result from improper closure of the neural tube within the first 28 days of pregnancy (4) . E xamples of NTDs include

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! ! GRUSPE 7 ! ! ! anencephaly, encephalocele , and spina bifida. Anencephaly is a lethal condition that occurs when the brain and skull do not form completely. Encephalocele results in a protrusion of the brain through the skull. This condition can result in men tal impairments or even death. In the case of spina bifida, the spinal cord does not develop properly and the defect can be classified as meningocele or myelomeningocele . Meningocele involves protrusion of only meninges and cerebrospinal fluid and is typic ally covered by skin. Myelomeningocele is a more severe form of spina bifida in which neural tissue is exposed. Complications of spina bifida include paralysis, bladder/bowel problems, hydrocephalus, and learning disabilities (4 7) . Folic Acid and Neural Tube Defect Risk Reduction A number of clinical trials have demonstrated that periconceptional intake of folic acid has a positive effect on NTD risk reduction. The first of these trials were conducted by Smithells et al. in the 1980's. These researchers found that supplementation with a multivitamin containing folic acid resulted in a significantly lower rate of NTD recurrence. This laid th e groundwork for the first randomized controlled clinical trial investigating the effect of folic acid on reducing the risk for recurrence of NTDs, which was directed by the United Kingdom Medical Research Council. Similar to the studies conducted by Smith ells et al., a protective effect against risk for NTD recurrence was observed among women consuming a folic acid containing supplement compared to the control group (8) . The first study to examine the effect of a folic acid containing supplement on risk for first occurrence of an NTD affected pregnancy was conducted in Hungary. In this study, women planning a pregnancy were randomly assigned to receive a multivitamin suppl ement containing folic acid or a supplement containing certain trace elements. The results of this study supported

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! ! GRUSPE 8 ! ! ! the idea that periconceptional vitamin use plays a role in decreasing the incidence of first occurrence of NTDs (9) . The largest randomized controlled trial investigating the impact of folic acid on NTD risk reduction was conducted in China by Berry et al. (10) . This study eliminated the potential effect of other nutrients on NTD risk reduction by using a supplement that only contained folic acid. It also addressed the timing of supplementation by providing it prior to pregnancy and throughout the first trimester . The results of this study showed that periconceptional intake of 400 mcg of folic acid per day reduced the risk for NTDs in areas with both high and low rates of these defects (10) . The most recent clinical tria l examining the effect of periconceptional folic acid intake on NTD risk reduction also was conducted in China. Similar to previous studies, the results of this study provided clear evidence for NTD risk reduction when folic acid was taken two months prior to and through out the second month of pregnancy (11) . In addition to clinical trials, several epidemiological studies have examined the potential role of consuming a folic acid containing supplement on NTD risk reducti on. All but one of these studies supported findings from the clinical trials (12 18) . Based on t he results of clinical trials and epidemiological studies, it is estimated that consumption of 400 mcg of folic acid every day one month prior to conception and throughout the first trimester of pregnancy can reduce the incidence of NTDs by 50 to 70% (19) . Recognizing the importance of folic acid in NTD risk reduction, t he US Public Health Service and Institute of Medicine recommend that women who are able to become pregnant consume 400 m cg of folic acid every day. Additionally, the Institute of Medicine states that these women also should consume food folate from a varied diet (3,20) .

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! ! GRUSPE 9 ! ! ! Alth ough the US established a folic acid fortification program in 1998, and pregnancy outcomes began to improve, approximately 3,000 pregnancies per year are still affected by NTDs , some of which may be preventable if women follow the recommendations issued by the US Public Health Service and the Institute of Medicine (19) . In particular, the importance of taking folic acid prior to conception cannot be overlooked because the neural tube deve lops during the first 28 days of gestation, before most women know they are pregnant (4) . A t least half of all pregnancies in the US are unplanned , so it is imperative that women who are able to become pregnant take folic acid on a regular basis (7) . Furthermore, only 30% of women between the ages of 18 and 24 years take a folic acid containing supplement d aily, making it vitally important to identify strategies to motivate this group to ensure that they consume the level of folic acid associated with NTD risk reduction (20) . Intake and K nowledge of Folate/Folic Acid in Young Women Several studies have shown that many women, especially those between the ages of 18 and 24 years, have limited knowledge, awareness , and intake of folate/folic acid. In a study conducted at a small private coll ege in western North Carolina, only one third of participants reported daily multivitamin use. The study suggested that low intake might have been due to a lack of education about folic acid (21) . Another study in volving college age women found that only 13% of participants regularly took folic acid supplements, and 36% met the daily recommendation of 400 mcg of folic acid. Supplement usage, awareness of folic acid , and knowledge of its benefits were factors associ ated with folic acid consumption (22) . Other US universities show similar trends to what was observed in a study conducted at the University of New Hampshire in which female participants completed a three day diet

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! ! GRUSPE 10 ! ! ! record. Sixty eight percent of these participants failed to meet the dietary reference intakes (DRI) for food folate, let alone meet the recommendation of 400 mcg of folic acid every day (23) . Additionally, the result s from a web based survey conducted at a southeastern university found that 78% of women had heard or read about folic acid, but 86% did not know how much to consume, 77% could not name a good food source of folic acid, and 81% did not use a multivitamin s upplement daily (24) . Furthermore, in the Central Pennsylvania Women's Health Study, researchers discovered that only 17% of women ages 18 to 24 took a folic acid containing supplement daily compared to 27% of women ag es 25 to 45 (25) . Data from these studies suggest an urgent need for folic acid education and interventions among younger women , especially considering that this age group accounts for appro ximately one third of US births (20) . Impact of Education and Text Messaging Educational interventions such as health related presentations and text messaging programs show promising results for increasing knowledge and health behaviors. A study specifically looking at folic acid awareness in female college students found that almost 88% of participants were not aware of the role of folic acid in NTD risk reduction ; h owever, after a lecture on the subject, 8 2.9% thought they would use folic acid before becoming pregnant, and 98.6% said they would relay the message to others. These data suggest that folic acid education has the potential to increase awareness and intake of folic acid in college age women (26) . Additionally, in another research study, pharmacy students and faculty at an Ohio university developed a health promotion program that included an oral presentation and email reminder messages about folic acid. Significan t increases in folic acid knowledge and self report s of

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! ! GRUSPE 11 ! ! ! multivitamin intake were detected in this study (27) . Furthermore, in another study of college age women, educational messages about folic acid were tailor ed to the stage of change of individual participants, and folic acid intake from a multivitamin increased significantly com pared to those who did not receive tailored education (28) . Text messaging has become a common method of communication, especially in younger adults, and studies have shown that text messaging programs can be utilized to increase positive health behaviors. Initial results from the Stop My Smoking USA study , a text messaging based program for young adults, provided evidence for positive short term effects on health behaviors for participants who were randomized into the program (29) . Researchers evaluating the efficacy of text messaging programs on weight loss in overweight adults and reduction of screen time in children also have reported improved outcomes (30, 31) . These studies suggest that educational programs and text message reminders may be effective strategies for promoting behavior change. Impact of Providing Supplements There may be several barriers preventing women from consuming folic acid every day. One of the barriers to taking a multivitami n supplement containing folic acid could be the lack of availability of supplements at home. Increasing access to multivitamins by providing them free of charge has led to increased supplement use in pregnant women ( 32) . Similar results were reported in a study that provided multivitamin supplements to non pregnant Hispanic women ages 18 to 35 (33) . Even though supplements can be made more readily available, there may be other barriers to taking these multivitamins. For example, s ome women may perceive the supplements as unnecessary, forget to take them on a daily basis , or have unfounded beliefs ab out taking a multivitamin such as thinking that taking them leads to weight gain.

