Editing Folate (section)

==Food fortification==
{{See also|Food fortification}}
''Folic acid fortification'' is a process where synthetic folic acid is added to wheat flour or other foods with the intention of promoting public health through increasing blood folate levels in the populace. It is used as it is more stable during processing and storage.<ref name=Choi2014/><ref name="adavidsmith">{{cite journal|vauthors=Smith AD|title=Folic acid fortification: the good, the bad, and the puzzle of vitamin B-12|journal=The American Journal of Clinical Nutrition|volume=85|issue=1|pages=3–5|date=January 2007|pmid=17209170|doi=10.1093/ajcn/85.1.3|doi-access=free}}</ref> After the discovery of the link between insufficient folic acid and [[neural tube defects]], governments and health organizations worldwide made recommendations concerning folic acid [[dietary supplement|supplementation]] for women intending to become pregnant. Because the neural tube closes in the first four weeks of gestation, often before many women even know they are pregnant, many countries in time decided to implement mandatory food fortification programs. A meta-analysis of global birth prevalence of spina bifida showed that when mandatory fortification was compared to countries with voluntary fortification or no fortification program, there was a 30% reduction in live births with spina bifida,<ref name=Atta2016/> with some countries reporting a greater than 50% reduction.<ref name=Castillo2013 />

Folic acid is added to grain products in more than 80 countries, either as required or voluntary fortification,<ref name=Wald2018/><ref name=Map /> and these fortified products make up a significant source of the population's folate intake.<ref>{{cite journal|vauthors=Dietrich M, Brown CJ, Block G|title=The effect of folate fortification of cereal-grain products on blood folate status, dietary folate intake, and dietary folate sources among adult non-supplement users in the United States|journal=Journal of the American College of Nutrition|volume=24|issue=4|pages=266–74|date=August 2005|pmid=16093404|doi=10.1080/07315724.2005.10719474|s2cid=24699315}}</ref>  In the U.S., there is concern that the federal government mandates fortification but does not provide monitoring of potential undesirable effects of fortification.<ref name="adavidsmith" /> The Food Fortification Initiative lists all countries in the world that conduct fortification programs,<ref name=WhyFortify /> and within each country, what nutrients are added to which foods. The most commonly mandatory fortified vitamin – in 62 countries – is folate; the most commonly fortified food is wheat flour.<ref name=Map />

===Australia and New Zealand===
[[Australia]] and [[New Zealand]] jointly agreed to wheat flour fortification through the [[Food Standards Australia New Zealand]] in 2007. The requirement was set at 135&nbsp;μg of folate per 100&nbsp;g of bread. Australia implemented the program in 2009.<ref>{{cite web|url=http://www.foodstandards.gov.au/consumer/nutrition/folicmandatory/Pages/default.aspx|title=Folic Acid Fortification|date=2016|website=Food Standards Australia New Zealand|access-date=25 September 2018|archive-date=26 September 2018|archive-url=https://web.archive.org/web/20180926051839/http://www.foodstandards.gov.au/consumer/nutrition/folicmandatory/Pages/default.aspx}}</ref> New Zealand was also planning to fortify bread (excluding organic and unleavened varieties) starting in 2009, but then opted to wait until more research was done. The Association of Bakers and the [[Green Party of Aotearoa New Zealand|Green Party]] had opposed mandatory fortification, describing it as "mass medication".<ref>{{cite press release|title=Work Starts on Wilkinson's Mass Medication Plan|publisher=Association Of Bakers|date=8 July 2009|url=http://www.scoop.co.nz/stories/BU0907/S00210.htm|access-date=13 July 2009|url-status=live|archive-url=https://web.archive.org/web/20090710084803/http://www.scoop.co.nz/stories/BU0907/S00210.htm|archive-date=10 July 2009}}</ref><ref>{{cite press release|title=NZ should push pause on folic fortification|publisher=Green Party|date=9 July 2009|url=http://www.scoop.co.nz/stories/PA0907/S00132.htm|access-date=13 July 2009|url-status=live|archive-url=https://web.archive.org/web/20090710015728/http://www.scoop.co.nz/stories/PA0907/S00132.htm|archive-date=10 July 2009}}</ref> Food Safety Minister [[Kate Wilkinson (politician)|Kate Wilkinson]] reviewed the decision to fortify in July 2009, citing as reasons to oppose claims for links between over consumption of folate with increased risk of cancer.<ref>{{cite news|author=NZPA|title=Bakers, Govt battle over folic acid|publisher=[[The New Zealand Herald]] |date=8 July 2009|url=http://www.nzherald.co.nz/food/news/article.cfm?c_id=206&objectid=10583249|access-date=13 July 2009|archive-date=14 February 2012|archive-url=https://web.archive.org/web/20120214223246/http://www.nzherald.co.nz/food/news/article.cfm?c_id=206&objectid=10583249|url-status=live}}</ref> In 2012 the delayed mandatory fortification program was revoked and replaced by a voluntary program, with the hope of achieving a 50% bread fortification target.<ref>{{cite journal|vauthors=Houghton LA|title=A country left behind: folic acid food fortification policy in New Zealand|journal=The New Zealand Medical Journal|volume=127|issue=1399|pages=6–9|date=August 2014|pmid=25145300}}</ref>

