Folate and fortification - understanding the basics by Lieven Bauwens

Folate and Fortification: Understanding the Basics Presented by Lieven Bauwens Secretary General IF Member of Flour Fortification Initiative EMT 24th Annual International Conference on Spina Bifida and Hydrocephalus 29 June 2013

The Plan…

• … folate Importance for health

Sources of Folate

• … flour fortification What is it?

Why is it important?

Measuring Intake

Global Support & Impact

Supplement Use

Best Practices

S-AdenosylHomocysteine Homocysteine

Food 5-methyl

Tetrahydrofolate

5-methyl

Tetrahydrofolate

5-methyl

Tetrahydrofolate

(Proteins, DNA Lipids, Myelin) Methyl Translerases

S-AdenosylMethionine Methionine

Methionine Synthase (B12)

5-methyl

Tetrahydrofolate

Tetrahydro -folate

Methylene Tetrahydro -folate Uracil Fortified Food or Supplements

Dihydro -folate Thymidylate synthase

Dihydro -folate reductase

Thymine DNA

Dihydro -folate reductase

Cell Division Folic Acid Intestine

Folic Acid Gut Wall

Folic Acid Circulation

Folic Acid Dividing Cells

Folic Acid

Folate is Important for Everyone’s Health • Needed for DNA, RNA and amino acid synthesis required for cell division • Prevents certain types of anemia • Important for maintaining cardiovascular health • Reduces the risk for neural tube defects • May reduce the risk for other congenital defects and autism, and others

Relationship of Early Pregnancy Maternal RCF to Risk of NTD. NTD Risk per 1000 Births

12

• Nested case-control study with 84 NTD affected pregnancies and 266 controls

10

8

• Risk was graded throughout the entire normal RCF range

6

• Increasing the RCF to above 400 µg/L would be highly protective.

4 2

• Risk is never 0

0 453 (200)

906 (400)

1360 (600)

1813 (800)

Red Cell Folate, nmol/L (µg/L)

Daly et al JAMA 1995

Folate FOOD FOLATE

FOLIC ACID

• Found in liver, dark green • Found in fortified foods and vegetables, lentils, beans, oranges, supplements • Water-soluable

• Stable

• Bioavailability ~50% in comparison • Bioavailability to folic acid supplement taken on 1. Supplements taken on empty empty stomach stomach~100% 2. Folic acid taken with food ~85%

Folate Intake Europe Average Folate Intake* 450 400

Intake (Âľg/day)

350 300 250 200 150 100 50 0

Estonia

Italy

Portugal Denmark

*without supplements or fortified foods

Russia

Norway

UK

Sweden

Ireland

Recommendation for Women of childbearing Age

“ It is recommended that women capable of becoming pregnant consume 400 Îźg* of folate daily from supplements, fortified foods, or both in addition to consuming food folate from a varied diet.â€?

-Institute of Medicine * As dietary folate equivalents (DFE)

Preconceptional Folic Acid Use 100 90

% Study Participants

80 70 60 50 40 30

31.5

27.6

20

18.6

19.2

Portugal

Spain

12.2

12

Turkey

UK

10 0

Hungary

Norway

1. Paulik E et al. Eur J Obstet Gynecol Reprod Biol. 2009 Jul; 145(1) 49-52. 4. Navarrete-Mu単oz EM. Med Clin (Barc). 2010 Nov 13;135(14):637-43.

5. Baykan Z et al. Arch Gynecol Obstet (2011) 283:1249-1253.

2. Nilson R et al. Am J Clin Nutr 2006; 84 : 1134-1141.

6. Brough L. J Hum Nutr Diet. 2009 Apr; 22(2): 100-107.

3. Pinto, E et al. Public Health Nutr. 2009 Jul; 12(7):922-931.

BUT:

Daily Intake of Folic Acid

N= 100

450 400

micro grams

350 300 250 200 150 100 50 0 1

6

11 16 21 26

31 36 41 46

51

56

61 66 71 76 81 86

91

96

Termination is not prevention

Ignoring NTDs is not prevention NTDs

Other health outcomes: FA deficiency Stroke Heart disease Low birth weight Pre-term birth Other birth defects ‌ Autism?

