Mandatory Food Fortification Research Articles

Maternal use of folic acid supplements and infant risk of neural tube defects in Norway 1999-2013.

Like most European countries, Norway has refrained from mandatory food fortification with folic acid to reduce the number of neural tube defects. We explored the role of folic acid and multivitamin supplements in the prevention of neural tube defects among newborn infants. We used data from the Medical Birth Registry of Norway, 1999-2013. A total of 528,220 women had 880,568 pregnancies resulting in 896,674 live- and stillborn infants, of whom 270 had neural tube defects. Relative risks were estimated with log-binomial regression. From 1999 to 2013, intake of folic acid supplements increased from 4.8% to 27.4%. Vitamin supplement use was more frequent in older, married or cohabiting women and those with lower parity, as well as women who did not smoke during pregnancy. The overall adjusted relative risk of infant neural tube defects associated with maternal vitamin intake before pregnancy relative to no intake was 0.76 (95% confidence interval: 0.53-1.10). When we divided our study period in two (1999-2005 and 2006-2013), we found a significantly reduced risk of neural tube defects overall by vitamin use in the second time period, but not in the first: adjusted relative risk 0.54 (95% confidence interval: 0.31-0.91) and 1.02 (95% confidence interval: 0.63-1.65), respectively. OVER THE FULL STUDY PERIOD, WE FOUND NO STATISTICALLY SIGNIFICANT ASSOCIATION BETWEEN VITAMIN USE AND NEURAL TUBE DEFECTS OVERALL HOWEVER, VITAMIN USE WAS ASSOCIATED WITH A SIGNIFICANTLY LOWER RISK OF NEURAL TUBE DEFECTS IN THE SECOND HALF OF THE STUDY PERIOD, 2006-2013.

Abstract TMP86: Folic Acid Therapy Prevents Stroke in Countries Without Mandatory Folic Acid Food Fortification: A Meta-analysis of Randomized Controlled Trials

Background: Additional folic acid treatment appears to have a neutral effect on reducing vascular risk in countries that mandate fortification of food with folic acid (e.g. US and Canada). However, it is uncertain whether folic acid therapy reduces stroke risk in countries without folic acid food fortification. Objective: To comprehensively evaluate the efficacy of folic acid therapy on stroke prevention in countries without folic acid food fortification. Methods: Pubmed, EMBASE, and Clinicaltrials.gov from January 1966 to August 2015 were searched to identify relevant studies. Relative risk (RR) with 95% CI was used as a measure of the association between folic acid supplementation and risk of stroke, after pooling data across trials in a random-effects model. Results: The search identified 14 randomized controlled trials involving treatment with folic acid that had enrolled 71,334 participants, all of which stroke was reported as an outcome measure. Across all trials, folic acid therapy vs. control was associated with a lower risk of stroke (RR=0.84; 95% CI, 0.76-0.93; P=0.0007) and there was no heterogeneity among include trials (P for heterogeneity =0.27, I2=17%) (Figure). The RR of stroke in primary prevention trials was 0.81 (12 trials, 95% CI, 0.72-0.91; P=0.0006). Among 3 trials, which distinguished ischemic from hemorrhagic stroke as endpoints, folic acid therapy reduced risk of ischemic stroke (RR=0.77; 95% CI 0.67-0.90, P=0.0006), but had a neutral effect on hemorrhagic stroke (RR=0.92, 95% CI 0.66-1.28, P=0.61). Conclusion: Among people living in countries without mandatory folic acid food fortification, folic acid therapy reduces the occurrence of a stroke.

Long term trends in prevalence of neural tube defects in Europe: population based study

Study question What are the long term trends in the total (live births, fetal deaths, and terminations of pregnancy for fetal anomaly) and live birth prevalence of neural tube defects...

Vitamin A, Iron, and Zinc Content of Fortified Maize Meal and Bread at the Household Level in 4 Areas of South Africa.

