Folic acid is an important B-vitamin that plays a huge role in biosynthesis, cell division, and tissue growth. It is also important in the prevention of complications associated with pregnancy among women of child-bearing age. In the early 90s, foods were fortified with folic acid to reduce the risk of Neural Tube Defects and other folate deficiency diseases. This paper examined both mandatory and voluntary folic acid regulations implemented by different countries. Findings according to this report revealed that about 55 countries operate the mandatory regulation and these countries have recorded at least a 50% risk reduction post fortification.
This paper, therefore, recommends that based on findings of this report, countries yet to implement the mandatory regulation should do so, as the benefits outweigh that of the voluntary regulation. Also, comparative studies of these regulations should be carried out as well as further research that targets the impact of folic acid fortification on the older population.
The deficiency of various nutrients during food consumption may occur as a result of different factors and these factors may differ from region to region in the world.
Micronutrients such as vitamins and minerals even though required in small quantities, can have devastating effects on health if there is a long-term untreated deficiency. This form of deficiency affects millions of people worldwide and thus, to prevent this, there is usually a need for food fortification.
Folic acid, also known as Vitamin B9 is a water-soluble vitamin and one of the important micronutrients needed by the body for several functions such as cell biosynthesis, cell division, tissue growth, and cognitive development (Hwang et al.
, 2017). Folic acid or folate deficiency as a result of inadequate intake has long been of Public Health concern as it may subsequently lead to an array of diseases such as megaloblastic anaemia, heart problems, and neural tube defects (NTDs). During the early stages of pregnancy, women deficient in serum folate often produce offspring with conditions such as spina bifida (paralysis), or anencephaly/ loss of the brain part function (Green, 2002). According to the United Nations International Children’s Emergency Fund (UNICEF), approximately 150000 severe cases of birth defects occur as a result of folic acid deficiency, therefore there is a need for folic-acid fortification and supplementation during pregnancy.
The World Health Organization (WHO) defines food fortification as an intentional addition of specific or combined micronutrients in food to increase the nutritional content as well as reduce the illness of public health concerns that occur as a result of these micro-nutrient deficiencies (WHO and FAO, 2011). The intervention is targeted towards populations suffering from micronutrient deficiencies and carried out by the food manufacturers. According to regulations in specific countries, the fortification of foods could be mandatory or voluntary depending on the severity and prevalence of these deficiencies in the said regions.
The transitioning of food products from the farm to fork, through different processing methods, as well as soil factors oftentimes result in a reduction or total loss of nutrients. The World Health Organization (WHO) and the Food and Agricultural Organization (FAO) recognizes food fortification as an important strategy of combating hidden hunger (micronutrient deficiencies) from a global perspective (WHO and FAO, 2011).
Voluntary Food fortification involves the addition of nutrients to foods by the manufacturers in levels that are stipulated and acceptable by the Food and Drug Administration (FDA) while the Mandatory Food fortification is more targeted at combating the prevalence of a specific micronutrient deficiency through the addition of this micronutrient to specific foods in stipulated quantity. An example of the mandatory food fortification is the addition of folic acid to flour to tackle neural tube defects and all folic acid fortified flour or cereals must be declared as “enriched” stating the addition of 140mcg/1kg of flour (CDC, 2010).
The regulation regarding folic acid fortification of foods vary across regions. For instance, countries such as Spain and New Zealand practice voluntary fortification while the United States mandated this intervention in the late 90s. This could be as a result of the difference in prevalence and severity of cases in these regions. The permitted level of fortification also differs in different cases. Voluntary folic acid fortification of bread at a level of 2.5mg/kg was permitted by the New Zealand government in 2012 (MPI, 2012) while some countries with mandatory regulation also have different permitted ranges. According to the Center for Disease Control and Prevention, about 55 countries operate the mandatory regulation. However, it has not been finally implemented by some of these countries (CDC, 2010)
FIGURE 1: Recommendations for folic acid intake, folic acid fortification policies and reduction of NTDs in four countries
In the early 90s, before the inception of folic acid fortification, several studies were conducted to access the correlational effect of folic acid consumption on pregnancy complications amongst women. It was reported by these studies that approximately 60% of cases of neural tube defects were prevented due to the consumption of supplements rich in folic acid prior to the period of pregnancy (Blom et al., 2006).