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! ! GRUSPE 12 ! ! ! Study Aims and Hypotheses No studies have evaluated the potential effectiveness of a combined approach of using text messages and/or providing a folic acid containing suppl ement to improve folate/folic acid knowledge and intake in college age women. Our research study aimed to fill this knowledge gap and appears to be the first of its kind conducted with women ages 18 to 24 who currently are not planning to become pregnant. Identifying effective strategies for improving folate/folic acid intake among college age women could have important public health implications with regard to NTD risk reduction in this population group. This study was part of a larger study whose purpose was to identify whether intervention strategies such as text messaging and/ or providing folic acid supplements are effective in enhancing folate related knowledge and improving health behaviors (i.e., increasing folate/folic acid intake) and self efficacy among college age women who currently are not planning to become pregnant. Because research has shown that this age group has the least knowledge, awareness, and intake of folic acid, it is important to determine the best methods for communicating folic a cid related health information and increasing the intake of folate/folic acid in this population. Our study randomized participants into four groups (i.e., control; text message only; supplement only; text message + supplement) , and our hypotheses initially were based on comparisons within and between these groups over time . The null hypotheses under investigation for the work reported in this thesis include the following: 1) There is no difference in knowledge or folate/folic acid intake among coll ege age women receiving folate/folic acid related text messages compared to those who do not receive these text messages.

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! ! GRUSPE 13 ! ! ! 2) There is no difference in knowledge or folate/folic acid intake among college age women receiving folic acid containing supplements compared to those who do not receive these supplements. 3) There is no difference in knowledge or folate/folic acid intake among college age women receiving both folic acid containing supplements and folate/folic acid related text messages compared to wom en only receiving folic acid containing supplements. 4) There is no difference in knowledge or folate/folic acid intake among college age women receiving both folic acid containing supplements and folate/folic acid related text messages compared to women o nly receiving folate/folic acid related text messages. 5) There is no difference in knowledge or folate/folic acid intake among college age women receiving both folic acid containing supplements and folate/folic acid related text messages compared to women who receive neither treatment (i.e., e folic acid containing supplements and folate/folic acid related text messages ) . MATERIALS AND METHODS Study Design and Participants Following IRB approval, we conducted a randomized controlled intervention study with female participants between the ages of 18 and 24 . These women were recruited mainly on the University of Florida (Gainesville, FL) campus using IRB approved advertisements. Recruitment began in November 2013 and ended in February 2014. Potential part icipants were initially screened by phone or at the study site on campus, and if all inclusion criteria were met, participants advanced to visit one (Appendix A: Initial Inclusion Criteria). At the first visit, participants were consented and enrolled into the study, and study staff confirmed participant

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! ! GRUSPE 14 ! ! ! eligibility by completing an inclusion criteria verification form with each individual (Appendix B: Inclusion Criteria Verification Form). Participants then completed a dietary recall using the National Can cer Institute's ASA24 software, a folate/folic acid knowledge quiz, a folate/folic acid self efficacy questionnaire, and a supplement intake questionnaire (Appendix C: Folate/Folic Acid Knowledge Quiz ; Appendix D: Folate/Folic Acid Self efficacy Questionna ire ; Appendix E: Supplement Intake Questionnaire). Two more ASA24s were to be completed before the second visit. During the second visit, an educational video and materials were provided, height/weight and demographic information were collected, and partic ipants completed another folate/folic acid knowledge quiz after viewing the educational video , and were sent home with a fact sheet on folate/folic acid ( Appendix F: Demographic Information; Appendix G : Folate/Folic Acid Fact Sheet). Participants were rand omized into the control group or one of three intervention groups using a block randomization scheme. Group 1: no text messages and no folic acid containing supplement (control) Group 2: receive folate/folic acid related text messages , but no folic acid co ntaining supplement Group 3: no text messages , but receive a folic acid containing supplement Group 4: receive both folate/folic acid related text messages and a folic acid containing supplement During the six week intervention period, folate/folic acid re lated text messages were sent three times per week to the text message groups. Participants who received text messages were asked to respond with a single keystroke to confirm receipt of the study text messages (Appendix H: Folate/Folic Acid Text Messages) . Participants randomized to either of the supplement groups were provided with a bottle of folic acid supplements, free of charge, with instructions to take one per day. Participants who received the folic acid supplement during the intervention period

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! ! GRUSPE 15 ! ! ! we re instructed to refrain from consuming vitamins or supplements they might have been taking prior to the study and were also told to save all unused study supplied supplements and to return them in the original container at the end of the study. Those who were not randomized into one of the folic acid supplement groups were not instructed to discontinue use of vitamins or supplements they might have been taking prior to the study. All study participants were asked to complete six more ASA24s (i.e., 3 during mid intervention period and 3 post intervention) and a supplement intake questionnaire before the third visit. At the third and final visit, participants took the folate/folic acid knowledge quiz, self efficacy questionnaire, and supplement intake questio nnaire again. Participants who had been randomized to one of the supplement group s returned their unused study supplied supplements and were informed that they could resume use of their regular multivitamin or supplements or they could begin taking a suppl ement if they wished to adopt this practice (Figure 1) . Participants received compensation for their participation in the study. ASA24 Dietary Recall The ASA24 Automated Self administered 24 hour recall tool, created by the National Cancer Institute, was used to gather data on food folate and folic acid intake among our study participants. This Web based tool is available free of charge to researchers and allows for highly efficient data collection and analysis. After completion of their first ASA24 at v isit one, participants were instructed via email and text message to complete their additional ASA24s on specific days throughout the study. If participants complied with the protocol, a total of nine dietary recalls were recorded from each