A national mandatory food fortification program, fortifying wheat flour and maize meal with various micronutrients, was introduced in South Africa in 2003 to address micronutrient deficiencies. This study aimed to determine vitamin A, iron, and zinc content of raw maize meal and wheat flour bread sampled at household level from 2 urban and 2 rural areas in South Africa and to compare with the regulatory minimum requirements. Maize meal (250 g) and/or supermarket/local shop bread (3 inner slices) were collected from 50 randomly selected households from each study area. Maize meal samples were reduced to 10 composite samples per area. Bread samples were composited similarly; 1 composite sample consisted of 15 intact slices. Overall, 8 composite samples were obtained for both brown and white bread. The Southern African Grain Laboratory analyzed the samples for vitamin A, iron, and zinc. Mean content of maize meal (100 g) represented ratios of 0.56 to 0.98 of the minimum fortification requirement for vitamin A, 0.76 to 1.08 for iron, and 0.89 to 1.00 for zinc; brown bread (100 g) represented ratios of 0.57, 1.97, and 1.67 of the minimum requirement for vitamin A, iron, and zinc, respectively, and white bread (100 g) represented ratios of 0.89, 2.22, and 2.07 for vitamin A, iron, and zinc, respectively. The variation in vitamin A, iron, and zinc content in maize meal and the higher than required iron and zinc content in wheat bread needs to be investigated in further studies.

Abstract LB-185: The effects of plasma folate and other B vitamins on breast cancer risk in BRCA1 and BRCA2 mutation carriers

Abstract Background: Women who inherit a deleterious BRCA mutation face a high lifetime risk of developing breast cancer, estimated at 80% compared with 11% in the general population. Current prevention options are limited to prophylactic surgery (removal of the breast and/or ovaries) and/or chemoprevention. Nonsurgical prevention options including dietary and lifestyle recommendations are highly desired by this population but have yet to be elucidated. Folate and other B-vitamins involved in folate metabolism are of particular interest given their essential roles in DNA synthesis and maintaining genomic stability, the reported dual effects on carcinogenesis (promoting or preventing), and the high levels of intake due to mandatory food fortification and supplement use. Given the heightened predisposition for cancer development among BRCA mutation carriers, clarifying the role of these nutrients on breast cancer development in this population is of extreme importance. Objectives: To prospectively investigate the relationship between plasma folate, B12 and B6 levels and the risk of breast cancer in women with a BRCA1 or BRCA2 mutation. Methods: We included 169 Canadian women who provided a blood sample at enrollment and had no history of cancer from an on-going international cohort of BRCA mutation carriers, the Risk Factor Analysis of Hereditary Breast and Ovarian Cancer Study. Baseline and biennial follow-up questionnaires collected relevant information regarding family, reproductive and medical histories, selected lifestyle factors, and disease incidence. Plasma folate and B12 levels were determined with microbiological microtitre assays, methylmalonic acid (MMA, a functional biomarker of vitamin B12) was quantified using reversed-phase LC-tandem mass spectrometry, and pyridoxal 5′-phosphate (PLP) measuring active B6 was determined with a non-radioactive apo-enzymatic assay. Cox proportional hazards models were used to estimate relative risks and 95% confidence intervals. Results: During a mean follow-up of 8 years, 21 women were diagnosed with invasive breast cancer. At baseline, the participants had a mean age of 52.7 ± 12.2 years and BMI of 25.0 ± 5.0 kg/m2. The mean plasma folate level was 17.8 ng/mL ± 11.9, ranging from 0.24 to 68.5 ng/mL. Unaffected women had an average plasma folate level of 21.7 ng/mL compared to 19.2 ng/mL in affected women (P = 0.46). Plasma B12 and B6 assays are currently underway. Results from statistical analyses are expected in March 2015. Impact: To our knowledge, this represents the first prospective study evaluating the effect of folate and other B vitamins on the risk of breast cancer among women with a BRCA1 or BRCA2 mutation. The results from this study will help develop safe and targeted recommendations for prevention in genetically predisposed women. Funding: Canadian Institutes of Health Research, Canadian Gene Cure Foundation. Citation Format: Shana J. Kim, Anna Zuchniak, Young-In Kim, Yvonne Lamers, Joanne Kotsopoulos, Steven Narod. The effects of plasma folate and other B vitamins on breast cancer risk in BRCA1 and BRCA2 mutation carriers. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr LB-185. doi:10.1158/1538-7445.AM2015-LB-185

Relationship Between Interpregnancy Interval and Adverse Perinatal and Neonatal Outcomes in Northern Alberta.

