Folate Folds (updated)
I see John Key has announced that the government will be abandoning the attempt to make folate supplementation of bread mandatory.
“Cabinet is expected to formalise the government’s position when it meets tomorrow, effectively putting the controversial issue on the back burner for three years and, crucially, beyond the next election.
“The government is not convinced that making folic acid a compulsory ingredient in all bread is necessary, and wants more time to assess the evidence. Folic acid has been shown to reduce the risk of babies being born with defects such as spina bifida, but bakers say women would need to eat at least 11 slices of bread a day to make a difference to the health of their unborn child.”
This is a shame since there are several studies due to come out next year that should provide a definitive answer as to whether folate supplementation is harmful. Putting the matter to one side until after the next election is political cowardice. As I have mentioned in a previous post, the US and canadian experience with folate supplementation appears to be wholly positive. The supposed increase in prostate cancer was an incidental observation from a study that was not designed to look at the incidence of prostate cancer. Its conclusions are therefore very debatable.
The bakers are being somewhat disingenuous with their 11 slices a day claim. That is the amount of bread you must eat if you wish to get your entire recommended daily dose of folate from bread. In reality, most people will get folate from other sources, including supplementation. The benefits of folate are also proportional; neural tube defects would be prevented even on 2-3 slices of bread a day (just not as many as with 11 slices a day).
Folate supplementation of flour was a simple and effective preventative measure that should not have succumbed to political pressure. People fuss of the iodisation of salt and the fluoridation of water, yet we continue to do this because the health results are good for very little cost. Folate supplementation of flour was in the category. The government has condemned dozens of mothers to give birth to non-viable or severely disabled babies because of their lack of political courage.
Additional:
It seems that I am not the only doctor who thinks that this back down by the government is going to be expensive in human and financial terms.
“Delaying plans to add folic acid to all bread will add about $10 million in health costs in the next three years and result in the equivalent of a classroom full of unborn babies being aborted, paediatricians say.”
What a complete waste of money and life.
“Rotorua paediatrician Johan Morreau, chairman of child health at the Royal Australasian College of Physicians, said doctors were “intensely frustrated” by the holdup. “What should have been a public health decision has become the subject of a political bun-fight. There is no scientific basis to justify the delay.
““Re-adding folate, which was removed from wheat during milling, would cut the incidence of spina bifida by about 80 per cent and of total birth defects by 40 per cent, he said.
“In 2004, the most recent year for which data is available, 16 babies were born with spina bifida and 29 pregnancies were terminated after scans showed the condition.”
Even on these figures, that is 36 children saved. The figures are almost certainly higher as many aborted spina bifida cases are not reported.
Note that this is not a weird chemical being added to “medicate” the public. This is a normal vitamin in whole wheat bread that is removed in refining. All that is being asked of bakers is to put the folate back into the bread.
It is a mystery to me why people would apparently prefer to see children die rather than be forced to eat a perfectly natural vitamin.
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Jul 20 09 12:33 am
The baker’s rebuttal on closeup was well done I thought. They showed the orange folate powder that they would have to add to the bread, and then they contended that it wasn’t possible within their manufacturing process to spread the powder evenly throughout each batch of bread, with the result that some bread would come up with more levels of folate than others.
I imagine that the kids would have fun playing “spot the orange bread” in the supermarket bread aisle, and that sales of breadmakers would certainly spike even without the orange bread eventuating.
Supporters of folate might need to look at the practicality of adding a substance like this during the production process. There doesn’t appear to be a way to add it without disrupting the bread market, and without majorly turning off consumers like myself. Mass medication of bread is unpalatable.
Jul 20 09 12:52 am
Johnnieboy:
By “within their manufacturing process”, the Bakers mean “Without buying upgraded equipment”. This is not an issue in Canada and the US, so presumably the issue for the bakers is merely one of capital expenditure.
The “Mass medication” meme is one of the more successful ones. It is very emotive and utterly illogical. Folate is not a “medication” but a natural substance that is essential to our diet. Nobody objects to the bakers adding salt (which is far more harmful) to bread, yet a small amount of folate is suddenly Nanny State “Mass medicating” everyone.
Weirdly, people seem completely happy with vitamin enriched cereals, iodised salt and fluoridated water but seem unwilling to accept a little folate in bread. This is a triumph of disinformation by the bakers. I feel inclined to send all bakers and all politicians Christmas cards with pictures of Spina Bifida babies on them.