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! ! GRUSPE 16 ! ! ! individual. Participants were assigned a unique username and password to be used to log into the ASA24 site. The data gathered from the dietary recalls were available only to the researchers. Folate/Folic Acid Knowledge Quiz Participants took the folate/folic acid k nowledge quiz a total of three times throughout the study. The quiz included 14 questions covering general information about folate/folic acid , health ben e fits, public health recommendations, and food and supplement sources . Data from the quizzes were anal yzed to determine if there was an increase in folate/folic acid knowledge within and between study groups and time points and if knowledge was correlated with changes in health behaviors. Statistical Analysis SAS statistical software (Version 9.4, SAS In stitute, Inc. Cary, North Carolina) was used to analyze the data for our study . Descriptive statistics were analyzed for differences among study group participant s using Kruskal Wallis for height, weight and body mass index (BMI) , and Pearson Chi Square an d Fisher's Exact Test were used for other variables depending on the size of the category . Other tests for differences between study variables within and between study groups and time points were conducted using generalized linear mixed models (GLIMMIX procedure in SAS) . Least square means and Tukey Kr a mer adjustments were made for multiple comparisons . Bowker's Test of symmetry and Pearson Chi Square were used , respectively, to evaluate changes in supplement intake frequency over time and for differences among groups at a given time . Study variables are shown in data tables as simple means, log transformed values (quiz score, total folate, food folate, DFE folate) or square root transformed values (folic acid).

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! ! GRUSPE 17 ! ! ! Study participants had to complet e baseline and post study dietary recalls in order to be considered in ASA24 data analysis , and recalls representing extremes in energy intake (<500 kcal or >5500 kcals/day) were excluded from analysis . The folate/folic acid knowledge quiz was scored as th e number of questions correctly answered out of a total of 14 questions. The level of significance for our study was set a t p<0.05. RESULTS Study Participants One hundred eighty (180) participants were enrolled in the study, and one hundred sixty seven ( 167) participants were randomized to one of the study groups. Thirteen (13) participants were not randomized to a group because they did not meet the inclusion/exclusion criteria after consenting, withdrew from the study, or were withdrawn by the principal investigator for not following protocol. After randomization, five (5) more participants failed to complete the study, resulting in a 90% completion rate with a total of one hundred sixty two (162) participants. No significant differences were detected am ong study groups for any demographic variables except for height (Table 1) . ASA24 Dietary Recall N o significant differences were detected in total energy or food folate intake throughout the study for all participants. However, a significant increase in total folate intake (mcg) was noted from baseline to mid study (p<0.0001) for all participants . This increase was a short term effe ct and by the end of the study, total folate intake was not significantly different from the baseline value. Compared to baseline, folate intake, measured as mcg DFE/day, was significantly

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! ! GRUSPE 18 ! ! ! greater (p =0.03 ) for all participants post study . S ignificant diffe rences were detected in folic acid intake when comparing baseline to mid study (p<0.0001), mid study to post study (p < 0.0001), and baseline to post study (p=0.0 25 ) for all participants (Table 2). Intake decreased significantly from mid study to post study, but post study values were still significantly greater than baseline values. Folate/Folic Acid Knowledge Quiz Analys i s of total knowledge scores showed a significant difference in knowledge for all participants combined when comparing baseline to mid study (p<0.0001) , mid study to post study (p<0.0001) , and baseline to post study (p<0.0001) . The average knowledge score increased after the education visit and post study compared to the average baseline score for all participants combined (Table 2) . Analysis of Text Messaging and Folic Acid Supplement Interventions No significant differences were detected for any of the response variables at any time point when making comparisons within or between each of the four study groups (data not shown; p>0. 0 5). Consequently, the data were combined and comparisons were made within and between the groups not receiving text messages (Groups 1 & 3) and those receiving text message s (Groups 2 & 4) (Table 3). Similarly, the data were combined and comparisons were m ade between and within the groups not receiving the folic acid supplement ( Groups 1 & 2 ) and those receiving the folic acid supplement (Groups 3 & 4 ) (Table 4 ) . No significant differences were detected for any study variable for any time point when making comparisons within or between the text message versus no text message groups combined. Additionally, no significant

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! ! GRUSPE 19 ! ! ! differences were detected in total knowledge scores , total energy intake or food folate intake between or within supplement intake groups (i.e., Groups 1 & 2 and Groups 3 & 4). However, significant differences were detected in mean intakes of total folate (micrograms/d and mcg DFE/d) and folic acid ( mcg/d) , with intake being greater in the supplement groups (Groups 3 & 4) compared to the no supplement group s (Groups 1 & 2) mid and post study compared to baseline (Table 4 ) . Supplement Intake Analysis For all participants, there was a significant increase in frequency of supplement intake from baseline to mid study (p<0.0001) and from baseline to post study (p<0.0001), with no significant differences from mid study to post study. Data from participants in Groups 3 & 4 combined displayed a significant increase in supplement intake frequency compared to those in Groups 1 & 2 combined at mid study (p<0.0001) and post study (p<0.0001), with no significant differences at baseline (p=0.39) . In fact, post study , 83 88% of participants in the supplement groups took a supplement 4 or more days per week compared to 5% in the non supplement groups. DISCUSSION Our research suggests that some intervention strategies were associated with a significant increase in fol ate/folic acid knowledge and intake in our study population . F olate/folic acid related knowledge increased among all study participants after the education visit. Even though the knowledge score decreased towards the end of the study, it was still signific antly greater th an the baseline value. This suggest s that some folate/folic acid related information was retained

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! ! GRUSPE 20 ! ! ! among participants through the end of the study, and thus the benefits of an educational video and materials appear to have had a positive effect on folic acid/folate knowledge/awareness, at least in the short term in this population group. Our r esults suggest that provision of a folic acid containing supplement was a successful intervention among our study population as supporte d by data showing an increas e in reported intake of a folic acid containing supplement and folate/folic acid intake measured as micrograms of total folate, folic acid , and DFE . At post study, the combined supplement groups had a folic acid intake of 304 ± 26.4 mcg /d, while the combined non supplement groups had a folic acid intake of 17 9 ± 16. 2 mcg /d a y . Additionally, based on a count of supplement pills returned at the end of the study, 83 88% of participants to who m supplements were provided took a supplement an average of four or more days per week compared to only 5% in the non supplement groups . P articipants in the combined supplement groups ( Groups 3 & 4 ) reported daily intakes of folic acid that exceeded 400 mcg only during the mid inter vention period , the time frame during which the supplements were being provided to them free of charge . Ideally, a folic acid intake of about 400 mcg per day would have been maintained following the conclusion of the intervention period; however, p articipa nts were notified to stop taking the study supplement at the end of the intervention period , and study staff did not make it clear until the final visit , which occurred approximately two weeks later, that participants could take their own supplements post study. In addition, participants were informed at the same time that they were told to stop taking the supplement that they must return the study supplied supplements . Consequently, it is possible that they had not yet had time to purchase their own supply if they wished to continue taking supplements , and they may have believed that they were following the study protocol by not taking any supplements . This may explain the reduction in

