Mandatory Fortification Of Flour Research Articles

Circulating Folate Concentrations and Risk of Peripheral Neuropathy and Mortality: A Retrospective Cohort Study in the U.K.

Background: Folate deficiency may increase the risk of peripheral neuropathy but there is a paucity of data from large prospective studies examining this association. Methods: Longitudinal analysis of electronic health records in The Health Improvement Network (THIN), a U.K. primary care database including 594,338 patients aged 18–70 years with a folate measurement and without a history of peripheral neuropathy. Results: After a mean follow-up of 3.71 (standard deviation (SD) = 3.14) years, 1949 patients were diagnosed with peripheral neuropathy and 20,679 patients died. In those <40 years, compared to patients with folate ≥13.6 nmol/L, those with folate <6.8 (deficient) and 6.8–13.5 nmol/L (insufficient) had a hazard ratio (HR) for peripheral neuropathy of 1.83 (95% confidence intervals (CI) = 1.16–2.91) and 1.48 (95% CI = 1.04–2.08), respectively. There was no significant association between folate and peripheral neuropathy among those aged 41–70 years. Compared to patients with folate ≥ 13.6 nmol/L, folate <6.8 nmol/L was associated with a greater risk of death among all ages. Conclusion: Folate deficiency and insufficiency was associated with a greater risk of peripheral neuropathy among younger patients. This investigation should be replicated in other large datasets and it may be important to monitor peripheral neuropathy incidence after the introduction of mandatory folic acid fortification of flour in the U.K.

DNA methylation and one-carbon metabolism related nutrients and polymorphisms: analysis after mandatory flour fortification with folic acid.

There is a growing research interest in determining whether changes in the global status of DNA methylation are related to the environment, in particular, to one-carbon metabolism. So, our aim was to investigate the effect of dietary methyl-group donor intake (methionine, folate, choline, betaine, vitamins B2, B6 and B12), biomarkers (total folate, unmetabolised folic acid (FA), 5-methyltetrahydrofolate, homocysteine, vitamins B6 and B12 concentrations) and genetic variants (polymorphisms involved in one-carbon metabolism) on global DNA methylation in a population exposed to mandatory flour fortification with FA. A cross-sectional study of health and living conditions was conducted among a representative sample of residents in São Paulo, Brazil. The mean of global DNA methylation was lower in young people than in adults and the elderly (P = 0·049). No differences between genotypes of polymorphism and global DNA methylation mean were identified. We observed that the increase in betaine intake led to an absolute change in percentage of DNA methylation (β = 0·0005, P = 0·024) using multiple regression. Betaine intake alone was associated with an absolute change in percentage of global DNA methylation. The study did not find an association between global DNA methylation and folate status even in a population exposed to mandatory flour fortification with FA.

Low proportions of folic acid deficiency after introduction of mandatory folic acid fortification in remote areas of northern Queensland, Australia: a secondary health data analysis

Background: Australia implemented mandatory folic acid fortification of bread-making flour in 2009.Objective: To assess the impact of folic acid fortification in remote vs. regional urban areas and Indigenous vs. non-Indigenous populations in northern Queensland.Methods: Routinely collected data on folic acid measurements in remote areas and two regional urban centres in northern Queensland between 2004 and 2015 were analysed (n = 13,929) dichotomously (folic deficient vs. non-deficient).Results: Overall prevalence of folic acid deficiency was 3.2% (235/7282) in urban centres compared with 7.2% (480/6647) in remote areas (p < 0.001), and 9.3% (393/4240) in the Indigenous population compared with 3.2% (273/8451) in the non-Indigenous population (p < 0.001). Prevalence of folic acid deficiency dropped from 12.2% (n = 481) in 2004–2008 to 1.5% (n = 126) in 2010–2015 (p < 0.001). This translates into a relative risk reduction (RRR) of 88%. RRR was 79% (7.2% vs. 1.5%) in urban centres, 91% (17.3% vs. 1.5%) in remote areas, 92% (20.5% vs. 1.6%) in the Indigenous population and 80% (7.4% vs. 1.5%) in the non-Indigenous population (p < 0.001 for all).Conclusions: Substantial declines of folic acid deficiency to low and comparable proportions in former high-risk populations indicate that mandatory folic acid fortification of flour has had a population-wide benefit in northern Queensland.