As a result of these findings, the intake of folic acid in the quantity of 400?g/day was recommended for all women of child-bearing age by the U.S Public Health Service in September 1992 (CDC, 1992). However, the awareness amongst women about the importance of this recommendation was relatively low and the US government decided that the best method of approach would be through the fortification of foods. Food manufacturers could voluntarily fortify their food products with folic acid as long as it doesn’t exceed the recommended daily intake (RDI).
The mandatory folic acid regulation was passed in March 1996 and fully implemented in the year 1998. The government recognized that the commonly consumed foods by the target population (women and children) were majorly cereals, grains and flour (Laurence et al., 1980) and thus made it mandatory for food manufacturers to fortify their enriched food products with 140 micrograms of folic acid per 100grams of grain (USDA, 1996).
There have been several researches about this intervention and most of the studies have shown the positive impact of the intervention on neural tube defects and other folic-acid deficiency disorder. A study carried out by Williams et al., 2015 to estimate the rate of NTDs among three different races after the mandatory intervention by the US government, reported a decline in the rate of NTDs and confirmed its effectiveness (Williams et al., 2015).
FIGURE 2: Prevalence of neural tube defects (NTDs) (anencephaly and spina bifida) before and after mandatory folic acid fortification, by maternal race/ethnicity.
About the same period in the early 90s that the US government mandated the fortification of cereal grains, Health Canada also passed the regulation on the fortification of folic acid, recognizing flour as the major vehicle. The government, however, made the intervention mandatory in 1998, stating that all white flour, enriched pasta, and cornmeal should be fortified with 1.5mg of folic acid/kg (Ray, 2004). The Canadian government implemented this intervention in order to achieve a 30-70% goal of folic acid intake among women (Canada Gazette, 1998).
Shortly after this intervention, a lot of research has also been carried out to assess the impact of mandatory folic acid fortification. A study conducted by De Walls et al., 2007 to access the difference in the levels of NTDs in Canada pre and post fortification recorded about 50% reduction of NTDs among study population, following a full-fortification period. This Study corroborated with Persad et al., 2002 in their findings on Open NTDs in Nova Scotia Canada following the mandatory fortification.
FIGURE 3: Decrease in the Rate of Neural-Tube Defects after Folic Acid Fortification Was Implemented, According to Baseline Prevalence in Canadian Provinces.
Since the occurrence of folic-acid fortification, there has been little or no comparative study that focuses on the long-term benefits of voluntary versus mandatory folic-acid intervention. Since the occurrence of folic-acid fortification, there has been little or no comparative study that focuses on the long-term benefits of voluntary versus mandatory folic-acid intervention. However, a few researches have been carried out to evaluate the drawbacks of voluntary folic acid fortification.
In a study conducted by Laird et al., 2018, the result revealed the ineffectiveness of voluntary folic acid fortification in the maintenance of serum folate levels in older adults. The implementation of the mandatory folic acid fortification by the Ireland government was also recommended in this study in order to prevent putting approximately 200000 older adults at risk of illnesses arising from low serum folate. This supports a recommendation made by Sweeny et al., 2009 in their study to assess the effect of unmetabolized, circulating folic acid as a result of voluntary folic acid fortification in Ireland. So far, there has been a limited drawback of the mandatory folic acid regulation, however, different researches have suggested the implementation of the mandatory regulations to countries still operating the voluntary intervention.
The fortification of different important food vehicles with folic acid has undoubtedly helped to improve the quality of life of target populations. Both the mandatory and voluntary folic acid regulations implemented in different countries have led to a drastic decrease in the risk of major illnesses caused by folate deficiency. This paper, therefore, recommends that based on findings of this report, countries yet to implement the mandatory regulation should do so, as the benefits outweigh that of the voluntary regulation. Also, comparative studies of these regulations should be carried out as well as further research that targets the impact of folic acid fortification on the older population.
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