Can we reduce birth defects?
The U.S. has created a modern Pandora's box by fortifying flour and cereal products with folic acid. This was done with good intentions but has created a problem with out a clear solution.
Folic acid is a synthetic form of the folate we get in natural foods. The foods shown above are good source of folate. The body uses folate to make vitamin B9 but in recent decades we have been eating less folate-rich natural foods. Folate deficiency results in insufficient vitamin B9. Vitamin B9 plays many roles in our body including some protection against the most common birth defect: neural tube birth defects (NTDs) such as spina bifida.
The causes of NTDs are unknown but involve a complex interaction of genetic factors and diet. (NTDs occur more often among Hispanic and Caucasians (particularly Irish descent), and on the East coast.) The best known dietary link is vitamin B9 insufficiency. Though a mother may not present any sign of B9 insufficiency, it can raise the risk of an NTD. The government looked for an answer to the NTD problem. Restoring whole foods to the diet would have been a good approach to solving the insufficiency of folate and other nutrients, but that was deemed too slow and too difficult. Folic acid offered the quickest answer so in 1998 flour and other cereal products were fortified. ("Fortify", as opposed to "enrich", means to add more than the original amount. In this case about twice as much folic acid replaced the folate removed from flour during refining.)
What was the result of fortifying flour and grain products with folic acid?
• Within a year there was a drop in NTDs, but only a 20-30% decrease, not the hoped for 50-70%. This was a form of progress, but of little comfort for the 70-80% of NTD infants still being born. Statistically, NTDs now occur at the rate of 1 in 1000—so with the 4 million annual U.S. births, there are about 4000 NTDs.
• There was a modest decline in strokes and heart attacks.
• Unfortunately there was a related increase in dementia among older people. There was also an increase in breast, prostate and colorectal cancers. Because the cancer-folic acid link is suspected but not proven, the wisdom of replacing natural folate with synthetic folic acid remains a smoldering issue.
• Finally, it was discovered that the liver clears folic acid slower than expected so a build-up of folic acid in the blood of some people has been detected. This is an unnatural development of unknown consequence.
We’ve gotten ourselves into quite a fix. The 2010 Dietary Guidelines for Americans (DGA 2010) may result in less folic acid intake (by replacing flour with whole grains) offset by more folate consumption (by adding folate-rich vegetables and legumes to our diets). This is the DGA guidance:
• Eat at least half of all grains as whole grains. (Roughly 10% of grains are eaten whole now, so this is a big change.)
• Eat a variety of vegetables, especially “dark-green veggies . . . and beans and peas”. (I have listed the foods richest in folate.)
• For women capable of becoming pregnant, continue the U.S. Public Health Service guidance to consume 400 micrograms (mcg) per day of synthetic folic acid (from fortified foods and/or supplements) in addition to food forms of folate from a varied diet.
Caution
People following the DGA 2010 will move in a healthy direction, but it's important to add the folate-rich foods as you reduce fortified flours and cereals. The DGA guidance on folic acid supplementation is difficult to apply because it requires you to estimate the folic acid in your diet and then supplement as needed. If becoming pregnant is a possibility, you should review this issue with your doctor well before conception and act accordingly.
I have tried to make this complex problem understandable, without over-simplifying. A basic understanding of the vitamin B9 issue is important, so I hope this information is helpful. Could you mothers please add to this discussion from your experience?
Friday, April 1, 2011 at 5:29PM | by Skip Hellewell | 15 Comments | 2 References | Share Article | in folate | Email Article
Reader Comments (15)
I have never heard of the folic acid vs folate problem. This is very interesting. I have 2 small boys, 9 months and 2. Thankfully they are both healthy. I guarantee I don't get enough folate, although when pregnant an nursing I take prenatal vitamins that contain folic acid I believe. But some of the side effects from folic acid are concerning. While there was good intentions, I sometimes question the government's intervention in matters like this. If they advise people to increase their folate that is a good idea and it's obviously good that they reduced the number of birth defects. But at what cost? Meaning, they don't seem to understand all the side effects. Unintended consequences...