Birth outcomes are known to be associated with birth spacing, but there are population differences. The purpose of this study was to examine the association between interpregnancy intervals and perinatal and neonatal outcomes in a Canadian population during the era of mandatory folate fortification of food. We conducted a study of 46 243 women who had two consecutive singleton births in northern Alberta between 1999 and 2007, using a linked provincial dataset. Perinatal outcomes of interest were preterm birth, low birth weight (LBW), small for gestational age, and perinatal death. Neonatal outcomes were low Apgar score, low arterial blood gas pH, need for neonatal resuscitation or admission to NICU, and neonatal death. Multivariable logistic regression was used to control for maternal demographic and obstetrical characteristics. The risk of preterm birth was increased for multiple interpregnancy intervals: for an interval of 0 to 5 months, the adjusted odds ratio (aOR) was 1.37 (95% CI 1.18 to 1.59), for 6 to 11 months the aOR was 1.18 (95% CI 1.04 to 1.34), for 24 to 35 months the aOR was 1.16 (95% CI 1.02 to 1.31), and for 36+ months the aOR was 1.36 (95% CI 1.20 to 1.53), compared with the reference interval of 12 to 17 months. The risk of LBW was increased with interpregnancy intervals of 0 to 5 months (aOR 1.48; 95% CI 1.23 to 1.80), 6 to 11 months (aOR 1.21; 95% CI 1.03 to 1.42), 24 to 35 months (aOR 1.21; 95% CI 1.03 to 1.41) and 36+ months (aOR 1.48; 95% CI 1.27 to 1.73). The risk of SGA was increased with intervals 0 to 5 months (aOR 1.29; 95% CI 1.09 to 1.52), 24 to 35 months (aOR 1.15; 95% CI 1.01 to 1.31), and 36+ months (aOR 1.26; 95% CI 1.11 to 1.44). The risk of perinatal death was increased with an interval of 36+ months (aOR 1.60; 95% CI 1.06 to 2.43). Similar associations were also observed for neonatal outcomes. This study suggests that both short and long interpregnancy intervals are associated with adverse perinatal and neonatal outcomes, and it provides risk estimates for a Canadian population in the era of folate fortification of food.

Awareness of folic acid use increases its consumption, and reduces the risk of spina bifida.

The majority of neural tube defects were believed to be folic acid (FA)-preventable in the 1990s. The Japanese government recommended women planning pregnancy to take FA supplements of 400 μg/d in 2000, but the incidence of spina bifida has not decreased. We aimed to evaluate the OR of having an infant with spina bifida for women who periconceptionally took FA supplements and the association between an increase in supplement use and possible promoters for the increase. This is a case-control study which used 360 case women who gave birth to newborns afflicted with spina bifida, and 2333 control women who gave birth to healthy newborns during the first 12 years of this century. They were divided into two 6-year periods; from 2001 to 2006 and from 2007 to 2012. Logistic regression analyses were conducted to compute OR between cases and controls. The adjusted OR of having an infant with spina bifida for supplement users was 0.48 in the first period, and 0.53 in the second period. The proportion of women who periconceptionally consumed supplements significantly increased from 10 % in the first period to 30 % in the second period. Awareness of the preventive role of FA was a promoter for an increase in supplement use, and thus an FA campaign in high school seems rational and effective. The failure of the current public health policy is responsible for an epidemic of spina bifida. Mandatory food fortification with FA is urgent and long overdue in Japan.

The key role of government in addressing the pandemic of micronutrient deficiency conditions in Southeast Asia.