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! ! GRUSPE 21 ! ! ! folic acid intake observed from mid to post study . In retrospect, resul ts might have been different if there was clearer communication with participants about taking their own supplement at the conclusion of the intervention period and information about purchasing a folic acid containing supplement (i.e., what to look for, where to purchase, etc.) . Additionally, a longer time interval between when participants were told to stop taking the study supplement and the next time their intake was assessed , which would have given them more time to make arrangements for securing their own supplement, might have produced different results . These factors should be considered in future research studies of this type. S ending folate/folic acid relate d text messages to study participants was not a n effective intervention in our study as it did not appear to impact any of the study response variables. In the health promotion program study conducted by Murphy et al . (27) , researchers found that sending reminder messages was effective in increasing knowledge and intake of folic acid, but we did not detect statistically significant differences in our data related to text messages. A lthough a t least 7 8 % of text messages sent were acknowledged with a single keystroke response from study participants , p articipants may have responded without actually reading the text messages or the text messages themselves may not have been formulated to effectively motivate folate /folic acid related intake in this study population. For example, the text messages sent to participants in our study w ere not tailored to the stage of change as they were in the study conducted by Milan and White (2 8) . In addition, differences may not have been detected because of a lack of statistical power due to a small sample size. Further research should be conducted to determine the types of messages that would successfully reach college age women who are cu rrently not planning a pregnancy.

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! ! GRUSPE 22 ! ! ! Participants had difficulty distinguishing the difference between foods that are naturally rich in folate and foods that are fortified with folic acid. A question o n the folate/folic acid knowledge quiz related to disting uishing between naturally occurring food folate and foods fortified with folic acid was found to be the most incorrectly answered question at baseline (79%) , mid study ( 50%) , and post study (88%) . Confusion about the difference between naturally occurring food folate and foods fortified with folic acid may partly account for the lack of a significant increase among study participants' food folate intake throughout the study. In addition, perhaps participants could not remember which foods were high in food folate or may not have liked these foods. Although folate/folic acid knowledge score and intake averages for all participants tended to peak at mid study and then decrease post study, some increased knowledge and intake behaviors were retained throughout the study. Our d ata suggest that folate/folic acid knowledge and health behaviors increase d relatively quickly after interventions such as provision of educational material s and/ or a folic acid containing supplement, but because the intervention period for this study lasted only six weeks, the long term effects are un known. Long term studies on the effects of text messaging and the provision of a supplement on folate/folic a cid knowledge, awareness , and intake in college age women could help further elucidate the most effective ways to reach this target population and decrease the risk of NTD affected pregnancies. LIMITATIONS One of the potential limitations of this study was a sample size that may have precluded the detection of differences among study participants, especially with regard to the groups who received folate/folic acid related text messages. Furthermore , we were unable to determine

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! ! GRUSPE 23 ! ! ! whether participants actual ly read the folate/folic acid related text messages or simply responded with a single keystroke without reading them. Also, we should have clearly explained to participants who received study supplied supplements that they could begin taking their own supp lements immediately following the intervention period if they wished. Participants may not have understood this key point until after we notified them at their final study visit , which occurred after completing the last set of three day 24 hour recalls . Fu ture studies using similar intervention strategies should take these factors into account. CONCLUSION Women between the ages of 18 and 24 have the least knowledge, awareness, and intake of folate/folic acid and many are not meeting the recommended intake s for women of reproductive potential, thereby increasing their risk for a NTD affected pregnancy should pregnancy occur. Data from this study suggest that provision of both educational materials (i.e., video and folate/folic acid fact sheet) and a supply of folic acid containing supplements are effective intervention strategies for increasing folic acid knowledge, awareness , and intake in college age women who currently are not planning to becom e pregnant. Although providing folate/folic acid related text messages did not produce any statistically significant results, this intervention strategy could be investigated in future research studies as research on other health behaviors have found it t o be a succe ssful intervention.

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! ! GRUSPE 24 ! ! ! LITERATURE CITED 1. Chan Y, Bailey R, O'Connor DL. Folate. Advances in Nutrition (Bethesda, Md.) . 2013;4(1):123 125. doi: 10.3945/an.112.003392. 2. Zeller JL, Burke AE, Glass RM. Folic acid. JAMA: The Journal of the American Medical Association . 2006;296(22):2758 2758. doi: 10.1001/jama.296.22.2758. 3. Institute of Medicine. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC : The National Academies Press; 1998:196. 4. Toriello HV, Professional Practice Guidelines, Professional Practice and Guidelines Committee,American College of Medical Genetics. Folic acid and neural tube defects. Genetics in Medicine : Official Journal of the American College of Medical Genetics . 2005;7(4):283 284. doi: 10.1097/00125817 200504000 00009. 5. Hasenau SM, Covington C. Neural tube defects: prevention and folic acid. MCN, The American Journal of Maternal/Child Nursing . 2002;27(2):87 91. doi: 10.1 097/00005721 200203000 00006. 6. Pitkin RM. Folate and neural tube defects. Am J Clin Nutr . 2007;85(1):285S 288S. 7. Botto LD, Moore CA, Khoury MJ, Erickson JD. Neural tube defects. N Engl J Med . 1999;341(20):1509 1519. doi: 10.1056/NEJM199911113412006.

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! ! GRUSPE 25 ! ! ! 8. Eskes TK. From anemia to spina bifida the story of folic acid. A tribute to Professor Richard Smithells. Eur J Obstet Gynecol Reprod Biol . 2000;90(2):119 123. doi: 10.1016/S0301 2115(00)00257 8. 9. Czeizel AE, Dud‡s I. Prevention of the first occurrence of neural tube defects by periconceptional vitamin supplementation. N Engl J Med . 1992;327(26):1832 1835. doi: 10.1056/NEJM199212243272602. 10. Berry RJ, Li Z, Li S, et al. Prevention of neural tube defects with folic acid in China. N Engl J Med . 1999;341 (20):1485 1490. doi: 10.1056/NEJM199911113412001. 11. Chen G, Song X, Ji Y, et al. Prevention of NTDs with periconceptional multivitamin supplementation containing folic acid in China. Birth Defects Research.Part A, Clinical and Molecular Teratology . 2008; 82(8):592 596. doi: 10.1002/bdra.20471. 12. Bower C, Stanley F. Dietary folate as a risk factor for neural tube defects evidence from a case control study in western Australia. Med J Aust . 1989;150(11):613 613. 13. Mills J, Rhoads G, Simpson J, et al. The absence of a relation between the periconceptional use of vitamins and neural tube defects. N Engl J Med . 1989;321(7):430 435. 14. Milunsky A, Jick H, Jick S, et al. Multivitamin folic acid supplementation in ea rly pregnancy reduces the prevalence of neural tube defects. JAMA Journal of the American Medical Association . 1989;262(20):2847 2852.