Thanks for this write up. I intend to do more research on folate, especially if we get pregnant again.
Lisa, thank you. I was worried this post would be confusing, but you got it. It's important to get more folate in our diet, especially as we follow the DGA 2010 guidance to reduce fortified white flour in favor of whole grains. The expansion of foods with added folic acid (breakfast cereals, health bars, energy drinks, etc.) is an experiment without precedent in history. Best, Skip.
I had my son in August 2010 and my father in law an OB told me the most important thing was to get folate preconception because that is when it is more crucial. When conception occurs if there is an adequate amount of folate it is less likely that neural tube defects will occur. Most women are told to use a prenatal once they are pregnant but for some they have missed this important window.
I took synthetic folic acid 800 mg preconception and my son was born with the beginnings of spina bifida which is ntd. Luckily it is just two small indentions on his lower back and he has no subsequent problems but I definitely feel like we dodged a bullet. My husbands cousin has SB and my father in law has the same indentions that my son has with no problems. My ped checks it every time and he is fine but this was a huge scare for me. I don't eat very many refined foods and don't eat refined cereal so maybe by trying to be healthier I wasn't getting enough folic acid.. that seems like a conundrum to me??
Anyways, there seem to be a complex set of variables that go into this problem but absolutely increase your dark leafy greens and legumes and supplement with a vitamin preconception if possible and hope for the best.
Great article, I had no idea before this occurred with us just how common this is.
just want to say Thank you for sharing your thoughts and wisdom on these varied subjects. I have been leading my own discovery, but haven't had the opportunity to dedicate the time to the learning process. or the patience. I truly appreciate your efforts to share all you have researched and learned in a way we can all appreciate and understand. I love sharing your link with friends and family to illustrate points I have tried to make, but have fallen short. Thank You.
Interesting post. Just to clarify, are you suggesting that perhaps the fortification was a mistake? I am by no means trying to put words in your mouth (or on your blog!) but am just trying to understand your message. You seem to think that perhaps the benefits have not been worth the risks. At this stage, I would argue that the advantages of fortification are "proven," while the disadvantages are not. Of course, ideally it would be best if we all got our vitamins (all of them, not only folate) naturally, without supplements or fortification. However, it's not easy to get sufficient folate on a daily basis only through food. It's possible, but not easy, and I would argue probably not very realistic for even the healthiest eaters. In a broader sense, I think fortification in general (with iron, vitamin A, etc.) is a very positive thing that should be promoted for vulnerable populations.
In terms of the NTDs, I would say that another complicating factor is the cultural differences in food consumption patterns. For example, as you pointed out, Hispanics have higher rates of NTDs than many other groups in the US. This could be linked in part to the fact that many of the foods that are fortified with folic acid (such as cereals and breads) are not traditionally a part of the Hispanic diet, so that segment of the population may not be getting the full benefits of the fortification. This may be part of the reason why the drop in NTDs was not as large as had been hoped, because one of the populations with the highest incidence of NTDs was not fully partaking in the fortified foods (ie, not because the fortification was not an effective intervention).
The DGA 2010 makes recommendations for the population as a whole, but it has no way of accommodating cultural differences. I suspect that neither the fortification nor the DGA 2010 will adequately address the problem within the Hispanic population, and a culturally appropriate solution is still needed. Sorry for the long comment... it's almost as long as your post!
Sheela, thanks for taking the time to write. A couple of thoughts on your comments:
First, replacing natural foods with processed foods was the original mistake. Replacing natural folate with folic acid was a band-aid, a desperate experiment with unknown consequence. David Kessler, FDA head when folic acid was added, remembered this as his most worrisome decision. Is the net result good or bad? We don't know; I just believe there's a better solution.
