Starting in 1998, the U.S. Food and Drug administration mandated that all products made with enriched wheat flour be fortified with folic acid, a synthetic form of the B vitamin folate. This includes breads, pastas, breakfast cereals, and a multitude of other products. You might be able find at least one food in your own pantry that has been fortified with folic acid – try looking at the ingredients list of your bread and pasta!

Why did the FDA decide to mandate that folic acid be added to these foods? The answer is to help prevent neural tube defects, a problem that occurs with development of the brain and spinal cord when folate levels in a woman’s body are too low during early pregnancy. The most common neural tube defects are spina bifida and anencephaly [2]. Spina bifida causes defects in the spinal cord and backbone. It may range from mild to severe, and often results in lifelong disability. Anencephaly is underdevelopment of the brain and spine that is always fatal. Closure of the neural tube happens during the first month of pregnancy, when many women may not be aware that they are pregnant [3]. Fortification of grain products increases the amount of folate in many women’s diets, ensuring that they have enough folate in their bodies before becoming pregnant to prevent a neural tube defect from happening [4].

Fortification of enriched grain products with folic acid has been called one of the most significant public health achievements of the last decade [4]. Fortification has prevented between 600 and 700 cases of neural tube defects per year in the U.S. This has resulted in an annual savings of 400 to 600 million dollars in healthcare costs and the saving of hundreds of young lives [1]. This is wonderful! But does everybody get the benefit of folic acid fortification? The answer, unfortunately, is no.

According to the Spina Bifida Association, Hispanic women are 20% more likely to have a child with neural tube defects than non-Hispanic white women [2]. Many women of Hispanic origin eat corn tortillas instead of wheat products as their main source of grain and the corn masa flour made to use corn tortillas is not fortified with folic acid the way wheat products are. Hispanic women that maintain a diet that includes corn tortillas as their main staple grain generally have lower folic acid intake than those that consume primarily wheat products [4].  This is also true of women who avoid gluten, a protein in wheat, but that is for another blog.

The number of women of Hispanic origin living in the U.S. is steadily increasing, with the total population expected to reach 62 million by 2060. Many of these women are not benefitting from folic acid fortification [4]. To add to this problem, Hispanic individuals are at higher risk than people of other backgrounds for a genetic mutation of the MTHFR gene that results in reduced folate metabolism and lower levels of folate in the body [1]. This is a significant health disparity that deserves our attention.

To remedy the situation, in 2012 the March of Dimes, the American Academy of Pediatrics, and many other groups petitioned the FDA to allow corn masa flour to be fortified in the same way enriched wheat products currently are. On April 15th, 2016, the FDA voted to allow manufacturers of corn masa flour to voluntarily fortify their products with folic acid [5]. Fortification had previously been banned in the U.S. because folic acid in corn masa flour was unstable and prone to degradation. However, manufacturers developed a new production process that does not affect the amount of folic acid in the final product [2].

It has been estimated that fortification of corn masa flour will increase folic acid intake in Mexican-American women by up to 31% . Intake of folic acid in other Hispanic populations is also expected to rise significantly [4]. However, folic acid fortification of corn masa flour is voluntary, not mandatory as with enriched wheat products [5]. All those that eat corn masa flour should make sure to check ingredient labels to see if folic acid has actually been added to the product. Many plant foods contain naturally-occurring folate; especially good sources are green vegetables, lentils, beans and many fruits [6]. Sufficient daily folate may also be obtained through these foods.

Although the fortification of corn masa flour is a step in the right direction towards improving this particular nutritional disparity, it is still important to remember that many others still exist in this country. Race, country of origin, socioeconomic status, and a multitude of other factors affect an individual’s ability to access proper nutrition to a great degree. There is much more work to be done.

 

 

Written by Jenna L., Bastyr Student Intern


References

  1. Jacob JA. Twenty years after folic acid fortification, FDA ponders expansion to corn masa flour. JAMA – J Am Med Assoc. 2016;315(17):1821-1822. doi:10.1001/jama.2016.2611.
  2. Zaragovia V. Coming Soon To A Tortilla Near You: A Vitamin To Prevent Birth Defects : The Salt: NPR. National Public Radio: The Salt. https://www.npr.org/sections/thesalt/2016/04/15/474388880/coming-soon-to-a-tortilla-near-you-a-vitamin-to-prevent-birth-defects. Published 2016. Accessed April 23, 2018.
  3. Gropper S, Smith J. Advanced Nutrition and Human Metabolism. 6th ed. Australia: Cengage Learning; 2013.
  4. Hamner HC, Tinker SC. Fortification of corn masa flour with folic acid in the United States: An overview of the evidence. Ann N Y Acad Sci. 2014;1312(1):8-14. doi:10.1111/nyas.12325.
  5. FDA approves folic acid fortification of corn masa flour. US Food and Drug Administration. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm496104.htm. Published April 14, 2016. Accessed April 30, 2018.
  6. Folate. World’s Healthiest Foods. http://www.whfoods.com/genpage.php?tname=nutrient&dbid=63. Accessed June 22, 2018.

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