Micronutrient deficiency conditions are a major global public health problem. While the private sector has an important role in addressing this problem, the main responsibility lies with national governments, in cooperation with international agencies and donors. Mandatory fortification of basic foods provides a basic necessary intake for the majority and needs to be supported by provision of essential vitamin and mineral supplements for mothers and children and other high risk groups. Fortification by government mandate and regulation is essential with cooperation by private sector food manufacturers, and in the context of broader policies for poverty reduction, education and agricultural reform. Iron, iodine, vitamin A, vitamin B complex, folic acid, zinc, vitamin D and vitamin B12 are prime examples of international fortification experience achieved by proactive governmental nutrition policies. These are vital to achieve the Millennium Development Goals and their follow-up sustainable global health targets. National governmental policies for nutritional security and initiatives are essential to implement both food fortification and targeted supplementation policies to reduce the huge burden of micronutrient deficiency conditions in Southeast Asia and other parts of the world.

Empowering people to be healthier: public health nutrition through the Ottawa Charter.

The WHO's Ottawa Charter highlights five priority areas for taking action in public health. Only one of them is at the individual level as action at more upstream intervention levels, such as community or policy levels, is critical for enabling individuals to succeed. The objective of the present paper is to give insight into the many complex processes involved in public health nutrition by describing the Ottawa Charter's five priority areas for taking action using public health nutrition initiatives I have been involved in. Evidence-based guidelines for healthy eating and infant feeding provide an essential basis for individuals to 'develop personal skills' (Action Area 1). 'Re-orienting health services' (Action Area 2) can address the needs of vulnerable population subgroups, such as the culturally sensitive diabetes prevention programme established for an Indo-Asian community in Canada. Identifying geographic areas at high risk of childhood obesity enables better strategic planning and targeting of resources to 'strengthen community action' (Action Area 3). Calorie menu labelling can 'create supportive environments' (Action Area 4) through encouraging a demand for less energy-dense, healthier food options. 'Building healthy public policy' (Action Area 5) to implement mandatory folic acid food fortification for prevention of birth defects has many advantages over a voluntary approach. In conclusion, evaluation and evidence-based decision-making needs to take account of different strategies used to take action in each of these priority areas. For this, the randomised control trial needs adaptation to determine the best practice in public health nutrition where interventions play out in real life with all its confounding factors.

An evaluation of the effectiveness of the flour iron fortification programme in Brazil.

The present communication reports a strategy to calculate the intake of Fe based on data available for folic acid and evaluate the programme of flour fortification in Brazil. Cross-sectional study conducted in Brazil during 2008 and 2009. A 2d dietary record of individuals was used. The usual intake of folic acid by sex and age group was estimated using the National Cancer Institute method. The quantity of folic acid and Fe established by mandatory food fortification in Brazil was used, and based on that quantity we calculated the amount of flour consumed and the intake of Fe from fortification and Fe from food. Then, the absorption of each nutrient was calculated. Brazilian households (n 16,764). Individuals (men and women, n 34,003, aged 10 to 60+ years) from a Brazilian nationwide survey. Mean intake and absorption of Fe from fortification (electrolytic Fe) was low in men and women. The impact from the consumption of fortified products is small in relation to Fe intake in Brazil. The strategy proposed to estimate Fe intake from the fortification programme indicates that the amount of flour intake observed in Brazil does not justify the current ranges of mandatory flour fortification and the form of Fe that is mainly used (electrolytic Fe).

High folate levels in Aboriginal children after subsidised fruit and vegetables and mandatory folic acid fortification.