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! ! GRUSPE 26 ! ! ! 15. Mulinare J. Epidemiologic associations of multivitamin supplementation and occurrence of neural tube defects. Ann N Y Acad Sci . 1993;678(1 Maternal Nutr):130 136. doi: 10.1111/j.1749 6632.1993.tb26115.x. 16. Werler M, Shapiro S, Mitchell A. Periconceptional folic acid exposure and risk of occurrent neural tube defects. JAMA Journal of the American Medical Association . 19 93;269(10):1257 1261. 17. Shaw GM, Schaffer D, Velie EM, Morland K, Harris JA. Periconceptional vitamin use, dietary folate, and the occurrence of neural tube defects. Epidemiology . 1995;6(3):219 226. doi: 10.1097/00001648 199505000 00005. 18. Stevenson RE , Allen WP, Pai GS, et al. Decline in prevalence of neural tube defects in a high risk region of the United States. Pediatrics . 2000;106(4):677 683. doi: 10.1542/peds.106.4.677. 19. Centers for Disease Control and Prevention. Spina Bifida and Anencephaly B efore and After Folic Acid Mandate --United States, 1995 -1996 and 1999 -2000. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5317a3.htm . Updated 2004. Accessed 9/19, 2014. 20. Centers for Disease Control and Prevention. Use of Supplements Containing Folic Acid Among Women of Childbearing Age --United States, 2007. http://www.cdc.gov/mmwr/preview /mmwrhtml/mm5701a3.htm . Updated 2008. Accessed 8/16, 2014.

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! ! GRUSPE 27 ! ! ! 21. Hilton JJ. Folic acid intake of young women. Journal of Obstetric, Gynecologic, & Neonatal Nursing . 2002;31(2):172 177. doi: 10.1111/j.1552 6909.2002.tb00037.x. 22. Stahlhut LM, Fernando PE. Th e impact of characteristics and knowledge on folic acid consumption among college aged women. J Am Diet Assoc . 2004;104, Supplement 2(0):62. doi: http://dx.doi.org.lp. hscl.ufl.edu/10.1016/j.jada.2004.05.188 . 23. Reilly RA, Burke JD, Lofgren IE, Morrell JS. Dietary folate consumption in college age women. J Am Diet Assoc . 2009;109(9, Supplement):A75. doi: http://dx.doi.org.lp.hscl.ufl.edu/10.1016/j.jada.2009.06.242 . 24. Hutcheon DA, Haque RS. Folic acid awareness, knowledge, and intake in never married, non pregnant college women ages 18 to 24. J Am Diet Assoc . 2010;110(9):A56 A56. do i: 10.1016/j.jada.2010.06.204. 25. Evans L, Weisman CS. Folic acid supplementation in younger and older nonpregnant women of reproductive age: findings from the Central Pennsylvania Women's Health Study (CePAWHS). Women's Health Issues : Official Publicati on of the Jacobs Institute of Women's Health . 2010;20(1):50 57. doi: 10.1016/j.whi.2009.10.001. 26. Kari J, Bardisi E, Baitalmal R, Ageely G. Folic acid awareness among female college students neural tube defects prevention. Saudi Med J . 2008;29(12):1749 1 751. 27. Murphy BL, DiPietro NA, Kier KL. Knowledge and use of folic acid among college women: a pilot health promotion program led by pharmacy students and faculty. Pharmacy Practice (Internet) . 2010;8(4):220 225. doi: 10.4321/S1886 36552010000400003.

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! ! GRUSPE 28 ! ! ! 28. Milan JE, White AA. Impact of a stage tailored, web based intervention on folic acid containing multivitamin use by college women. Am J Health Promot . 2010;24(6):388 395. doi: 10.4278/ajhp.071231143. 29. Ybarra ML, Holtrop JS, Prescott TL, Rahbar MH, S trong D. Pilot RCT results of stop my smoking USA: a text messaging based smoking cessation program for young adults. Nicotine & Tobacco Research : Official Journal of the Society for Research on Nicotine and Tobacco . 2013;15(8):1388 1399. doi: 10.1093/ntr /nts339. 30. Patrick K, Raab F, Adams MA, et al. A text message based intervention for weight loss: randomized controlled trial. Journal of Medical Internet Research . 2009;11(1):e1. doi: 10.2196/jmir.1100. 31. Shapiro JR, Bauer S, Hamer RM, Kordy H, Ward D , Bulik CM. Use of text messaging for monitoring sugar sweetened beverages, physical activity, and screen time in children: a pilot study. Journal of Nutrition Education and Behavior . 2008;40(6):385 391. doi: 10.1016/j.jneb.2007.09.014. 32. Seck BC, Jackso n RT. Providing iron/folic acid tablets free of charge improves compliance in pregnant women in Senegal. Trans R Soc Trop Med Hyg . 2009;103(5):485 492. doi: 10.1016/j.trstmh.2008.11.022. 33. Thomas KB, Hauser K, Rodriguez NY, Quinn GP. Folic acid promotion for Hispanic women in Florida: a vitamin diary study. Health Educ J . 2010;69(3):344 352. doi: 10.1177/0017896910364833.

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! ! GRUSPE 29 ! ! ! SUPPORTING FIGURES/TABLES Figure 1: Research Study Design Pre Intervention Period Intervention Period (6 weeks) Groups 2 and 4 : send three text messages per week. Groups 3 and 4 : receive folic acid supplements and are instructed to take one supplement per day. Week s 3 4: ASA24 x 3 and Supplement Intake Questionnaire After Week 6: ASA24 x 3 Post Intervention Period Initial Screening Receive phone call from interested participant; initial screening inclusion/exclusion criter ia; If OK to participate, set consent visit date Consent Visit (Visit #1) Informed consent: I f consent provided , collect SSN for payment; folate/folic acid knowledge quiz; folate/folic acid self efficacy questionnaire; supplement intake questionnaire; ASA24; set education visit E ducation Visit (Visit #2) Receive folate/folic acid education (video & handout) ; folate/folic acid knowledge quiz; demographic questionnaire; measure height and weight; randomization; folate/folic acid fact sheet; supply folic acid containing supplement (if randomized to those study groups) Group 1 Control: No supplement and no text message Group 2 Folate/folic acid text message and no supplement Group 3 Folic acid containing supplement and no text message Group 4 Folic acid containing supplement and folate/folic acid text message Final Visit (Visit #3) Folate/folic acid knowledge quiz; folate/folic acid self efficacy questionnaire; supplement intake questionnaire; return used/unused supplement bottles ASA24 x 2