Folate Status and Neural Tube Defects in Aboriginal Australians: the Success of Mandatory Fortification in Reducing a Health Disparity

ABSTRACTHistorically, neural tube defects (NTD) in Australia affected around 2 in every 1000 births; 42% higher for Aboriginal births. Following firm evidence of the protective effect of periconceptional folate, health promotion activities encouraged increased folate intake through diet and supplements and limited voluntary food fortification. A 30% reduction in NTD was observed in non-Aboriginal but not Aboriginal infants, widening the disparity between Aboriginal and non-Aboriginal rates. Mandatory flour fortification with folic acid in 2009, led to further reductions in overall NTD, and greater reduction among Aboriginal infants, such that rates in Aboriginal and non-Aboriginal infants were similar by 2010–2014. Elimination of this disparity will make a small but important contribution to the Australian government's Closing the Gap initiative to reduce disadvantage among Aboriginal people. Long-term, complete, high-quality surveillance data on NTD have been of great value in monitoring trends in and evaluation of public health interventions for NTD in Australia.

CARACTERÍSTICAS EPIDEMIOLÓGICAS DAS ANOMALIAS CONGÊNITAS DO TUBO NEURAL EM MENORES DE 5 ANOS DE IDADE E POSSÍVEIS FATORES DE RISCO PARA A SUA OCORRÊNCIA EM CAMPOS DOS GOYTACAZES-RJ

As anomalias congênitas, possuem etiologia multifatorial, envolvendo aspectos genéticos e ambientais. Entre diversos fatos geradores, é evidente a importância do ácido fólico na redução ou mesmo prevenção de malformações. Esta vitamina relaciona-se com a síntese de DNA e RNA, portanto, com o desenvolvimento fetal. Foi implementada no País a fortificação compulsória das farinhas de trigo e milho com ferro e ácido fólico resultando em redução de anomalias em 35%. Já níveis diários de suplementação medicamentosa superiores a 5mg de ácido fólico reduz entre 75% e 91%. Tal fato demonstra a relevância e benefícios do folato no pré-natal. O período ideal de administração seria o periconcepcional, de 1 a 3 meses antes da gestação e até 4 meses após a concepção. Este estudo objetiva avaliar a prevalência de Anomalias Congênitas do tubo neural de menores de 5 anos de idade no município de Campos dos Goytacazes-RJ, através de um estudo de caso controle para serem analisados possíveis fatores de risco para ocorrência de tais anormalidades. Para análise da distribuição de defeitos do tubo neural foram usadas as variáveis: nível socioeconômico e educacional, idade materna, utilização ou não do ácido fólico, realização de pré-natal, número de consultas, entre outras. A amostra coletada é do tipo probabilística aleatória simples, período de realização, 1º de março de 2016 à 30 de maio de 2017. Este projeto atenderá a resolução 196/96 versão 2012 do CNS relativas ás questões da ética em pesquisa com humanos.&#x0D;

Folate: Deja vu – all over again

Folate: Deja vu – all over again

Real-World Cost Effectiveness of Mandatory Folic Acid Fortification of Bread-Making Flour in Australia.

In 2009, mandatory folic acid fortification of bread-making flour was introduced in Australia to reduce the birth prevalence of preventable neural tube defects (NTDs) such as spina bifida. Before the introduction of the policy, modelling predicted a reduction of 14-49 NTDs each year. Using real-world data, this study provides the first ex-post evaluation of the cost effectiveness of mandatory folic acid fortification of bread-making flour in Australia. We developed a decision tree model to compare different fortification strategies and used registry data to quantify the change in NTD rates due to the policy. We adopted a societal perspective that included costs to industry and government as well as healthcare and broader societal costs. We found 32 fewer NTDs per year in the post-mandatory folic acid fortification period. Mandatory folic acid fortification improved health outcomes and was highly cost effective because of the low intervention cost. The policy demonstrated improved equity in outcomes, particularly in birth prevalence of NTDs in births from teenage and indigenous mothers. This study calculated the value of mandatory folic acid fortification using real-world registry data and demonstrated that the attained benefit was comparable to the modelled expected benefits. Mandatory folic acid fortification (in addition to policies including advice on supplementation and education) improved equity in certain populations and was effective and highly cost effective for the Australian population.