To evaluate the impact of a fruit and vegetable (F&V) subsidy program for disadvantaged Aboriginal children in Australia, implemented alongside the introduction of mandatory folic acid fortification of bread-making flour. A before-and-after evaluation was undertaken of a F&V subsidy program at three Aboriginal community-controlled health services in New South Wales. The program provided a weekly box of subsidised F&V linked to preventive health services and nutrition promotion for families. In this analysis, red blood cell (RBC) folate was assessed together with self-reported dietary intake at baseline and 12 months later in a cohort of 125 children (aged 0-17 years). No children had low RBC folate at baseline or at follow-up; however, 33 children (26%) exceeded the reference range of RBC folate at baseline and 38 children (30%) exceeded the reference range at follow-up. Mean RBC folate levels increased substantially in children at follow-up (mean RBC folate z-score increased +0.55 (95%CI 0.36-0.74). Change in F&V intake (p=0.196) and mean bread intake (p=0.676) were not statistically significant predictors for change in RBC folate levels. RBC folate levels increased among these disadvantaged Aboriginal children following mandatory folic acid fortification and participation in a subsidised F&V program. Even before mandatory folic acid fortification, none of these children had low RBC folate. The effect on health of mandatory fortification of foods with folate is not clear, hence, ongoing population-based monitoring of folate levels to assess the impact of mandatory folic acid fortification is important.

Neural tube defects in the Republic of Ireland in 2009-11

Neural tube defects (NTDs) are associated with deficient maternal folic acid peri-conceptionally. In Ireland, there is no mandatory folic acid food fortification, partly due to declining NTD rates in recent years. The aim of this study was to ascertain the incident rate of NTD during the period 2009-11 and describe epidemiologically NTD in Ireland. Cases were ascertained through multiple sources, including three regional congenital anomaly registers, all maternity hospitals nationally and paediatric hospitals providing care for children with spina bifida in the Republic of Ireland during the period 2009-11. From 225 998 total births, 236 NTDs were identified, giving an incidence of 1.04/1 000 births, increasing from 0.92/1 000 in 2009 to 1.17/1 000 in 2011. Of all cases, 45% (n = 106) had anencephaly, 49% (n = 115) had spina bifida and 6% (n = 15) had an encephalocoele; 78% (n = 184) were liveborn or stillborn and 22% (n = 52) were terminations abroad. Peri-conceptional folic acid supplement intake was 13.7% among the 52.5% (n = 124) of cases whose folic acid supplement intake was known. The incidence of NTDs in the Republic of Ireland appears to be increasing. Renewed public health interventions, including mandatory folic acid food fortification, must be considered to reduce the incidence of NTD.

Haematological implications of folate food fortification

Reports from some Western countries indicate that mandatory folate food fortification (FFF) has substantially reduced the prevalence of folate deficiency, leading to calls for folate testing following FFF to be limited to specific indications such as macrocytic anaemia. This is premature for low-income countries, where folate deficiency is predominantly the result of poor intake coupled with the increasing demand in pregnancy. There is also evidence that HIV infection is prejudicial to folate nutrition, and low-income HIV-infected women and their offspring could be among the most susceptible to folate deficiency. In assessing folate nutrition, the value of serum folate has been compromised by FFF, and both serum and red cell folate are necessary for optimal assessment of folate status. Although the limited data available suggest that large-scale masking of vitamin B12 deficiency by FFF has not occurred, it has been suggested that B12 be incorporated into folate-fortified foods. However, significant B12 deficiency is usually due to malabsorption, and physiological doses added to food would be of questionable value because they would not be absorbed. Extensive work, especially randomised clinical trials, must be done before dietary intervention with B12 on a national scale can be justified.

Risk factors for the occurrence of spina bifida (a case–control study) and the prevalence rate of spina bifida in Japan

The Japanese government recommended in 2000 that women planning pregnancy should take 400 μg of folic acid daily to decrease the risk of having an infant with spina bifida. We aimed to identify risk factors for the occurrence of spina bifida and to evaluate how the prevalence rate has altered over the past 3 decades. Subjects comprised 360 women who gave birth to spina bifida-affected offspring and 2333 women who gave birth to offspring without spina bifida between 2001 and 2012. A self-administered questionnaire was used to collect data, which were analyzed by multiple logistic regression models. The prevalence rate of spina bifida was obtained through data provided by international and domestic organizations. Four variables were significantly associated with the increased risk of having newborns afflicted with spina bifida: not taking folic acid supplements (odds ratios [OR], 2.50; 95% confidence interval [CI], 1.72-3.64), presence of spina bifida patients within third-degree relatives (OR, 4.26; 95% CI, 1.12-16.19), taking anti-epileptic drugs without folic acid (OR, 20·20; 95% CI, 2.06-198.17), and low birth weight in the newborns ≤ 2500 g (OR, 4.21; 95% CI, 3.18-5.59). The prevalence rate of spina bifida has remained 5 to 6 per 10,000 total births and has not shown any decreasing trend over the past 11 years. Four risk factors were identified among Japanese women. Because recommendations and information have not decreased the occurrence of spina bifida, the Japanese government should implement mandatory food fortification.