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! ! GRUSPE 30 ! ! ! Table 1: Participant Descriptive Statistics Descriptor All Participants (n=162) Group 1 Control (n=41) Group 2 Text Message (n=38) Group 3 Supplement (n=42) Group 4 Text Message + Supplement (n=41) P value Age, years (mean " SD) 20.4 " 1.4 20.5 " 1. 3 20.3 " 1. 4 20.4 " 1.4 20.3 " 1.4 0.95 Age group, n (%) 0.20 18 12 (7.4%) 0 (0.0%) 5 (13.2%) 1 (2.4%) 6 (14.6%) 19 31 (19.1%) 10 (24.4%) 4 (10.5%) 12 (28.6%) 5 (12.2%) 20 48 (29.6%) 13 (31.7%) 15 (39.5%) 11 (26.2%) 9 (22.0%) 21 42 (25.9%) 10 (24.4%) 6 (15.8%) 11 (26.2%) 15 (36.6%) 22 18 (11.1%) 4 (9.8%) 6 (15.8%) 4 (9.5%) 4 (9.8%) 23 7 (4.3%) 3 (7.3%) 1 (2.6%) 1 (2.4%) 2 (4.9%) 24 3 (1.9%) 1 (2.4%) 1 (2.6%) 1 (2.4%) 0 (0.0%) 25 1 1 (0.6%) 0 (0.0%) 0 (0.0%) 1 (2.4%) 0 (0.0%) Race, n (%) 2,3 American Indian or Alaska Native 1 (0.6%) 1 (2.4%) 0 (0.0%) 0 (0.0%) 0 (0.0%) -Asian 36 (22.2%) 11 (26.8%) 7 (18.4%) 6 (14.3%) 12 (29.3%) 0.32 Black or African American 18 (11.1%) 3 (7.3%) 7 (18.4%) 7 (16.7%) 1 (2.4%) 0.053 Native Hawaiian or Other Pacific Islander 1 (0.6%) 0 (0.0%) 0 (0.0%) 1 (2.4%) 0 (0.0%) -White 119 (73.5%) 31 (75.6%) 24 (63.2%) 35 (83.3%) 29 (70.7%) 0.22 Hispanic or Latino, n (%) 3 33 (20.5%) 8 (19.5%) 9 (24.3%) 9 (21.4%) 7 (17.1%) 0.88 Highest grade completed, n (%) 0.74 High School or GED 17 (10.5%) 4 (9.8%) 5 (13.2%) 4 (9.5%) 4 (9.8%) Some College 123 (75.9%) 31 (75.6%) 28 (73.7%) 35 (83.3%) 29 (70.7%) Undergraduate Degree 21 (13.0%) 6 (14.6%) 4 (10.5%) 3 (7.1%) 8 (19.5%) Graduate/Professional Degree 1 (0.6%) 0 (0.0%) 1 (2.6%) 0 (0.0%) 0 (0.0%)

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! ! GRUSPE 31 ! ! ! Table 1: Participant Descriptive Statistics (continued) Descriptor All Participants (n=162) Group 1 Control (n=41) Group 2 Text Message (n=38) Group 3 Supplement (n=42) Group 4 Text Message + Supplement (n=41) P value Have taken a nutrition course for high school or college credit, n (%) 55 (34.0%) 10 (24.4%) 19 (50.0%) 14 (33.3%) 12 (29.3%) 0.092 Level of daily activity, n (%) 0.63 Sedentary 28 (17.3%) 8 (19.5%) 7 (18.4%) 6 (14.3%) 7 (17.1%) Low active 77 (47.5%) 23 (56.1%) 16 (42.1%) 19 (45.2%) 19 (46.3%) Active 54 (33.3%) 9 (22.0%) 15 (39.5%) 17 (40.5%) 13 (31.7%) Very active 3 (1.9%) 1 (2.4%) 0 (0.0%) 0 (0.0%) 2 (4.9%) Height, cm (mean " SD) 163.6 " 6 . 2 164.9 " 6 . 0 ab 161.3 " 6 . 4 b 165.1 " 5 . 7 a 163.1 " 6 . 6 ab 0.019 Weight, kg (mean " SD) 59.0 " 9 . 5 57.7 " 8 . 7 59.5 " 10 . 0 60.1 " 9 . 8 58.8 " 9 . 7 0.69 BMI, kg/m 2 (mean " SD) 22.1 " 3 . 4 21.2 " 2 . 8 22.9 " 3 . 9 22.1 " 3 . 3 22.1 " 3 . 5 0.18 BMI categories, kg/m 2 , n (%) 0.15 <18.5 17 (10.5%) 7 (17.1%) 5 (13.2%) 3 (7.1%) 2 (4.9%) 18.5 24.9 115 (71.0%) 28 (68.3%) 21 (55.3%) 33 (78.6%) 33 (80.5%) 25.0 29.9 24 (14.8%) 6 (14.6%) 10 (26.3%) 4 (9.5%) 4 (9.8%) ! 30 6 (3.7%) 0 (0.0%) 2 (5.3%) 2 (4.8%) 2 (4.9%) Footnotes 1. One study participant was 24 when consented, but turned 25 prior to completing the demographic questionnaire. 2. Study participants could have selected more than one category; therefore, percentages may not add to 100. 3. Study participants were not required to provide this information and some chose not to answer. Data are for all randomized participants. Differences among groups for mean a ge, height, weight, and BMI evaluated using Kruskal Wallis. Fisher's Exact Test was used to evaluate differences among study groups for Black or African American race, highest grade com pleted, level of daily activity, and BMI categories. No test was perfor med for American Indian or Alaska Native or Native Hawaiian or Other Pacific Islander race categories since there was only one participant in each of these categories.

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! ! GRUSPE 32 ! ! ! Pearson Chi Square was used for all other variables. Values within a row with no supersc ript or superscripts that have the same letter are not significantly different. Abbreviations: BMI, body mass index; cm, centimeters; kg, kilograms; m, meters; SD, standard deviation.

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! ! GRUSPE 33 ! ! ! Table 2 : Temporal Changes for All Participants All Participants (mean ± SE ) Baseline Mid Study (i.e., Post Education 1 ) Post Study Folate/Folic Acid Knowledge Quiz Score (out of 14) 8.0 " 0.1 a 12.8 " 0.1 b 11.0 " 0.1 c Energy, Folate/Folic Acid Intake Energy, kcal 1647 " 39.8 1614 " 45.4 1577 " 42.0 Total folate, µ g 396 " 14.9 a 562 " 28.1 b 432 " 17.1 a Folic acid, µ g 192 " 11.8 a 362 " 25.1 b 242 " 16.3 c Food folate, µ g 204 " 8.0 201 " 11.2 189 " 7.2 Total folate, DFE 535 " 23.0 a 870 " 49.3 b 628 " 31.5 c Footnotes 1 Folate/folic acid knowledge quiz results represent post education, but pre intervention scores. All other values were obtained at the mid point of the 6 week intervention period. Values within a row with no superscripts or superscripts that have the same l etter are not significantly different. Simple means are presented. Transformed data were used in the comparative analysis. Abbreviations: DFE, dietary folate equivalents; SE, standard error.