Projected effectiveness of mandatory industrial fortification of wheat flour, milk, and edible oil with multiple micronutrients among Mongolian adults.

Industrial fortification of wheat flour is a potentially effective strategy for addressing micronutrient deficiencies in Mongolia, given its ubiquitous consumption and centralized production. However, Mongolia has not mandated fortification of any foods except for salt with iodine. This study modeled the effectiveness and safety of mandatory industrial fortification of wheat flour alone and in combination with edible oil and milk in reducing the prevalence of multiple micronutrient intake deficiencies among healthy non-pregnant adults in Mongolia. Six days of diet records (3 summer, 3 winter) were collected from 320 urban and rural adults across the country and analyzed for food and nutrient consumption using a purpose-built food composition table, and the Intake Monitoring and Planning Program (IMAPP) was used to project the effects of fortification on summer and winter bioavailable micronutrient intake and intake deficiency under different fortification guidelines within population subgroups defined by urban or rural locality and sex. Projections showed that flour fortification would be effective in reducing intake deficiencies of thiamin and folate, while marginal benefits of fortification with iron and riboflavin would be smaller given these nutrients’ higher baseline consumption, and fortification with zinc, niacin, and vitamin B12 may be unnecessary. Fortification of flour, oil, and milk with vitamins A, D, and E at levels suggested by international guidelines would substantially reduce vitamin A intake deficiency and would increase vitamin D intake considerably, with the greatest benefits elicited by flour fortification and smaller benefits by additionally fortifying oil and milk. These results support mandatory industrial fortification of wheat flour, edible oil, and milk with iron, thiamin, riboflavin, folate, and vitamins A, D, and E in Mongolia. Considerations will be necessary to ensure the fortification of these nutrients is also effective for children, for whom the potential benefit of zinc, niacin, and vitamin B12 fortification should be assessed.

A 2017 global update on folic acid-preventable spina bifida and anencephaly.

Spina bifida and anencephaly are largely preventable birth defects through mandatory folic acid fortification. Our objective was to estimate the proportion of folic acid-preventable spina bifida and anencephaly (FAP SBA) prevented worldwide through mandatory fortification of wheat and/or maize flour with folic acid during the year 2017. Using existing data, we identified countries with mandatory fortification policies that added at least 1.0 ppm folic acid to wheat and/or maize flour and had information on percentage of industrially milled flour that is fortified. We assumed mandatory folic acid fortification at 200 μg/day of folic acid fully protects against FAP SBA, reducing the prevalence of spina bifida and anencephaly to 0.5 per 1,000 live births. Overall, 59 countries met our criteria for implementing mandatory folic acid fortification of wheat and/or maize flour in 2017. These countries prevented about 50,270 out of 280,500 FAP SBA births in 2017. Thus, we have only achieved 18% prevention of FAP SBA worldwide. Several countries in Africa and Asia with a high number of FAP SBA-affected births do not have mandatory fortification. About 230,000 children unnecessarily developed FAP SBA globally in 2017. There is an urgent need for all countries to implement mandatory folic acid fortification, a proven, safe public health intervention that saves money and prevents infant mortality and disability. Prevention of FAP SBA can play an important role in helping countries to achieve their Sustainable Development Goals for health.

Countries with an immediate potential for primary prevention of spina bifida and anencephaly: Mandatory fortification of wheat flour with folic acid.