Second, about the benefit being "proven". We got a short-term benefit but at the cost of deferring a better cure. We haven't really solved the NTD problem—this band-aid only reduced spina bifida 20-30%; worse, everyone relaxed thinking the problem solved. I know of no significant progress since 1998, do you? Few illnesses are the result of just one nutrient missing—-rather, they are multifactorial. There's a good chance NTDs fall in this category so we should invest in finding the other factors. Scientists are in love with a genetic solution, it's the hot science, but I suspect (for the current generation at least), the most achievable answer lies in better nutrition, etc. You're right about the issue of different food cultures.
Third, I haven't seen any work suggesting a healthy diet won't supply sufficient folate. Though the post noted foods highest in folate, it is found in a wide variety of foods. There may be a hidden benefit to getting folate in these varied natural ways.
Finally, the idea that "fortification in general is a very positive thing" makes me uneasy. Take flour: there seems to be a benefit if you compare it to eating non-fortified flour. But compared to eating whole grains, there's a mountain of studies that suggest fortification is a bad idea that will lead to more bad ideas. It's hard to improve on Mother Nature. :)
Best, Skip
When I spoke with my OB prior to becoming pregnant she told me about the importance of folic acid before becoming pregnant (as another reader pointed out) and during. However, rather than suggesting getting my folate through food, I was given a prescription for a prenatal vitamin that contained folic acid, told to drink lots of orange juice with folic acid and eat "healthy". I'm glad I got the multivitamin, but I would have liked to know the importance of getting folate (and other vitamins and minerals) naturally.
Thanks for all the great information.
Hi Skip, I fully agree that many health conditions, including NTDs, are multi-factorial and that our attempts to combat them are often myopic, lacking a comprehensive understanding of their complexity. Infertility would be another very good example of this. And of course, as I wrote earlier, it’s always advisable to get nutrients from natural sources whenever possible.
I suppose my argument in favor of fortification (not that I have a very strong opinion on this, truly) would be two-fold. One point is that there have been at least some benefits that have been “proven,” as much as anything can be proven in the field of medicine or public health, while we still lack conclusive evidence of the risks. This, in the accounting of the public health world, makes it a success, although I certainly appreciate your points about fostering complacency and missing an opportunity to promote healthy eating. Would we have been more effective in reducing NTDs if we had promoted healthful eating and invested the money in researching the causes of NTDs rather than in fortification? It’s hard to say. But this is always the dilemma of public health: how to most effectively use limited resources to achieve the largest population-level benefit. Again, within the current context, I fully agree with you that it would be better to eat fewer processed foods and more whole grains (although, as you pointed out in a previous post, there are a few boxed cereals and similarly processed foods that would count as being both fortified and a whole grain).
My second point would be that I do think fortification is a positive thing for vulnerable populations, which I meant in a global sense. For example, there are many, many places in the world where nutritional disorders such as iron deficiency anemia, vitamin A deficiency, zinc deficiency, and iodine deficiency disorders are very serious public health problems. These forms of micronutrient malnutrition, which affect literally billions of people around the world, require a multi-pronged approach. Of course, we can urge people to eat healthfully, but this is not always realistic for the food insecure, including those who are food insecure in the US. (This also goes back to my point about it not being a simple thing – possible, absolutely, but simple, not always – to get sufficient folate from food.) In many cases, fortification of staple grains and cooking oils (not to mention something as simple as adequately iodizing salt) is a very cost-effective intervention that can have a significant impact on improving nutritional status and health. So, in combination with programs to improve food security and alleviate poverty, I do think that fortification can be extremely beneficial and even necessary. Sometimes band-aids can be useful, don’t you think? Sorry again for another long comment...!
Sheela, in my youth I spent 2-1/2 years in Central America. I lived in ten villages or cities in five countries and though too young to fully appreciate the issues, saw numerous examples of the deficiencies you mention. The images have stayed with me despite the passage of time. (You could add essential protein deficiency and stomach parasites to the list.)
One thing I remember is how the people turned to Europe for cultural influence but to the U.S. for lifestyle fashions. Their dress may have been more European, but they were watching our movies, singing our songs, and starting to eat our foods. (In Guatemala there was an upscale hamburger bar called Pecos Bill; in San Salvador a donut hang-out simply called Pete's.) So the export of American foods, especially fast food, in recent years is a growing problem.