Dietary adequacies among South African adults in rural KwaZulu-Natal.

BackgroundFood quality, determined by micronutrient content, is a stronger determinant of nutritional status than food quantity. Health concerns resulting from the co-existence of over-nutrition and under-nutrition in low income populations in South Africa have been fully recognized in the last two decades. This study aimed to further investigate dietary adequacy amongst adults in rural KwaZulu-Natal, by determining daily energy and nutrient intakes, and identifying the degree of satisfaction of dietary requirements.MethodsCross-sectional study assessing dietary adequacy from 24-hour dietary recalls of randomly selected 136 adults in Empangeni, KwaZulu-Natal, South Africa.ResultsResults are presented for men (n = 52) and women (n = 84) 19–50 and >50 years old. Mean energy intake was greatest in women >50 years (2852 kcal/day) and exceeded Dietary Reference Intake’s for both men and women, regardless of age. Mean daily energy intake from carbohydrates was 69% for men and 67% for women, above the Dietary Reference Intake range of 45–65%. Sodium was also consumed in excess, and the Dietary Reference Intakes of vitamins A, B12, C, D, and E, calcium, zinc and pantothenic acid were not met by the majority of the population.ConclusionDespite mandatory fortification of staple South African foods, micronutrient inadequacies are evident among adults in rural South African communities. Given the excess caloric intake and the rising prevalence of obesity and other non-communicable diseases in South Africa, a focus on diet quality may be a more effective approach to influence micronutrient status than a focus on diet quantity.

Vitamin B12 and ageing: current issues and interaction with folate

A compromised vitamin B12 status is common in older people despite dietary intakes that typically far exceed current recommendations. The maintenance of an optimal status of vitamin B12 is not only dependent on adequate dietary intake but more critically on effective absorption which diminishes with age. The measurement of vitamin B12 is complicated by the lack of a gold standard assay. There are a number of direct and functional indicators of vitamin B12 status; however, none of these are without limitations and should be used in combination. Vitamin B12 is of public health importance, not only because deficiency leads to megaloblastic anaemia and irreversible nerve damage, but also because emerging evidence links low B12 to an increased risk of a number of age-related diseases, including cardiovascular disease, cognitive dysfunction, dementia and osteoporosis. Furthermore, there are concerns relating to potential adverse effects for older adults with low vitamin B12 status of over-exposure to folic acid in countries where there is mandatory fortification of food with folic acid. The aim of this review is to examine the known and emerging issues related to vitamin B12 in ageing, its assessment and inter-relationship with folate.

Regulatory Monitoring Systems of Fortified Salt and Wheat Flour in Selected Asean Countries

Considerable efforts have been made over the past decade to address vitamin and mineral deficiencies. An increasing number of countries in the Association of Southeast Asian Nations (ASEAN) are adopting mandatory food fortification as one of the primary strategies to overcome these deficiencies. Experience shows that fortified foods can reach large parts of the population, including the poor, if the fortification is done on a mandatory rather than a voluntary basis and if the food vehicle is widely consumed. To review the importance of regulatory monitoring as an essential component of food fortification efforts in selected ASEAN countries, with special focus on the available information on regulatory monitoring systems for iodized salt and fortified wheat flour. The role of regulatory monitoring in strengthening food fortification programs was discussed during a joint regional meeting of the World Health Organization, UNICEF, the Flour Fortification Initiative, the Global Alliance for Improved Nutrition, the Micronutrient Initiative, and the World Bank on regulatory monitoring of salt and wheat flour fortification programs in Asia, which took place in Manila, Philippines, on 27-29 September 2011. This paper reviews the regulatory monitoring systems of selected ASEAN countries that participated in this meeting. Problems and challenges in regulatory monitoring systems for iodized salt and fortified wheat flour in selected ASEAN countries are identified, and a description of the role of regulatory monitoring in strengthening food fortification initiatives, particularly of salt and flour, and highlights of areas for improvement are presented. Regulatory monitoring consists of monitoring activities conducted at the production level, at customs warehouses, and at retail stores by concerned regulatory authorities, and at the production level by producers themselves, as part of quality control and assurance efforts. Unless there are appropriate enforcement and quality assurance mechanisms in place to stimulate compliance by food producers, i.e., regulatory monitoring, having national legislation will not necessarily lead to increased coverage of fortified products and associated outcomes.

