Bread fortification with folic acid, vitamin B12, and vitamin B6 in Hungary

Abstract

The recent recommendation of the US National Academy of Sciences on the daily intake of folate and folic acid, reported in Therese Droste's April 11 news item,1Droste TM US study recommends daily amounts of vitamins.Lancet. 1998; 351: 1113Summary Full Text Full Text PDF Google Scholar reinforced the Hungarian efforts for prevention of neural-tube defects and other congenital abnormalities by periconceptional folic acid/multivitamin supplementation. However, only 45% of women plan their pregnancies and a 1996 country-wide campaign found that only 12% of women used periconceptional care. A new curriculum subject, entitled “preparing for family life”, was introduced in 1997 for pupils aged 14–16, but it will be many years before educational measures have the desired impact. Food fortification seems to be the medium-term solution. In Hungary, the national basic food is bread, and the average daily intake is 200 g, thus it can deliver the necessary supplements of folic acid, vitamin B12, and B6 to the target population. Another purpose of bread fortification with these three vitamins is to attempt the reduction of vascular diseases.2Boushey CJ Beresford SAA Omenn GS Motulsky AG A quantitative assessment of plasma homocysteine as a risk factor for vascular diseases.JAMA. 1995; 274: 1049-1057Crossref PubMed Scopus (3495) Google Scholar The role of folic acid does not need explanation. Vitamin B12 is an independent risk factor for neural-tube defects and may be appropriate to neutralise the possible adverse effect of pharmacological dose (>1000 μg) of folic acid in people affected with pernicious anaemia. Vitamin B6 is also important in the prevention of homocysteine-related vascular diseases.3Rimm EB Willett WC Hu FB et al.Folate and vitamin B6 from diet and supplements in relation to risk of coronary heart disease among women.JAMA. 1998; 279: 392-393Crossref PubMed Scopus (748) Google Scholar We made two proposals for bread fortification in June, 1997. The minimum requirement was 160 μg folic acid, 0·80 μg vitamin B12, and 880 μg vitamin B6 for 100 g of flour. The proportion of flour is 75% in the bread and there is a 20% loss of these vitamins during production, therefore, the daily intake of folic acid, vitamin B12, and B6 is about 200 μg, 1 μg, and 1080 μg, respectively, in 200 g of bread. Daily intake of 200 μg folic acid results in a 41% estimated reduction in risk of neural-tube defects.4Daly S Mills JL Molloy AM et al.Minimum effective dose of folic acid for food fortification to prevent neural-tube defects.Lancet. 1997; 350: 1666-1669Summary Full Text Full Text PDF PubMed Scopus (241) Google Scholar The optimum requirement would include 330 μg folic acid, 20 μg vitamin B12, and 3000 μg vitamin B6 for 100 g of flour. Thus, in 200 g of bread, there is 400 μg folic acid, 25 μg vitamin B12, and 3600 μg vitamin B6. With the fortification of bread with 330 μg of folic acid 1–2% of the Hungarian population would exceed the tolerable upper intake level (1000 μg), however, 25 μg of vitamin B12 can protect the so-called masking effect of folic acid in patient with pernicious anaemia.5Herbert V Bigaouette J Call for endorsement of petition to the Food and Drug Administration to always add vitamin B-12 to any folate fortification or supplement.Am J Clin Nutr. 1997; 65: 572-573PubMed Google Scholar About 1% of oral dose of vitamin B12 can be absorbed via nonphysiological mass action in these patients. Thus, vitamin B12 has no toxic effect under 1000 μg. The tolerable upper intake level of vitamin B6 is 100 mg. In April 1998, the minimum requirement proposal was accepted by the authorities and the initial production of fortified bread began in August, 1998. However, we will attempt to get support from the scientific authorities to introduce at a later date the optimum requirements of the three vitamin B groups.