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! ! GRUSPE 34 ! ! ! Table 3 : Group Evaluation Ð No Text Message versus Text Message (Groups 1 and 3 versus Groups 2 and 4) No Text Message (Groups 1+3; mean ± SE) Text Message (Groups 2+4; mean ± SE) P Values Comparing Groups (1 & 3 vs. 2 & 4) Baseline Mid Study (i.e., Post Education 1 ) Post Study Baseline Mid Study (i.e., Post Education 1 ) Post Study Baseline Mid Study (i.e., Post Education 1 ) Post Study Folate/Folic Acid Knowledge Quiz Score (out of 14) 8.0 " 0. 2 12.9 " 0.1 11.0 " 0. 2 8.0 " 0.2 12.7 " 0.1 11.1 " 0. 2 NS NS NS Energy, Folate/Folic Acid Intake Energy, kcal 1588 " 51.5 1543 " 54.5 1511 " 59.3 1709 " 60.7 1686 " 72.2 1646 " 58.9 NS NS NS Total folate, µ g 383 " 17.9 520 " 37.1 412 " 24.9 410 " 24.1 605 " 42.0 452 " 23.4 NS NS NS Folic acid, µ g 169 " 13.6 320 " 32.6 217 " 24.2 216 " 19.1 403 " 37.9 269 " 21.4 NS NS NS Food folate, µ g 214 " 11.2 199 " 13.4 195 " 11.5 193 " 11.5 202 " 17.9 184 " 8.6 NS NS NS Total folate, DFE 503 " 26.2 794 " 65.7 585 " 46.4 567 " 37.9 946 " 72.8 673 " 42.2 NS NS NS Footnotes 1 Folate/folic acid knowledge quiz results represent post education, but pre intervention scores. All other values were obtained at the mid point of the 6 week intervention period. Values within a row with no superscript or the same superscript are not significantly different from one another. Simple means are presented. Transformed data were used in the comparative analysis. Abbreviations: DFE, dietary folate equivalents; NS, not statistically significant; SE, standard error.

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! ! GRUSPE 35 ! ! ! Table 4 : Group Evaluation Ð No Supplement versus Supplement (Groups 1 and 2 versus Groups 3 and 4) No Supplement (Groups 1+2; mean ± SE) Supplement (Groups 3+4; mean ± SE) P Values Comparing Groups (1 & 2 vs. 3 & 4) Baseline Mid Study (i.e., Post Education 1 ) Post Study Baseline Mid Study (i.e., Post Education 1 ) Post Study Baseline Mid Study (i.e., Post Education 1 ) Post Study Folate/Folic Acid Knowledge Quiz Score (out of 14) 8.0 " 0. 2 12.8 " 0.1 1 0 .7 " 0. 2 8.0 " 0. 2 12.8 " 0.1 11.3 " 0. 2 NS NS NS Energy, Folate/Folic Acid Intake Energy, kcal 1646 " 61 . 7 1592 " 70 . 3 1531 " 59 . 9 1649 " 51 . 2 1636 " 57 . 9 1622 " 58 . 9 NS NS NS Total folate, µ g 412 " 22.6 405 " 35.3 376 " 20.3 381 " 19.6 a 720 " 35.5 b 486 " 26.2 c NS <0.0001 0.0006 Folic acid, µ g 205 " 17.2 199 " 28.2 179 " 16.2 180 " 16.0 a 525 " 31.8 b 304 " 26.4 c NS <0.0001 <0.0001 Food folate, µ g 207 " 12.9 207 " 19.5 197 " 11.0 200 " 9.7 195 " 11.0 182 " 9.3 NS NS NS Total folate, DFE 558 " 33.7 550 " 54.0 509 " 32.8 512 " 31.2 a 1189 " 63.4 b 745 " 50.3 c NS <0.0001 <0.0001 Footnotes 1 Folate/folic acid knowledge quiz results represent post education, but pre intervention scores. All other values were obtained at the mid point of the 6 week intervention period. Values within a row with no superscript or the same superscript are not significantly different from one another. Simple means are presented. Transformed data were used in the comparative analysis. Abbreviations: DFE, dietary folate equivalents; NS, not statistically significant; SE, standard error.

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! ! GRUSPE 36 ! ! ! APPENDIX A Initial Inclusion Criteria To participate you must: • Be a healthy women 18 24 years of age at recruitment with no diagnosed chronic disease such as diabetes, heart disease, cancer, or serious gastrointestinal diseases or conditions including but not limited to celiac disease/gluten intolerance or inflammatory bowel disease (IBD) • Have a mobile phone with unlimited text messaging capability • Have Internet access at home or a convenient location • Be available to participate in the study through the end of the spring 2014 semester • Take a multivitamin/mineral or other vitamin supplement less than 3 times per week; this means you never or rarely take m ultivitamin/mineral or other vitamin supplement or only take it once or twice a week • Not be taking a supplement based on a doctor's prescription or order • Be willing to take a vitamin supplement daily for 6 weeks and discontinue the use of any multivitamin or supplement you currently take if you are randomized to a group that gets a folic acid containing supplement • Be able to read and understand English • Currently not be participating in any other research study • Not have participated in other folate/folic ac id research studies conducted in the past 5 years • Not be known to be pregnant and have no intention of becoming pregnant within the next 6 months • Not be a current or former student, faculty, or staff member of the Food Science and Human Nutrition Department, at the University of Florida