Mandatory fortification of flour with folic acid has been proven to be a highly effective way to prevent spina bifida and anencephaly. Yet, over 100 countries worldwide do not implement this intervention. Our objectives were to identify countries with an immediate potential for mandatory fortification of wheat flour with folic acid and to estimate the number of preventable cases of spina bifida and anencephaly that would be averted each year through the intervention. We examined folic acid fortification characteristics in countries as of September 2017. Country selection criteria included current fortification status, existing industrial capacity for flour production, fortification coverage, and daily grams of per capita wheat flour available for human consumption. We estimated the country-specific number of preventable cases of spina bifida and anencephaly by calculating the difference between the observed prevalence (prefortification) and expected prevalence that can be achieved postfortification (0.5 per 1,000 live births). We identified 71 countries with an immediate potential for mandatory fortification of 145 million metric tons of wheat flour with folic acid. Fortification in identified countries would avert approximately 57,000 live births associated with folic acid-preventable spina bifida and anencephaly annually and increase global prevention from the current rate of 13% to a new rate of 34%. Fortification can be achieved immediately in many countries with existing industrial milling infrastructure. Effective fortification interventions can accelerate global primary prevention efforts of folic acid-preventable spina bifida and anencephaly, especially in developing countries with a high prevalence of neural tube defects and associated morbidity and mortality.

Effect of Folate Supplementation on Inflammatory Markers in Individuals Susceptible to Depression: A Systematic Review

Folate has been proposed to be an efficacious treatment strategy for depression. The mandatory fortification of flour with synthetic folic acid (FA) in over 80 countries has yielded improvements in folate intake; however, depression is still a considerable public health concern. While there are established benefits of FA fortification in reducing risk of neural tube defects, the implications regarding depression are unclear, especially in individuals with certain genetic polymorphisms. Therefore, a systematic review was conducted to examine the effects of folate to treat depression. Following PRISMA guidelines, a systematic review was conducted of electronic databases (PUBMED, Scopus, CINAHL, and Cochrane Library) to identify human clinical trials examining the effects of folate (including FA) supplementation in the management or prevention of depression, the impact on inflammatory markers and if genetic polymorphisms were considered. Ten trials met the inclusion criteria. Seven trials examined effects of either adjunctive FA or L-methylfolate (L-MTHF) supplementation with antidepressants in the management of depression and three examined effects of FA supplementation alone for prevention of depression. No benefit of FA was found compared to placebo (all, p > 0.05). The single L-MTHF trial that explored the interplay of genetic polymorphisms and methylation status found benefit in the Hamilton depression rating scale from adjunctive treatment with 15 mg/day of L-MTHF compared with placebo (−6.8 ± 7.2 vs. −3.7 ± 6.5; p = 0.017) and improvement with L-MTHF for most genetic markers. Currently, there is no evidence to support FA supplementation for the management or prevention of depression. More research is required to determine the efficacy of L-MTHF and folinic acid in certain clinical populations.

Association between Serum Unmetabolized Folic Acid Concentrations and Folic Acid from Fortified Foods

Objective: To investigate the association between serum unmetabolized folic acid (UMFA) concentrations and folic acid from fortified foods and nutrients known as dietary methyl-group donors (folate, methionine, choline, betaine and vitamins B2, B6 and B12) in participants exposed to mandatory fortification of wheat and maize flours with folic acid.Methods: Cross-sectional study carried out with 144 healthy Brazilian participants, both sexes, supplement nonusers. Serum folate, UMFA, vitamin B12 and total plasma homocysteine (tHcy) were biochemically measured. Dietary intake was assessed by 2 non-consecutive 24-hour dietary recalls (24-HRs) and deattenuated energy-adjusted nutrient data were used for statistical analysis.Results: Ninety eight (68.1%) participants were women. Median (interquartile range) age was 35.5 (28.0–52.0) years. Elevated serum folate concentrations (>45 nmol/L) were found in 17 (11.8%), while folate deficiency (<7 nmol/L) in 10 (6.9%) participants. No one had vitamin B12 deficiency (<148 pmol/L). An elevated serum UMFA concentration was defined as > 1 nmol/L (90th percentile). UMFA concentrations were positively correlated with folic acid intake and negatively correlated to choline, methionine and vitamin B6 intakes. Participants in the lowest quartile of UMFA concentrations had lower dietary intake of total folate (DFEs) and folic acid, and higher dietary intake of methionine, choline and vitamin B6 than participants in the highest quartile of UMFA. Folic acid intake (OR [95% CI] = 1.02 [1.01–1.04)] and being a male (OR [95% CI] = 0.40 [0.19–0.87) were associated with increased and reduced odds for UMFA concentrations > 0.55 nmol/L (median values), respectively.Conclusion: UMFA concentrations were directly influenced by folic acid intake from fortified foods in a healthy convenience sample of adult Brazilians exposed to mandatory flour fortification with folic acid.