Jul 20 09 12:25 pm
I think at a political level, a large part of the electorate got sick of the previous government acting like they ‘always knew best’. The folate issue is a casualty of that. Most of the electorate who voted for National did so because it was a government that came without the aura of social engineering and nanny-state interference- that were the hallmarks of Labour.
Being told that we had to eat something that we had no consultation about- a [I]fait accompli[/I] by Annette King- with no explanation or justification- was never going to meet the electorates’ aspirations for consideration. It was dumb and arrogant.
Vitamin enriched cereals are readily avoided (I prefer plain porridge) in the market-place. Iodised salt is easily avoided. Flouridated water is harder to avoid but the social benefit of mass improvements in dental-health ensured at least, benefits commensurate with the effort.
The bread schema was designed to make avoiding the additive onerous and difficult. And the benefit was to be concentrated in a statistical sense, in a small number of women. Who would also coincidentally, have to be big bread eaters.
I’m not particularly comfortable with this (and yes, I’m aware of the grim effects of spina bifida).
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Jul 20 09 1:14 pm
It comes down to choice McDoctor. Why wasn’t it proposed the you could buy bread with folate or without (And I dont count organic bread yuk!) just as you can but milk with or without fat/vitamins etc (or iodised/plain/sea salt for that matter)
I would wholeheartedly agree with you, if I believed that ANY baker would add folate voluntarily.
Jul 20 09 1:37 pm
I agree with a lot of the points raised. Overall I would prefer that the government take another route to ensuring folate intake is increased- government subsidisation of folate supplements. Just tie it to the community services card when presented at a pharmacy, or make it universally subsidised.
From the baker’s point of view, they face severe disruption in order to prevent 3 cases of spina bifida per year (their words not mine). The millions of dollars spent nationally to upgrade equipment and lost revenue (as people like me won’t buy supermarket bread any more) will obviously be diverted from wages and from efforts to retain jobs in the industry. The result is that we could be laying off maybe a hundred people who are trying to put food on the table for their families, they go on the dole, we have further stress, illness, family break-ups and ongoing social costs, and in doing so we might improve the lives of 3 children. Maybe this was the government’s rationale for shelving it- if these companies start to lay people off after forcing folate on them, the government will look like idiots.
Maybe we are taking away from a lot of children somewhere in NZ in order to improve life for a few children somewhere else in NZ. Maybe in less emotive terms the government has recognised that the costs of adding folate outweigh the benefits.
The bakers are intentionally understating the benefits. We could be talking hundreds of children as no-one knows the number of children aborted (naturally or unnaturally) for this.
Jul 20 09 11:09 pm
\The government has condemned dozens of mothers to give birth to non-viable or severely disabled babies because of their lack of political courage.\
Horse radish.
This whole thing is predicated by a study of women who had given birth to a baby with a neural tube defect and who have therefore a statistically higher chance of having another such baby than the general population. The study found that these women had folate deficiencies and supplimenting their diet with folate acid reduced but did not eliminate the subsequent children with neural tube defects in these particular women.
It is actually a huge stretch to assume that adding folic acid to the general populations food supply will have any beneficial effect on this particular issue at all.
Yes I know California claims a reduction but their numbers are as dodgy as hell and bureaucrats and epidemiologists for that matter, are masters at twisting figures to show what clever people they are.
Here is an abstract of an article published in PosMedicine
Unfoliated food for thought
Jul 20 09 11:19 pm
Andre:
While the Californian data may be dubious, it is hard to argue with this study in no less than the New England Journal of Medicine. It is highly statistically significant and demonstrates conclusively (in my opinion) that folate supplementation does indeed prevent neural tube defects.
I am a hardened statistics sceptic, like the writer of the PosMedicine article. But this study was well done and gives a result that is very hard to argue with.
Jul 21 09 10:32 pm
Very interesting precis of a paper – the number crunching wasn’t there though.
What caught my attention was the geographical correlation mentioned in the paper ie why does the incidence of these birth defects vary geographically and why do the claimed benefits of folic acid fortification have the most significant effect where the rates are high and a much lower effect elsewhere?
Answer these questions, beyond providing a few powerpoint slides of tables, and
provide a plausible biochemical explanation as to why folic acid is beneficial and perhaps I’ll be less skeptical.