Cancer occurrence?

Cognitive decline / Alzheimer?

Prevention of NTDs Different strategies • Supplementation • Fortification • Diet • Oral contraceptive + Folic Acid • Other

Potential Solution 1: Supplements • Limitations:

– Cost and inconsistent use – Minority of women use folic acid supplements at the correct time for preventing NTDs (even when the pregnancy is a planned one) – important relation with socio-economic background – Prior to conception and during the first 12 weeks of pregnancy, women need 400 microgram folate or folic acid per day.

Potential Solution 2: Fortified flour • Pro

– Effective – Simple and inexpensive – Requires no change in dietary patterns or individual decision – Non-discriminating

• Contra – Controversial (myths) – Reach – Challenge of monitoring and enforcing of legislation

What is Flour Fortification? • Fortification adds vitamins and minerals to flour during the milling process so that the foods made with wheat flour are more nutritious. • Flour = wheat and maize flour (rice is very different)

Essential Nutrients are Lost During the Wheat Milling Process

Adapted from “Wheat in Human Nutrition” by W.R. Aykroyd and Joyce Doughty Food and Agriculture Organization of the United Nations, Rome, 1970.

Why Fortification of Cereal Grains?

• It is a public health intervention • It helps address micronutrient malnutrition by providing nutrients to deficient populations and preventing new cases of deficiency • Bread is widely consumed in Europe by individuals from all economic backgrounds • It improves diet quality without requiring behavior change • It is inexpensive per person per year

IF Supports Fortification

Consensus for Fortification

Resolution on Birth Defects WHO WHA 63.17 To support Member States in developing national plans for implementation of effective interventions to prevent and manage birth defects within their national maternal, newborn and child health plan, strengthening health systems and primary care, including improved coverage of vaccination against diseases such as measles and rubella, of addressing tobacco and alcohol use among pregnant women and women trying to conceive, and food fortification strategies, for the prevention of birth defects, and promoting equitable access to such services

• Click to edit Master text styles – Second level – Third level • Fourth level – Fifth level

Success of fortifying flour with folic acid • Eight regional studies from Argentina, Canada, Chile, South Africa, and the United States report: – 31% to 78% reduced risk of neural tube defects after fortifying wheat flour with folic acid – Overall 46% reduction in neural tube defects after fortifying flour with folic acid

Blencowe, H: Folic acid to reduce neonatal mortality form neural tube disorders International Journal of Epidemiology. April 2010 (suppl_1):i110-i121 . Istockphoto

Success of fortifying flour with folic acid Globally, an estimated 22,000 birth defects were prevented in 2008 - an average of 60 a day because wheat flour is fortified with folic acid.

However this amounted to just 9% of FApreventable NTDs.

Bell, Karen N., Oakley, Godfrey P. Update on Prevention of Folic Acid-Preventable Spina Bifida and Anencephaly.

Birth Defects Research (Part A): Clinical and Moleculra Teratology. 85 2009:102-107

Global Best Practices To plan a grain fortification program, consider: • Local culture and cereal consumption • Nutritional needs • Industry analysis • Creation of a multi-sector national fortification alliance • Legislation for mandatory fortification • Monitoring the process and surveillance for birth defects

Role of SB associations • Understanding the issue – NTD registration – Food and nutrition intake

• Understanding the local situation • Build and be part of a National Fortification Alliance • Advocacy • Monitoring of the actions undertaken by government

Conclusions • Folate is one of essential micronutrients, intake often problematic in women of childbearing age • Relationship FA and NTDs is clearly established • There is a relationship with FA and other health issues • Fortification is a proven strategy to improve FA status in the whole population • AND/AND, not OR/OR • We have already achieved a lot, but still a lot of work needs to be done • Spina Bifida associations are crucial partners in the FA debate

Thank you!