Large -scale wheat flour folic acid fortification program increases plasma folate levels among women of reproductive age in urban Tanzania.

There is widespread vitamin and mineral deficiency problem in Tanzania with known deficiencies of at least vitamin A, iron, folate and zinc, resulting in lasting negative consequences especially on maternal health, cognitive development and thus the nation’s economic potential. Folate deficiency is associated with significant adverse health effects among women of reproductive age, including a higher risk of neural tube defects. Several countries, including Tanzania, have implemented mandatory fortification of wheat and maize flour but evidence on the effectiveness of these programs in developing countries remains limited. We evaluated the effectiveness of Tanzania’s food fortification program by examining folate levels for women of reproductive age, 18–49 years. A prospective cohort study with 600 non-pregnant women enrolled concurrent with the initiation of food fortification and followed up for 1 year thereafter. Blood samples, dietary intake and fortified foods consumption data were collected at baseline, and at 6 and 12 months. Plasma folate levels were determined using a competitive assay with folate binding protein. Using univariate and multivariate linear regression, we compared the change in plasma folate levels at six and twelve months of the program from baseline. We also assessed the relative risk of folate deficiency during follow-up using log-binomial regression. The mean (±SE) pre–fortification plasma folate level for the women was 5.44-ng/ml (±2.30) at baseline. These levels improved significantly at six months [difference: 4.57ng/ml (±2.89)] and 12 months [difference: 4.27ng/ml (±4.18)]. Based on plasma folate cut-off level of 4 ng/ml, the prevalence of folate deficiency was 26.9% at baseline, and 5% at twelve months. One ng/ml increase in plasma folate from baseline was associated with a 25% decreased risk of folate deficiency at 12 months [(RR = 0.75; 95% CI = 0.67–0.85, P<0.001]. In a setting where folate deficiency is high, food fortification program with folic acid resulted in significant improvements in folate status among women of reproductive age.

Effects of folic acid fortification on orofacial clefts prevalence: a meta-analysis.

Orofacial clefts (OFC) are the most prevalent craniofacial birth defect. Folic acid (FA) supplementation has been demonstrated as an effective intervention to reduce risk of OFC occurrence. However, the effect of mandatory FA fortification of wheat and/or maize flour on OFC prevalence has shown controversial results among countries adopting this policy. Thus, we performed a meta-analysis to synthesize the available evidence evaluating the global impact of this mandatory policy on OFC occurrence. Literature search in conventional and grey medical/scientific databases showed fifteen studies considering OFC prevalence in pre- and post-fortification periods with FA. The effect of this policy was evaluated by computing relative risk (RR) and separating samples into total OFC, non-syndromic forms, cleft lip with or without cleft palate (CL/P) and cleft palate only (CPO). We found a significant effect of FA fortification only on non-syndromic CL/P (RR=0·88; 95 % CI 0·81, 0·96), whereas neutral effects were detected for total OFC (syndromic plus non-syndromic) and CPO. Our results may reflect the different aetiology of syndromic OFC with respect to non-syndromic forms and the CL/P related to CPO. Although the number of non-syndromic CL/P samples was lower than that for total OFC, the absence of both between-study heterogeneity and publication bias leads us to conclude that FA fortification may have beneficial effects on non-syndromic CL/P.