===Canada===
Canadian public health efforts focused on promoting awareness of the importance of folic acid supplementation for all women of childbearing age and decreasing socio-economic inequalities by providing practical folic acid support to vulnerable groups of women.<ref>{{cite web|url=http://www.hc-sc.gc.ca|title=Welcome to the Health Canada Web site|publisher=Hc-sc.gc.ca|access-date=9 September 2012|url-status=live|archive-url=https://web.archive.org/web/20120910203617/http://www.hc-sc.gc.ca/|archive-date=10 September 2012}}</ref> Folic acid [[food fortification]] became mandatory in 1998, with the fortification of 150&nbsp;μg of folic acid per 100&nbsp;grams of [[enriched flour]] and uncooked [[cereal]] grains.<ref name=Mason2007>{{cite journal|vauthors=Mason JB, Dickstein A, Jacques PF, Haggarty P, Selhub J, Dallal G, Rosenberg IH|title=A temporal association between folic acid fortification and an increase in colorectal cancer rates may be illuminating important biological principles: a hypothesis|journal=Cancer Epidemiology, Biomarkers & Prevention|volume=16|issue=7|pages=1325–9|date=July 2007|pmid=17626997|doi=10.1158/1055-9965.EPI-07-0329|doi-access=free}}</ref> The results of folic acid fortification on the rate of neural tube defects in [[Canada]] have been positive, showing a 46% reduction in prevalence of NTDs; the magnitude of reduction was proportional to the prefortification rate of NTDs, essentially removing geographical variations in rates of NTDs seen in Canada before fortification.<ref>{{cite journal|vauthors=De Wals P, Tairou F, Van Allen MI, Uh SH, Lowry RB, Sibbald B, Evans JA, Van den Hof MC, Zimmer P, Crowley M, Fernandez B, Lee NS, Niyonsenga T|title=Reduction in neural-tube defects after folic acid fortification in Canada|journal=The New England Journal of Medicine|volume=357|issue=2|pages=135–42|date=July 2007|pmid=17625125|doi=10.1056/NEJMoa067103|doi-access=free}}</ref>