But if these questions were fully answered I’d posit that there would be a far more efficacious solution to reducing or perhaps even eliminating neural tube defects than dosing the entire population through the food supply – whether they like it or not.
The simplest explanation for the variability is that the areas with more neural tube defects are the areas with most folate deficiency, hence the areas most likely to show improvement. This is also the most likely explanation.
Jul 22 09 9:43 pm
The simplest explanation for the variability is that the areas with more neural tube defects are the areas with most folate deficiency, hence the areas most likely to show improvement. This is also the most likely explanation.
That is a hand waving answer that does not address the question at all. Actually worse in some ways because the data would suggest that what fortification brings the rate in those areas with high rates more into line with the rates observed in areas with lower occurrences without actually answering the question of why this occurs in the first place. Which is the question if answered correctly could potentially resolve the problem for once and for all.
Examples
Why the geographical distribution of goitre?
Answer: lack of iodine in the soil ==> lack of iodine in the diet ==> increased incidence of goitre.
Solution: add iodine to salt if it is not naturally found within the salt sold within that region.
Similarly
why the geographical distribution of Pellagra
Answer: This is a problem of people who do not have a varied diet in regions where the staple food is Maize which (after preparation) lacks vitamin B3
Best solution increase the variety of foods available to the poor. Otherwise add yeast to food etc
Why the geographic distribution of Thalassemia
Answer Genetics – related to the prevalence of Malaria since carriers a less subject to this disease. No solution other than pre nuptial genetic testing of pairs drawn from susceptible populations.
So why are there areas with B9 deficiencies. Soil? very unlikely, regional dietary differences possible, genetics plausible?
Perhaps the B9 link with neural tube defects a red herring. Or maybe the purportedly observed B9 deficiency in women who are prone to producing children with this defect is just a symptom of another underlying problem which is the true cause which if identified just might lead to the elimination of this disease.
Real progress in science is always made by asking the right questions and answering them – not by jumping to conclusions and running off half cocked.
Have you ever heard of the disease SMON? A medical catastrophe where a “new disease” of the spinal cord similar to polio was identified in Japan.
Hmm – it turned out that the disease was caused by the very drug, Clioquinol, used to treat its symptoms.
It took about twelve years of fruitless pursuit of a virus and multiple deaths before the truth came out.
Not one of medical science’s finest hours.
And that is not an isolated incident.
The only way of preventing similar catastrophes in the future (and they will undoubtedly occur, such is the human condition) is healthy skepticism of grandiose medical claims on miracle programs which will resolve this health issue or that
Jul 22 09 11:37 pm
Andrei: That is a hand waving answer that does not address the question at all
Methinks you expect too much of the MacDoctor. I am no expert on the specific causes of folate deficiency though, in New Zealand’s case, I suspect it is our lamentable lack of fresh green leafy vegetables in our diet.
Be that as it may, I don’t accept that generalised epidemiological data such as the NEJM study is somehow invalid because we are not asking more specific questions. Several hundred fewer neural tube defects are several hundred fewer NTDs. Nor do I accept that we need to know the exact specific causes of a problem before attempting to rectify it.
Knowing the why of the geographical distribution of thalassemia does not alter the fact that we need to eradicate the mosquito to prevent Malaria, nor does it alter specific research on curing or ameliorating thalassemia. Likewise, I don’t need to know the specific reasons for folate deficiency in an area if I can ameliorate the problem by replacing the folate removed from refined flour.
Frankly, if we waited until we knew all the answers to a problem, we would never get anything done. I am happy to have clever people asking the right questions and doing the research, but if something works up front why not use it?
Always with a bit of healthy skepticism, of course…
Jul 24 09 3:17 pm
OTOH, one of the classic stories in medical entomology is that to control malaria you do have to target the right Anopheles mosquito. And in some instances, failure to make the correct taxonomic diagnosis (mosquitoes species have very small morphological differences, even if the genetic differences are large) led to a lot of wasted effort. And the destruction of a lot of innocent mosquitoes
In the case of folate, there should have been a range of options presented and discussed to reduce NTDs. We don’t try to treat osteoporosis by mandating calcium-fortification of food stuffs.
That we only had one option for NTDs, and the consultation was appalling, it’s not surprising the public hasn’t warmed to the compulsory intake.
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