The mortality rate after hospital discharge in patients with myelomeningocele decreased after implementation of mandatory flour fortification with folic acid.

To evaluate the mandatory folic acid fortification of flour on mortality rates after the hospital discharge of children born with myelomeningocele, the most affected age group and the most frequent cause of death. A retrospective study of 383 children born with myelomeningocele from January 1990 to December 2013 in a high-fetal-risk reference hospital. A total of 39 patients died (10.1%),of which 23 (6%) died after discharge. Most children who died were younger than 12 months of age. The most frequent cause of death was infection of the central nervous system, followed by urinary tract sepsis and infections of the respiratory system. Symptomatic Chiari II malformation was the most frequent comorbidity factor. Although there was no significant difference in infant mortality before and after folic acid fortification, there was a significant reduction in deaths after hospital discharge in babies born after implementation of mandatory folic acid fortification.

Anemia among pregnant women attending primary healthcare units in the municipality of São Paulo, Brazil: evaluations after the mandatory fortification of wheat and maize flours with iron

Abstract Background Improvements in the iron status of a population as result of food fortification are expected at the long term. In Brazil, the effectiveness of mandatory flour fortification with iron has been evidenced mostly from surveys on gestational anemia after 1 or 2 years from its implementation, in 2004. Our aim was to assess hemoglobin (Hb) concentrations and the prevalences of anemia and linked erythrocyte morphology patterns among pregnant women in 2006 and 2008. Methods The study design was retrospective and cross-sectional. The analysis was based on secondary data in 546 medical records from women at the times of their first prenatal attendance in 13 public primary healthcare units of the Butantan Administrative Region from São Paulo (SP), Brazil. Anemia was evaluated from Hb concentration (cut-off &lt;11.0 g/dL) and erythrocyte morphology patterns from mean corpuscular volume (MCV), mean corpuscular Hb concentration (MHC), and red cell distribution widths (RDW). Recorded sociodemographic and obstetric data included maternal age, gestational age, ethnoracial self-classification, and residence type. Student’s t tests, analysis of variance, Chi-squared tests, and multiple linear and logistic regressions were employed in the statistical analysis using a significance level of 5 %. Results The prevalence of anemia was 9.7 % in 2006 and 9.4 % in 2008 (P = 0.922), with no significant difference in mean Hb concentrations (P = 0.159). Normocytosis (normal MVC), normochromia (normal MHC), and anisocytosis (high RDW) were found in most anemia cases, suggesting that the low Hb concentrations resulted from mixed causes. In multiple regression analysis, gestational age at the first prenatal attendance was an independent predictor of low Hb and of having anemia. Moreover, black ethnoracial self-classification was associated with lower Hb. Conclusions The prevalence of gestational anemia was low among women in both of the studied periods, representing a mild public health problem. Our results highlight the importance of early prenatal care as a means of reducing gestation-associated risks. The erythrocyte morphology pattern found in most cases of low Hb levels suggests that, besides iron deficiency, hemoglobinopathies and nutritional deficiencies of folate and vitamin B12 are common complicating factors of gestational anemia in our setting.

Brazilians' experiences with iron fortification: evidence of effectiveness for reducing inadequate iron intakes with fortified flour policy.

To assess Fe intake, calculate the prevalence of inadequate Fe intake and identify food contributors to Fe intake during 2003 and 2008 in a population-based study, reflecting before and after the mandatory fortification of flour with Fe. Two cross-sectional population-based studies conducted in 2003 and 2008. Dietary intake was evaluated by 24 h recall and the Software for Intake Distribution Estimation (PC-SIDE) was used to estimate within-person variance and prevalence of inadequate Fe intake. The statistical analysis was conducted considering the complex survey design. São Paulo, Brazil. Adolescents, adults and elderly adults of both sexes, interviewed in 2003 (n 2386) and 2008 (n 1661). The Fe intake mean increased in all populations in the post-fortification period. A reduction of over 90 % was observed in the prevalence of inadequate Fe intake among men for all age groups analysed. When evaluating women, despite the substantial reduction (over 63 %), prevalence of inadequate Fe intake remained high (34 %) in those aged 19-50 years. Major food contributors to Fe intake before fortification were beans, beef, vegetables and dairy. There was an alteration in the contributors in the post-fortification period, with bread, beef, beans and biscuits as main contributors. The mandatory fortification with Fe significantly furthered the reduction in the prevalence of inadequacy, except among women of reproductive age, and changed the main contributors to this nutrient in the studied population. Therefore, monitoring of Fe addition in flour is essential to assess compliance to the fortified flour policy and to guarantee a safe Fe intake for all the population.