===United Kingdom===
While the [[Food Standards Agency]] recommended folic acid fortification,<ref>{{cite web|url=http://www.food.gov.uk/news/newsarchive/2007/may/folatefort|title=Board recommends mandatory fortification|access-date=18 May 2007|author=FSA|date=17 May 2007|url-status=live|archive-url=https://web.archive.org/web/20070624183523/http://www.food.gov.uk/news/newsarchive/2007/may/folatefort|archive-date=24 June 2007}}</ref><ref>{{cite news|url=http://news.bbc.co.uk/1/hi/health/6665109.stm|title=Backing for folic acid in bread|access-date=18 May 2007|work=[[BBC News]] |date=17 May 2007|url-status=live|archive-url=https://web.archive.org/web/20070618010640/http://news.bbc.co.uk/1/hi/health/6665109.stm|archive-date=18 June 2007}}</ref><ref>BBC [http://news.bbc.co.uk/1/hi/health/6648059.stm Experts back folic acid in flour] {{webarchive|url=https://web.archive.org/web/20070818132738/http://news.bbc.co.uk/1/hi/health/6648059.stm|date=18 August 2007}} 11 May 2007</ref> and wheat flour is fortified with iron,<ref name=ffi>{{Cite web|url=http://www.ffinetwork.org/why_fortify/index.html|publisher=Food Fortification Initiative|title=Why fortify?|date=2017|access-date=4 April 2017|url-status=live|archive-url=https://web.archive.org/web/20170404131451/http://www.ffinetwork.org/why_fortify/index.html|archive-date=4 April 2017}}</ref> folic acid fortification of wheat flour is allowed voluntarily rather than required. A 2018 review by authors based in the United Kingdom strongly recommended that mandatory fortification be reconsidered as a means of reducing the risk of neural tube defects.<ref name=Wald2018>{{cite journal|vauthors=Wald NJ, Morris JK, Blakemore C|title=Public health failure in the prevention of neural tube defects: time to abandon the tolerable upper intake level of folate|journal=Public Health Reviews|volume=39|page=2|date=2018|pmid=29450103|pmc=5809909|doi=10.1186/s40985-018-0079-6 |doi-access=free }}</ref> In November 2024 the UK government announced legislation to require folic acid fortification in bread by the end of 2026.<ref>{{cite web|url=https://www.gov.uk/government/news/birth-defects-prevented-by-fortifying-flour-with-folic-acid |title=Birth defects prevented by fortifying flour with folic acid }}</ref>

===United States===
[[File:GrainProducts.jpg|right|thumb|In the United States and many other countries, wheat flour is fortified with folic acid; some countries also fortify maize flour and rice.<ref name=Map/>]]

In 1996, the United States [[Food and Drug Administration]] (FDA) published regulations requiring the addition of folic acid to enriched breads, cereals, flours, corn meals, pastas, rice, and other grain products.<ref>{{cite web |url=https://www.govinfo.gov/content/pkg/FR-1996-03-05/pdf/96-5014.pdf |title=Food and Drug Administration. Food standards: amendment of standards of identity for enriched grain products to require addition of folic acid. Final Rule. 21 CFR Parts 136, 137, and 139. |date=March 1996 |volume=61 |issue=44 |pages=8781–89 |website=Federal Register |access-date=6 October 2019 |archive-date=6 October 2019 |archive-url=https://web.archive.org/web/20191006122713/https://www.govinfo.gov/content/pkg/FR-1996-03-05/pdf/96-5014.pdf |url-status=live }}</ref> This ruling took effect on 1 January 1998, and was specifically targeted to reduce the risk of neural tube birth defects in newborns.<ref name=Crandall1998>{{cite journal|vauthors=Crandall BF, Corson VL, Evans MI, Goldberg JD, Knight G, Salafsky IS|title=American College of Medical Genetics statement on folic acid: fortification and supplementation|journal=American Journal of Medical Genetics|volume=78|issue=4|page=381|date=July 1998|pmid=9714444|doi=10.1002/(SICI)1096-8628(19980724)78:4<381::AID-AJMG16>3.0.CO;2-E}}</ref> There were concerns expressed that the amount of folate added was insufficient.<ref>{{cite news|url=http://www.boston.com/yourlife/health/women/articles/2004/01/06/fda_muffed_chance_to_prevent_birth_defects/?pages=full|title=FDA muffed chance to reduce birth defects|newspaper=Boston Globe|date=6 January 2004|url-status=live|archive-url=https://web.archive.org/web/20070313013804/http://www.boston.com/yourlife/health/women/articles/2004/01/06/fda_muffed_chance_to_prevent_birth_defects/?pages=full|archive-date=13 March 2007}}</ref>

