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Should Ireland have a mandatory folic acid fortification policy?
The objective of this report is to research the advantages & disadvantages of folic acid fortification and to conclude regarding a decision whether folic acid fortification should be mandatory in Ireland. Folic acid is the synthetic form of the B vitamin folate. The folate found naturally in foods has poor bioavailability and is unstable in food storage and preparation. As a result, folate’s effect on blood folate levels is quite minimal. However, folic acid is used in supplements and fortified foods as it is highly stable and bioavailable. Folic acid about twice as bioavailable as folate. There is conclusive scientific evidence linking low folate status with spina bifida and other related birth defects such as anencephaly. These conditions are known as neural tube defects (NTDs). These are major birth defects caused by the incomplete closure of the neural tube. The prevalence of NTDs in Ireland has risen in recent years, and Ireland has one of the highest rates of NTDs in the world. Such high rates are unacceptable in a developed country like Ireland. Folic acid fortification should be considered in Ireland as women of childbearing age require 700μg of folic acid per day (400μg supplement & daily adult needs of 300μg).
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NTDs affect approx. 1 in 1000 pregnancies in Ireland, this equates to about 75 cases per year. Spina bifida is the most common, it accounts for 51% of all NTDs. NTDs are serious birth defects and are major causes of mortality & morbidity especially in childhood. Adequate folic acid intake before conception and during pregnancy can prevent up to 70% of NTDs such as spina bifida. A satisfactory level of folic acid is required to ensure the neural tube closes correctly. There is evidence to show that in Ireland, women do not get enough folic acid from foods (NANS, 2011). It is difficult to get the recommended amount of folate from diet alone, as a result of this a folic acid supplement is recommended. This brings attention to the possible need for a mandatory folic acid fortification policy in Ireland. It is recommended that all women of childbearing age who are sexually active should take a folic acid supplement (400μg) every day to help prevent neural tube defects (NTDs) in babies. This is paramount for at least 4 weeks prior to conception and during the first 12 weeks of pregnancy. Women who have given birth to an infant with an NTD, who are diabetic, obese or have a family history of NTDs should be prescribed a supplement of 4000μg of folic acid at least 4 weeks prior to conception and for the first 16 weeks of pregnancy to aid in the prevention of an NTD recurrence. Most women start taking folic acid after 5 weeks (35 days), which means it is too late as neural tube closure is usually complete by day 28. There is a lack of education in Ireland regarding the importance of folic acid supplementation. Poor compliance with folic acid recommendations increases the risk of the development of NTDs. It is currently estimated that only 36% of women of childbearing age in Ireland have blood folate levels that are adequate for optimal protection against NTDs (FSAI, 2016). This evidence shows that perhaps there should be a mandatory folic acid fortification policy put in place in Ireland.
Over half of pregnancies in Ireland are unplanned, therefore the healthcare professionals of Ireland should recognise this and educate the public and provide policies in order to prevent NTDs and other folic acid deficiency symptoms such as a lower birth weight (Scholl et al, 1996). According to the FSAI, women should eat foods fortified with folic acid such as cereals, and high folate foods such as green leafy vegetables, inclusive to taking folic acid supplement. In 2006, due to the low levels of folate intake, mandatory fortification of flour was discussed. This was delayed due to the link between high levels of folic acid intake with various types of cancer, specifically colon cancer (Cole et al 2007). It also might mask vitamin B12 deficiency (FSAI, 2006). The long-term effects of high folic acid intakes are still unknown. There are a few companies who voluntarily fortify their food in Ireland. Many breakfast cereals and breads are fortified with folic acid. For example, ‘Weetabix’ contains 170μg of folic acid/100g. The average rates of NTDs in Europe were recently calculated to be 1.6 times higher than in places where folic acid fortification is mandatory. Over 80 countries have introduced mandatory fortification of cereals and no evidence of any adverse health effects has been observed. In America, mandatory folic acid fortification has led to 600-700 babies born without a birth defect each year. This results in a saving of $400-$600 million saved per year.
The economy in Ireland has had a massive impact on folic acid fortification & the prevalence of NTDs. During the height of the Celtic tiger, people could buy a wide range of foods of which were fortified voluntarily. Companies often did this as a marketing ploy in order to increase prices, this showed a drop in the level of NTDs in Ireland. However, when the economy crashed people could no longer afford these fortified branded cereals and most avoided the more expensive fortified cereals or began to shop in cheaper shops such as Lidl and Aldi. These companies did not fortify their cereals, as it would have raised the price of the product for the consumer. These own brand foods were cheaper and became more popular. One’s priority was to put food on the table in these times, they were not concerned with the folic acid content of the products they were buying. A small team of researchers in D.C.U, found that there was a link between the increasing numbers of NTDs in the population with the change in shopping trends and the decreased availability of fortified foods. It was found that there were up to 100 fortified products in one mainstream supermarket at the time and only 1 in Lidl. The FSAI published in 2015, that the mandatory folic acid fortification of bread/flour is the most effective way of reducing Ireland’s rate of birth defects. Although despite this recommendation from the experts, the minister for health still only recommends that companies voluntarily fortify their products and women to take the recommended supplement of folic acid per day. Women from lower socioeconomic backgrounds are more likely not to follow current guidelines, therefore they are still left at a higher risk of their child developing an NTD. However, one can understand the delay in a mandatory fortification in Ireland as there are concerns with providing too much folic acid to those who don’t need it (e.g. elderly). Professor Mary Flynn, chief specialist in public health nutrition in the FSAI, stated that the voluntary fortification of foods does contribute to the reduction of pregnancies affected by NTDs. “It is estimated that the risk of NTDs is approximately 11-14% lower as a result of consumption of voluntarily fortified foods, e.g. ready-to-eat breakfast cereals, resulting from an additional average daily intake of 50-63 µg folic acid in women of childbearing age” (FSAI, 2016). According to NANS, women classed as a reproductive age (18-50) had median daily intakes of total folate of 260 µg/day, folate of 189 µg/day and folic acid from fortified foods and supplements of 52 µg/day. However, while 78% of women in this category consumed fortified foods, only 16% consumed folic acid supplements. There is a clear distinction between those who consume supplements and fortified foods. There is potential to significantly reduce the risk of NTDs in Ireland through the fortification of food.
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Based on my research, mandatory fortification should be introduced in Ireland. “The mandatory fortification of bread or flour in Ireland would provide about 150 micrograms of folic acid per day in women of childbearing age. This could reduce the prevalence of NTDs by around 30%” (Deborah Condon, 2016). This is the most effective way of increasing folate levels and therefore, reducing rates of NTDs. Also, voluntary fortification of cereals etc could continue, and recommendations should still be followed by women of a childbearing age taking a folic acid supplement every day. As stated by the FSAI in 2016, there is unsubstantial evidence to show that voluntary fortification has the capability to reduce rates of NTDs from the current rate. A small amount of bread on the market could be excluded from fortification to provide choice for consumers who are worried about getting too much folic acid if they do not require it. If this legislation should come into place, monitoring should be done on folate levels and NTD rates in order to assess its impact and to determine health risks if any. Although the fortification of bread will significantly reduce the risk of NTDs, it will not provide adult women with the amount of folic acid they require. To conclude, there should be a mandatory folic acid fortification process in Ireland, and the provision of information to the Irish public about the importance of taking folic acid supplements. Information could be provided through schools, the internet, and advertisements amongst other marketing ideas.
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