Monday, 18 May 2009

Folic acid in bread: mass medication or sensible health measure?

There's been quite a bit in the media on this matter over the last few years, and it seems to be coming up again. Here's a snippet from a Herald on Sunday article:
In four months, bakers will be forced to begin putting a synthetic form of folic acid into almost every loaf made in New Zealand.

...The plan aims to reduce the number of brain-damaged babies, although the fall may be a few as four a year.

But new research shows folic acid may cause an increase in colon cancer cases. And another study suggests it may cause colon cancer to grow faster.
This seems pretty different from mass vaccination schemes to me - it's pretty hard to opt out if it is made compulsory for bread to include folic acid, plus it's aimed at a very small proportion of the population, namely pregnant women who are not already taking an appropriate supplement. And it seems there may be some unintended consequences downstream in terms of other health issues that could be exacerbated. Oddly enough I've never heard that there is any relationship betwen folic acid intake and colon cancer in discussions about pregnant women taking it. This concern only seems to be coming up now that a wider section of the population could be at risk. Hopefully that's just because it's new research.

Dear readers I know there are many of you out there who know about sciencey things, and definitely about pregnancy health stuff. What say you; should our bread be folated or not?


anna c said...

I'm something of an absolutist when it comes to control over what goes into one's body, and I'd prefer folic acid wasn't added to bread, but surprisingly I'm not really bothered by this issue. I don't really get the mentality that private food manufacturers can effectively remove choice, universally fail to provide food which caters for certain dietary requirements of put it out of the price range of many, but the minute the government imposes a restriction on food everyone's up in arms.

What does concern me is the exceptions to the requirements (organic bread, and I think some small bakers are exempt). If I was really concerned about the effects of folic acid I would use my breadmaker all the time, and I could probably afford to buy organic bread. It's pretty obvious that many people don't have those options.

Completely impractical, I know, but I'd like to see every supermarket etc stock equivalent bread with and without folic acid at the same price - I think that's the only way people would genuinely have a choice in the matter.

Trouble said...

My (rather limited) understanding of the issue is that the evidence in support of folate being good for preventing birth defects is a whole lot stronger than the evidence in support of a link to colon cancer. This seems to be the paper in question, and to my untrained eye it's pretty equivocal about whether folate prevents or progresses colorectal cancer.

Andrei said...

Folate or vitamin b9 is found in many foodstuffs, particularly liver, and green vegetables like brocoli.

It is important in cell division, hence the implications for anemia and pregnancy but also possibly for cancer.

Folic acid is a chemical which is easily absorbed, more so than natural folates which behaves biochemically in the same manner.

The supposed adult daily requirement for dietary folates is 400 micrograms per day and also supposedly much the population doesn't achieve this although given a healthy diet it is hard to see why this should be so.

There is some evidence that women who have children with neural tube defects have low folate levels and perhaps raising the folate in their diets will reduce the incidence of these defects.

Since 1998 cereal products in the USA have by law been fortified and this supposedly has cut the incidence of babies born with neural tube defects by up to 50%. However this is far from clear cut, given the number of terminations of such babies and the changing demographics of the US.

Folic acid is not a natural product - I doubt it will harm you but by putting it in bread it removes your informed choice as to whether or not you consume it.

In my opinion it should not be added, the benefits are dubious at best and the long term risks though probably small are unknown.

Deborah said...

Hmmm.... I'm not keen on it, but then I'm not keen on additives at all, for the most part. Having said that, I'm pro fluoride-in-water, pro iodine-in-salt and pro-vaccination. And I was very careful to take folic acid leading into my each of my pregnancies and for the first trimester.

I think the difference is population wide benefits vs small subset of the population, 'though I have to think more about this.

Bottom line - I'm confused!

Paul said...

People who need folic acid should be provided with it. Those of us who do not need it should not be forced to consume it whenever we eat one of the staples of our diet. We should not be obliged to consume products that will do us no benefit and may do us harm.

Joanna said...

I'm a bit torn on this one - I would hope that all pregnant women have enough access to folic acid, but on the other hand, I don't like the idea of treating all women as being pre-pregnant. Not everyone will choose to breed, so why should they be treated as if they're baby factories?

stephen said...

"given a healthy diet it is hard to see why this should be so."

I suspect that this is the crucial point. No doubt many of the deficient people are not eating a healthy diet.

Green leafy vegetables are relatively expensive, and time "wasted" on cooking and preparation is precious. However fortifying the cheapest foods is much easier than trying to fix systemic problems with our food supply and demands for labour.

stephen said...

PS: how do people feel about iodine in salt?

Anna said...

I don't really mind public health initiatives like this one so long as the pros outweigh the cons (I'm a huge fan of fluoridated water and iodine in salt). The only problem I have is that it's very difficult for a layperson to judge the pros and cons. I tend to assume that the powers that be know what they're doing - but, then, I couldn't actually name the powers that be who make these sorts of public health recommendations.

Trouble said...

The Ministry of Health and the NZ Food Safety Authority are the powers that be - more info here.

The rationale for fortification is because so few people get the standard RDI, let alone the pregnant RDI, and because around half of pregnancies are unplanned, fortification reaches a population that would otherwise be at greater risk - you're meant to start supplementing a month before you conceive. The whole point of fortification is to catch the people who don't realise that it could be of benefit to them or their children - perhaps they don't want to spend the $10-$80 on the available supplements. It looks like it's got general benefits to the wider populace as well as the potentially pregnant. I'm happier with dragging everyone in than just targeting reproductive-age women.