Folic acid fortification of wheat flour: A cost‐effective public health intervention to prevent birth defects in Europe

SummaryNeural tube defects (NTDs) annually affect an estimated 320 000 newborns worldwide. Folic acid (FA), provided through supplementation and fortification, is an effective primary‐prevention strategy for NTDs if consumed in the periconceptional period. However, the potential impact of FA supplementation is tempered by low compliance. Countries that mandate FA fortification of wheat flour report an average reduction of 46% in NTD birth prevalence and favourable benefit : cost ratios of 12–48:1. Despite the well‐documented benefits of fortification and the new evidence that provides a better understanding of purported risks associated with FA, European countries have yet to embrace this public health initiative. Viable primary‐prevention strategies are needed given that an estimated 4500 NTDs occur in the 27 countries of the European Union annually, of which 72% end in terminations. Many existing factors will facilitate the success of FA flour fortification programs in the region: widespread consumption of wheat‐based products, a technologically advanced milling industry, experience adhering to and monitoring food safety measures, and familiarity with mandatory food fortification.

PS16 Which is more Effective, A Universal or Targeted Approach, to Implementing the National Healthy Start Programme? A Mixed Methods Study

BackgroundHealthy Start is a statutory scheme in the UK, aiming to improve the health of children and pregnant or lactating women by providing food vouchers and vitamins. The Department of...

Efficacy of Adding Folic Acid to Foods

In the past, food fortification along with nutritional education and the decrease in food costs relative to income have proven successful in eliminating common nutritional deficiencies. These deficiencies such as goiter, rickets, beriberi, and pellagra have been replaced with an entirely new set of "emergent deficiencies" that were not previously considered a problem [e.g., folate and neural tube defects (NTDs)]. In addition, the different nutrition surveys in so-called affluent countries have identified "shortfalls" of nutrients specific to various age groups and/or physiological status. Complex, multiple-etiology diseases, such as atherosclerosis, diabetes, cancer, and obesity have emerged. Food fortification has proven an effective tool for tackling nutritional deficiencies in populations; but today a more reasonable approach is to use food fortification as a means to support but not replace dietary improvement strategies (i. e. nutritional education campaigns). Folic acid (FA) is a potential relevant factor in the prevention of a number of pathologies. The evidence linking FA to NTD prevention led to the introduction of public health strategies to increase folate intakes: pharmacological supplementation, mandatory or voluntary fortification of staple foods with FA, and the advice to increase the intake of folate-rich foods. It is quite contradictory to observe that, regardless of these findings, there is only limited information on food folate and FA content. Data in Food Composition Tables and Databases are scarce or incomplete. Fortification of staple foods with FA has added difficulty to this task. Globally, the decision to fortify products is left up to individual food manufacturers. Voluntary fortification is a common practice in many countries. Therefore, the "worldwide map of vitamin fortification" may be analyzed. It is important to examine if fortification today really answers to vitamin requirements at different ages and/or physiological states. The real impact of vitamin fortification on some key biomarkers is also discussed. An important question also to be addressed: how much is too much? It is becoming more evident that chronic excessive intakes may be harmful and a wide margin of safety seems to be a mandatory practice in dietary recommendations. Finally, the "risk/benefit" dilemma is also considered in the "new" FA-fortified world.