The fortification program was expected to raise a person's folic acid intake level by 70–130&nbsp;μg/day;<ref name=Choumenkovitch2002>{{cite journal|vauthors=Choumenkovitch SF, Selhub J, Wilson PW, Rader JI, Rosenberg IH, Jacques PF|title=Folic acid intake from fortification in United States exceeds predictions|journal=The Journal of Nutrition|volume=132|issue=9|pages=2792–8|date=September 2002|pmid=12221247|doi=10.1093/jn/132.9.2792|doi-access=free}}</ref> however, an increase of almost double that amount was actually observed.<ref name="Quinlivan">{{cite journal|vauthors=Quinlivan EP, Gregory JF|title=Effect of food fortification on folic acid intake in the United States|journal=The American Journal of Clinical Nutrition|volume=77|issue=1|pages=221–5|date=January 2003|pmid=12499345|doi=10.1093/ajcn/77.1.221|doi-access=free}}</ref> This could be from the fact that many foods are fortified by 160–175% over the required amount.<ref name="Quinlivan"/> Much of the elder population take [[dietary supplement|supplements]] that add 400&nbsp;μg to their daily folic acid intake. This is a concern because 70–80% of the population have detectable levels of unmetabolized folic acid in their [[blood]], a consequence of folic acid supplementation and fortification.<ref name=Chustecka2009/> However, at blood concentrations achieved via food fortification, folic acid has no known cofactor function that would increase the likelihood of a causal role for free folic acid in disease development.<ref name=Obeid2012/>

The U.S. National Center for Health Statistics conducts the biannual National Health and Nutrition Examination Survey (NHANES) to assess the health and nutritional status of adults and children in the United States. Some results are reported as What We Eat In America. The 2013–2014 survey reported that for adults ages 20 years and older, men consumed an average of 249&nbsp;μg/day folate from food plus 207&nbsp;μg/day of folic acid from consumption of fortified foods, for a combined total of 601&nbsp;μg/day of dietary folate equivalents (DFEs because each microgram of folic acid counts as 1.7&nbsp;μg of food folate). For women, the values are 199, 153 and 459&nbsp;μg/day, respectively. This means that fortification led to a bigger increase in folic acid intake than first projected, and that more than half the adults are consuming more than the RDA of 400&nbsp;μg (as DFEs). Even so, fewer than half of pregnant women are exceeding the pregnancy RDA of 600&nbsp;μg/day.<ref>{{cite web|url=https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/1314/Table_1_NIN_GEN_13.pdf|title=TABLE 1: Nutrient Intakes from Food and Beverages|website=What We Eat In America, NHANES 2012–2014 (2016)|access-date=12 October 2018|archive-date=24 February 2017|archive-url=https://web.archive.org/web/20170224042515/https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/1314/Table_1_NIN_GEN_13.pdf|url-status=live}}</ref>

Before folic acid fortification, about 4,100 pregnancies were affected by a neural tube defect each year in the United States. The [[Centers for Disease Control and Prevention]] reported in 2015 that since the addition of folic acid in grain-based foods as mandated by the FDA, the rate of neural tube defects dropped by 35%. This translates to an annual saving in total direct costs of approximately $508 million for the NTD-affected births that were prevented.<ref>{{cite journal|title=Updated Estimates of Neural Tube Defects Prevented by Mandatory Folic Acid Fortification — United States, 1995–2011|journal=MMWR. Morbidity and Mortality Weekly Report|volume=64|issue=1|pages=1–5|date=16 January 2015|pmid=25590678|pmc=4584791|url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6401a2.htm|author=Centers for Disease Control Prevention (CDC)|access-date=15 September 2019|archive-date=31 July 2020|archive-url=https://web.archive.org/web/20200731174802/https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6401a2.htm|url-status=live}}</ref><ref name="cdc.gov">{{Cite web|title=Birth Defects COUNT {{!}} Folic Acid {{!}} NCBDDD {{!}} CDC|url=https://www.cdc.gov/ncbddd/folicacid/global.html#1|website=www.cdc.gov|access-date=16 November 2015|url-status=live|archive-url=https://web.archive.org/web/20151113191745/http://www.cdc.gov/ncbddd/folicacid/global.html#1|archive-date=13 November 2015}}</ref>