Now two threats are combined: the old poverty-based deficiencies, and U.S.-sourced malnutrition. Food fortification can help the former, even save lives, but we must reform our food supply here to influence the latter. They will follow us.
I confess to a modest goal: reform America. You cover the rest of the world, please. Best, Skip
p.s. Infertility will be a future post.
This discussion brings to mind my questions about salt. Iodized vs. noniodized vs. sea salt. What is the healthiest? I would appreciate it if you could share anything you know about it.
Also, I have questions regarding sugar, stevia and agave? Which is the most natural and beneficial?
Thanks!
Shanna, yes, there is a post on salt in the schedule. Best, Skip
I think this is a great post that effectively lays out the issues without being confusing. Tough to do for many nutritional topics. You have a gift. And a great illustration of why taking supplements or fortifying otherwise nutritionally empty food does not fully compensate for a lack of whole plant foods in the diet.
I am a mother of a child with spina bifida. I posed this folate/folic acid question to researchers at a Spina Bifida Conference a few years ago. I asked them why government policy is pushing fortification of a synthetic and not emphasizing the consumption of the real nutrient. They responded that reductions in NTDs were being seen and thus policy would stay in force. Futhermore, they said that NTDs are multi-factorial and proper diet was not effective in all cases. I also asked them about the human bodies inability to metabolize folic acid as efficiently as folate. They could not comment.
About the time of this conference, we considered getting pregnant again, I researched folic acid extensively, especially after being told I would have to take 4 mg (or 4000 mcg) daily. From my research, folate is essential for DNA/RNA synthesis and is the basis of the quick expansion from two cells to embryo to fetus. Folate is essential as the neural tube, the percursor to the spinal cord and its branches of the heart, brain, and other organs, forms in the fourth to fifth week. It is helpful to supplement before conception and before one may even consider conception has occured.
Certainly, even the Spina Bifida community falls prey to the marketing of "fortified" bars, drinks, cereals and multi-vitamins. I see ads in industry literature and cringe. Even though those products are only 10 percent or smaller of daily allowance, these products are misleading. Thats a lot of sugar and fillers to eat to get one's folic acid for the day. Especially, thanks to Skip's explanation that our bodies require folate, not folic acid to build our bodies and our children's.
Nothing can be said for dark, leafy greens and a great whole food prenatal. And I ate and took many during my pregnancy with my first child. (We later learned that her issues stem from toxin exposure. She has a rare genetic disorder that is name after my her. She is only one in the medical literature identified with this 6th chromosome deletion. It is a cluster of defects that branch off the neural tube: brain, endocrine, pituitary, heart, spine, bowel and bladder are all affected.)
Where is the list of folate rich foods? I can see a picture of artichokes ( ummm any one know how serve them to children with out dipping in butter- yes I saw the butter post and I have always been pro butter, but is there anything else/)
Also Skip that reminds me ,if you are reading this...when is the recipe part going to be enhanced????? :D I loved the echiladas campote and now will try the bread....how about a hint on making beets enjooyable to 6 yr old boys? I added orange zest but...... Need bean recieps too ( in all your spare time).
While I was out for a walk/run ( see challenge #5), The Mormon Radio had an interesting broadcast about your very cause, in fact I tuned in late and thought it was you!
Here is the link
http://radio.lds.org/programs/insights-episode-16?lang=eng
I've just been tested positive for MTHFR C677T homozygous gene mutation, which means that my body cannot process folic acid at all, and instead it just sits in my body and acts as a toxin (if you google MTHFR C677T you can find a lot more about it). This is a fairly common condition and is really important for women/mothers who have it to know about. Taking folic acid supplements during pregnancy will do nothing to protect against NTDs. There are a lot of alternative supplements to get more folate in your diet though. Just thought I'd mention it here in case anyone is concerned about taking folic acid during pregnancy and wants to know a good route to go in their research.