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! ! GRUSPE 37 ! ! ! APPENDIX B ! ! ! ! ! !"#$%&'(")*+#$%&'(",-.'/0.'1,20.'3'#1/'(",4(.5 , , "#$!%&'!(!)'##$*+!&#!,&#-$#!.+'/$*+0.+(,,!1*!+2$!3&&/! 4)1$*)$!(*/!5'-(*!6'+#1+1&*!7$8(#+-$*+9 ! !!!!!! :;;;;;;;!!!!6;;;;;;; ! "#$!%&'!/1(<*&.$/!=1+2!(!)2#&*1)!/1.$(.$! .')2!(.!/1(>$+$.?! 2$(#+!/1.$(.$?!)(*)$#?!&#!.$#1&'.!<(.+#&1*+$.+1*(@!/1.$(.$.! &#!)&*/1+1&*.!1*)@'/1*'+!*&+!@1-1+$/!+&!)$@1()! /1.$(.$0<@'+$*!1*+&@$#(*)$!&#!1*,@(--(+&#%!>&=$@!/1.$(.$! ABC7D9 ! ! ! !!!!!! :;;;;;;;!!!!6;;;;;;; ! "#$!%&'!+(E1*(.$/! &*!(!/&)+&#F.! 8#$.)#18+1&*!&#!&#/$#9 ! !!!!!! :;;;;;;;!!!!6;;;;;;; ! "#$!%&'!)'##$*+@%!8(#+1)18(+1*$!8#$<*(*+9 ! !!!!!! :;;;;;;;!!!!6;;;;;;; ! B,!%&'!(#$!*&+!E*&=*!+&!>$!8#$<*(*+?!/&!%&'!1*+$*/!+&! >$)&-$!8#$<*(*+!=1+21*!+2$!*$H+!I!-&*+2.9 ! !!!!!! :;;;;;;;!!!!6;;;;;;; ! , !3,1"6,(3,/70,18(90,:%0&/'("&,1.0,1"&;0.0<, =>0&?@,'"3(.5,/70,A.(&A0#/'90, A1./'#'A1"/,/71/,/706,<(,"(/,:%1$'36,1"<,/71"B,/705,3(.,/70'.,/'50C , , "#$!%&'!,$-(@$9 ! !!!!!! :;;;;;;;!!!!6;;;;;;; ! "#$!%&'!>$+=$$*!+2$!(<$.!&,!JK!(*/!LM9 ! !!!!!! :;;;;;;;!!!!6;;;;;;; ! "#$!%&'!1*!<&&/!2$(@+29 ! !!!!!! :;;;;;;;!!!!6;;;;;;; ! 7&!%&'!&=*!(!)$@@!82&*$!(*/!2(G$!())$..!+&!'*@1-1+$/! +$H+1*<9 ! !!!!!! :;;;;;;;!!!!6;;;;;;; ! "#$!%&'!(G(1@(>@$!+2#&'<2!+2$!$*/!&,!+2$!.8#1*%!;;;;;;;;;;;;;;;;;;;;;;;;;; ! ! P1-$07(+$!;;;;;;;;;;;;;;;;;;;;;;;;;;;;; !

PAGE 38

! ! GRUSPE 38 ! ! ! !"#$%#&%#'()"!*'&"#+ ( ! "#$%&'&()*! ,-%./(&0(*))(1"2%.(*3%(4*35%6(7-89: ! +() ! ,! ! ! ! ! !

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׽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

PAGE 44

! ! GRUSPE 44 ! ! ! ! """ ! ! #$!%&'()*)(!+',%$! ! """!./0'+ ! 1#$/'2!30'!* $44$5)-6!78'%/)$-!5)44!,&&',+!$-!/0)%!78'%/)$--,)+'!$-49!50'-!)/!)%!%'-/!/$! &,+/)()&,-/%!:); < %/8;9=> ! ! ?+'!9$8!(8++'-/49!@-$5-!/$!A'!&+'6-,-/B ! ! """""!C'% ! """""!#$ ! !

PAGE 45

! ! GRUSPE 45 ! ! ! APPENDIX F Demographic Information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

PAGE 46

! ! GRUSPE 46 ! ! ! !"#$% &&&&&&&&&&&&&&& '#()* +,,-)./"#,-% &&&&&&&&&&&&&&&&&&&&&& '#()* 0 &&&&&&&&&&&&&&&& !"# #"$%& '"$ (%)**+,' '"$%./.% ", &)+%' )(0+/+0'1 &&&&& '$)$/#"-* 1 #*2.3"4 )".4* 4.5./6 "3#.5.#.$7 8$969: ;,(7$;,4) #"7<7: ="4<./6 #, #;$ >(7? &&&&& @,= "3#.5$ 1 #*2.3"4 )".4* 4.5./6 "3#.5.#.$7 A@B' CD #, ED F./(#$7 ,G )".4* F,)$-"#$ "3#.5.#* 8$969: ="4<./6 "# H #, I "/)7: 34.27 ,,#;$#;./67 =,-/ ./ #;$ ;".#;"# =,(4) >$ ./ #;$ ="* ,G #"<./6 #;$ F$"7(-$F$/#9 OG #;$ 2"-#.3.2"/# ;"7 ;$;"../ " >(/ ,,#;$7#*4$ #;"# ./#$-G$-$7 =.#; -$7#./6 #;$ ;$")>,"-) ,/ #,2 ,G ;$;$"): "7< .G 7;$ =,(4) F./) ")P(7#./6 ;$;".-7#*4$ G,#;$ F$"7(-$F$/#9 OG .# .7 /,# 2,77.>4$ #, F"<$ ")P(7#F$/#7: F"<$ " /,#$ ,G #;.7 #, #;$ -.6;# "/) "##$F2# #, -$73;$)(4$ " 5.7.# #, 6$# #;$ ;$.6;# "# "/,#;$#.F$9 O/G,-F #;$ 2"-#.3.2"/# #, 7#"/) =.#; ;$>"3< "/) ;$$47 "6"./7# #;$ ="44 #, =;.3; #;$ 7#").,F$#$.7 F,(/#$)9 Q"5$ #;$ 2"-#.3.2"/# 4,,< 7#-".6;# ";$") 7, ;$3;./ .7 2"-"44$4 #, #;$ G4,,-9 R$44 #;$ 2"-#.3.2"/# #, #"<$ " )$$2 >-$"#; "/) $S;"4$9 R"<$ F$"7(-$F$/# #, #;$ /$"-$7# D9M 3F "/) -$3,-)9 @$# #;$ 2"-#.3.2"/# -$4"S "/) ./G,-F ;$#;"# *,( =.44 -$2$"# #;$ F$"7(-$F$/#9 R$44 #;$ 2"-#.3.2"/# #, #"<$ " )$$2 >-$"#; "/) $S;"4$9 R"<$ F$"7(-$F$/# #, #;$ /$"-$7# D9M 3F "/) -$3,-)9 T"<$ 7(-$ #;$ #=, F$"7(-$F$/#7 "-$ =.#;./ UJ D9H 3F "/) -$3,-) #;$ "5$-"6$9 OG #;$ F$"7(-$F$/#7 ).GG$>* F,-$ #;"/ D9H 3F: ,>#"./ " #;.-) F$"7(-$F$/#: -$3,-) .#: "5$-"6$ #;$ #=, F$"7(-$7 #;"# "-$ =.#;./ D9H 3F ,G $"3; ,#;$"/) -$3,-) .# ./ #;$ 72"3$ 2-,5.)$)9 O/).3"#$ =;.3; #=, F$"7(-$F$/#7 =$-$ (7$) #, ,>#"./ #;$ "5$-"6$9 4+-*0 5.)*$-.5.607 888 888 8889 888 (5 :.("6& 5.)*$-.5.607 888 888 8889 888 (5 ;3+-& 5.)*$-.5.60 <+, 6..&.&=7 888 888 8889 888 (5 >/.-)2.7 888 888 8889 888 (5 >/.-)2. ?)*.& "6 #3+(3 ", 03. )?"/. 5.)*$-.5.60*1 8888 )6& 8888 @"0.*7

PAGE 47

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

PAGE 48

! ! GRUSPE 48 ! ! ! APPENDIX G Folate/Folic Acid Fact Sheet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

PAGE 49

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

PAGE 50

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