Folic Acid Food Fortification—Its History, Effect, Concerns, and Future Directions

Summary & key facts

Folic acid is a stable, synthetic form of the vitamin folate. Taking folic acid around the time of conception lowers the chance of neural tube birth defects (NTDs). Many countries have added folic acid to flour and other foods. These fortification programs have been linked with large drops in NTDs, but there are still questions about possible unintended effects. Ongoing monitoring is needed to measure benefit and watch for concerns.

Key facts:

• Randomized trials reported large reductions in NTD risk: one trial found a 70% lower recurrence risk with 4000 µg (micrograms) of folic acid per day, and a Hungarian trial reported prevention of first occurrences with a prenatal vitamin con
• Public health recommendations: women with a prior NTD-affected pregnancy were advised to take 4000 µg/day, while recommendations for all women of childbearing age are 400 µg/day from fortified foods or supplements in addition to diet.
• As of the review, regulations for mandatory fortification of wheat flour with folic acid existed in 53 countries, although not all had implemented those regulations.
• The U.S. mandatory program (implemented in 1998) adds 140 µg folic acid per 100 g of enriched cereal grain product and is estimated to provide about 100–200 µg of folic acid per day to women of childbearing age.
• Studies in the United States found decreases of about 19%–32% in overall NTD prevalence since fortification began in 1998.
• Other countries with mandatory fortification (Canada, South Africa, Costa Rica, Chile, Argentina, Brazil) reported NTD declines ranging from 19% to 55% after starting fortification.
• Before fortification, NTD rates varied about 10.6–17.0 cases per 10,000 live births; after fortification the range narrowed to about 6.3–10.0 cases per 10,000 live births. The review suggests a lower achievable prevalence of roughly 5–6 cas
• Folate deficiency cutoffs cited in the review are serum folate <7 nmol/L (~3 ng/mL) or red blood cell folate <315 nmol/L (~140 ng/mL). The review notes that the blood folate level tied to the maximum NTD risk reduction is unknown and may be
• Fortification does not reach all women equally. The review notes that up to 50% of pregnancies are unplanned, and education or supplement campaigns alone have not reached every high-risk group, so additional fortified foods might be needed
• The authors state that uncertainty about unintended consequences of higher folic acid intake exists (for example, questions about cancer or epigenetic effects are discussed in the literature). They emphasize the need to continually monitor

Abstract

Periconceptional intake of folic acid is known to reduce a woman's risk of having an infant affected by a neural tube birth defect (NTD). National programs to mandate fortification of food with folic acid have reduced the prevalence of NTDs worldwide. Uncertainty surrounding possible unintended consequences has led to concerns about higher folic acid intake and food fortification programs. This uncertainty emphasizes the need to continually monitor fortification programs for accurate measures of their effect and the ability to address concerns as they arise. This review highlights the history, effect, concerns, and future directions of folic acid food fortification programs.

Topics

Folate and B Vitamins Research Iron Metabolism and Disorders Phytase and its Applications

Categories

Health Sciences Medicine Rheumatology

Tags

Chemistry Environmental health Folic acid Food fortification Food science Fortification Fortified Food Internal medicine Medicine