A 2015 global update on folic acid-preventable spina bifida and anencephaly.

Spina bifida and anencephaly are two major neural tube defects. They contribute substantially to perinatal, neonatal, infant, and under-five mortality and life-long disability. To monitor the progress toward the total prevention of folic acid-preventable spina bifida and anencephaly (FAP SBA), we examined their global status in 2015. Based on existing data, we modeled the proportion of FAP SBA that are prevented in the year 2015 through mandatory folic acid fortification globally. We included only those countries with mandatory fortification that added at least 1.0 ppm folic acid as a fortificant to wheat and maize flour, and had complete information on coverage. Our model assumed mandatory folic acid fortification at 200 μg/day is fully protective against FAP SBA, and reduces the rate of spina bifida and anencephaly to a minimum of 0.5 per 1000 births. Our estimates show that, in 2015, 13.2% (35,500 of approximately 268,700 global cases) of FAP SBA were prevented in 58 countries through mandatory folic acid fortification of wheat and maize flour. Most countries in Europe, Africa, and Asia were not implementing mandatory fortification with folic acid. Knowledge that folic acid prevents spina bifida and anencephaly has existed for 25 years, yet only a small fraction of FAP SBA is being prevented worldwide. Several countries still have 5- to 20-fold epidemics of FAP SBA. Implementation of mandatory fortification with folic acid offers governments a proven and rapid way to prevent FAP SBA-associated disability and mortality, and to help achieve health-related Sustainable Development Goals. Birth Defects Research (Part A) 106:520-529, 2016. © 2016 Wiley Periodicals, Inc.

Impact of mandatory fortification of bread and flour with folic acid in the Republic of Ireland

Impact of mandatory fortification of bread and flour with folic acid in the Republic of Ireland

Folate status in Aboriginal people before and after mandatory fortification of flour for bread-making in Australia.

Mandatory fortification of wheat flour for bread-making was introduced in Australia in September 2009, to assist in the prevention of neural tube defects (NTD). NTD are twice as common in Aboriginal compared with non-Aboriginal infants, and folate levels are lower in the Aboriginal population. This study was undertaken to compare folate status and NTD in the Aboriginal population before and after fortification. Postfortification, 95 Aboriginal men and nonpregnant women aged 16-44 years in metropolitan and regional Western Australia (WA) completed a rapid dietary assessment tool and had blood taken to measure red cell folate. Measures were compared with prefortification values obtained in an earlier study using the same methods. Data on NTD in Aboriginal infants were obtained from the WA Register of Developmental Anomalies. No participant was folate deficient. The mean red cell folate increased after fortification to 443 ng/mL for males and 567 ng/mL for females. The mean difference between red cell folate after fortification compared with before was 129 ng/mL for males (95% CI 81-177); t = 5.4; P < 0.0001) and 186 ng/mL for females (95% CI 139-233); t = 7.9; P < 0.0001). Most participants ate fortified shop-bought bread at least weekly, resulting in an estimated additional folate intake per day of 178 (males) and 145 (females) dietary folate equivalents. NTD prevalence fell by 68% following fortification (prevalence ratio 0.32 (CI 0.15-0.69)). The population health intervention of mandatory fortification of wheat flour for bread-making has had the desired effect of increasing folate status and reducing NTD in the Australian Aboriginal population.