Some products are already fortified - breakfast cereals, for example. Marmite's got heaps as well. If you want to avoid folic acid (not that there's any good reason to do so), it's pretty damn easy - just cut out the leafy green vegetables. Cheaper than buying organic bread by a long shot.

The best argument I've heard against fortifying bread is that bread isn't consumed in large amounts by their target audience - young women. But I'm not sure what you'd do instead.

Anna said...

That's extremely useful, Trouble. The unplanned pregnancies thing is an important one. I know you're supposed to begin taking folic acid supplements a month before you start trying to conceive - but who's that organised? Or am I just speaking for my own disorganised self here? :-)

Trouble said...

Right, my armchair research (thanks wiki) has uncovered one possible negative of taking folate supplements - an increased risk of prostate cancer when it's taken at levels roughly ten times higher than the proposed fortification.

People in general are meant to have more than 400 micrograms (but seldom do, unless they're spinach fiends), pregnant women more than 800, fortification will increase consumption on average by 140 micrograms, and the levels at which men showed an increase in prostate cancer was when they were taking supplements at greater than 1000 micrograms. It's hard enough to hit 800 with a normal healthy diet let alone 1000.

This is something health professionals have been pushing for years, and as far as I can tell, bakers are resisting it because it would be a hassle, mainly.

Trouble said...

It's something I looked into very closely when I first started trying. It took a while before we had liftoff, so I was thoroughly folated up in advance. As I understand it, the crucial neural tube development period is very early in pregnancy, before many people even know they're up the duff.

What gets on my nerves isn't so much folating up the population at large, but the way the existing supplements are marketed. Elevit pitches itself as the only supplement clinically proven to reduce neural tube defects, but all it is is folate, iron and a few other goodies, at over $80 for a three month course. Other brands of pregnancy supplements are also expensive. But you can get just as much folate for $10-$20 if you know to ask the chemist for the generic sort.

Andrei said...

Why don't you just eat liver?

A good source of both natural folates and iron and way cheaper than supplements.

A Nonny Moose said...

I'm with Joanna. This seems only targeted at half the population, and even then most of that population aren't going to be pre-, preg, or post.

Can't they just come up with a type of bread that's "folate enriched"? But then, that's getting into a affordability problem, if the other calcium/energy/panic-vitamin-du-jour enriched foods are anything to go by. Boy Milk (full cream)anyone?

Trouble said...

Andrei - one, liver is yucky. Even fried with bacon. Heaven knows how my mum got me to eat it when I was little.
two - it contains very high levels of vitamin A, which at relatively easy to consume doses causes birth defects. Liver (and pate) is on the bad list for early pregnancy because of this. Pate also has the fun extra risk of listeria.

katy said...

I also feel compelled to point out that bread is not a staple in the diet of every NZer. Apart from those who choose not to eat it, there are a good number of Kiwis for whom it isn't part of their cuisine.

Anita said...

On top of all the of issues of consent and medicalisation, there's what Michael Pollan would describe as "nutritionism" to discuss here too. Is it healthy (physically, socially, mentally, intellectually) to separate the chemical out from the foods that contain it?

There is a huge conceptual difference between eating more greens and eating bread laced with a chemical. In changes the way we think about our food, our world and our bodies.

Trouble said...

I think what it comes down to for me is that measures like compulsory fortification will give the most benefit to the worst off - women with surprise pregnancies who have diets low in green veges and high in cheap carbs like bread. Compared with the costs to them and their families of longterm disabilities like spina bifida, not to mention the costs to the health system of corrective surgery or the devastating personal impact of anencephaly, I can live with losing the luxury of the choice of being finicky about my food additives.

There might be a conceptual difference between food additives and a healthy diet to some, but the practical difference when you're buying tiptop white from Pak N Save rather than wholegrain from Commonsense Organics is that you can afford one but not the other.

Tamara said...

I recall an article in a recent paper on this that said the worrying levels were in children aged 5 to 8 or something like that. So they must a eat huge amount of bread in proportion to their size, compared to other segments of the population. And I wouldn't be surprised that the target segment are people that wouldn't necessarily eat enough of the bread to make a difference. I remember reading that point being made last time this issue was in the media.

By the way, I used folic acid supplements in advance of my 2 pregnancies (a bit slacker the second time of course!) as have many of my friends. Not to be superior, but lots of us can be that organised! We are all older and well educated and informed though, so not the target either.

I don't buy into other supplements though, I think if you are having a pregnancy that allows you to eat fairly normally any other supplements are unnecessary and doctors tend to have confirmed that.

Trouble said...

Absolutely Tamara, I'd hope that any responsible health authority would consider the impact of fortification on kids. I've found a tolerable upper limit for all ages here, and it's still pretty high. I don't remember eating 11 slices of bread a day when I was 8. 4 slices, perhaps.

There's plenty of furore in the libertarian areas of the blogosphere on this. It's not their problem if some slapper breeds in an irresponsible way, therefore why should they be penalised by being forced to eat slightly healthier food? Anyone would think the nanny state is making them eat their broccoli.