Case for mandatory fortification of food with folate in Australia, for the prevention of neural tube defects

BACKGROUND: Since the publication of randomized controlled trials demonstrating the prevention of neural tube defects (NTDs) with periconceptional folate, several Australian states have promoted an increase in periconceptional use of folic acid supplements. Since 1996, voluntary fortification of food with folate has been allowed in Australia and New Zealand for the purpose of preventing NTDs. METHODS: For this report, we synthesized published and unpublished data on folic acid supplement use, voluntary fortification, and trends in NTDs. RESULTS: There has been an increase in the proportion of women (up to 30-40%) taking periconceptional folic acid supplements in Australia, and many foods (mainly breakfast cereals) are fortified. Supplement use is strongly correlated with educational and socioeconomic status; consumption of voluntarily fortified foods is not. There has been a fall in NTDs of about 30% in the non-Aboriginal population, but no change has been seen in the Aboriginal population. CONCLUSIONS: These data support mandatory fortification of food as a more equitable approach to achieving sufficient folate intake in the periconceptional period for all women in Australia and New Zealand to prevent the majority of NTDs in their offspring. In May 2004, based on these and other considerations, the Australia and New Zealand Food Regulation Ministerial Council agreed that mandatory fortification of food with folate should be considered as a priority.     

PROVISION OF COMMUNITY‐WIDE BENEFITS IN PUBLIC HEALTH INTERVENTION RESEARCH: THE EXPERIENCE OF INVESTIGATORS CONDUCTING RESEARCH IN THE COMMUNITY SETTING IN SOUTH ASIA

Background: This article describes the types of community‐wide benefits provided by investigators conducting public health research in South Asia as well as their self‐reported reasons for providing such benefits. Methods: We conducted 52 in‐depth interviews to explore how public health investigators in low‐resource settings make decisions about the delivery of ancillary care to research subjects. In 39 of the interviews respondents described providing benefits to members of the community in which they conducted their study. We returned to our narrative dataset to find answers to two questions: What types of community‐wide benefits do researchers provide when conducting public health intervention studies in the community setting, and what reasons do researchers give when asked why they provided community‐wide benefits? Findings: The types of community‐wide benefits delivered were directed to the health and well‐being of the population. The most common types of benefits delivered were the facilitation of access to health care for individuals in acute medical need and emergency response to natural disasters. Respondents' self‐reported reasons when asked why they provided such benefits fell into 2 general categories: intrinsic importance and instrumental importance.     

Scientific evidence supporting folic acid fortification of flour in Australia and New Zealand

BACKGROUND: Fortification of flour with folic acid is a safe, sustainable, and cost-effective approach for preventing spina bifida and anencephaly, and it is likely to confer multiple health benefits to the adult population. Scientists and advocates are bringing this intervention to the attention of policymakers in countries around the world, and consequently the demand for sound, science-backed policy rationale is increasing. METHODS: We recently prepared this scientific review for scientists, physicians, and advocates who were promoting mandatory folic acid fortification of flour in Australia and New Zealand. This short document references the most relevant published scientific data and national and international recommendations from other countries and presents an argument for fortification based on demonstrated need, proven effectiveness, safety, and multiple health benefits. CONCLUSIONS: With some modifications, this document could be utilized in other countries considering fortification of flour or other staple products with folic acid.     

Insufficient folic acid intake in the Netherlands: what about the future?

BACKGROUND: In 1993 all women of childbearing age in the Netherlands were advised to take a daily 0.5 mg folic acid pill to reduce the risk for neural tube defects. This study describes both recent and past awareness and use of folic acid supplements in relation to socio-economic status in the Northern Netherlands. The consequences of a recent report of the Dutch Health Council report will be discussed as well. METHODS: In the most recent cross-sectional study (November 2000), pregnant women filled out a questionnaire. Out of 473 women, 461 were willing to cooperate. The highest fulfilled level of education was taken as an indicator for socio-economic status. RESULTS: Seventy-seven percent (n = 357) of the respondents had heard about folic acid before being pregnant. Sixty-three percent (n = 289) knew about the protective effect for NTDs and 33% (n = 151) knew the entire advised period. Sixty-one percent (n = 265) of the respondents used folic acid in some part of the advised period and 36% (n = 164) used it in the entire advised period. Higher educated women knew more about folic acid and used it significantly more often in the periconceptional period than lower educated women. CONCLUSIONS: Because compliance to proper use of folic acid was poor, food fortification in the Netherlands must be seriously considered. The Dutch Health Council wants to limit the fortification of food products to those products that are especially aimed for women who wish to become pregnant. The fortification of specific products instead of staple foods is a missed chance to reduce NTDs and possibly other birth defects and cardiovascular defects as well.     

HISPANIC AND NON-HISPANIC RESPONSES TO CONCEPTS FOR FOUR FOODS

Hispanics and non‐Hispanics Americans participated in four sets of studies dealing with health‐oriented foods, with the goal to identify how they respond to food categories relevant in any cuisine. Each study comprised a conjoint analysis using 36 elements followed by a self‐profiling questionnaire to learn more about Hispanic and non‐Hispanic food responses to concepts for four different product categories (morning bread, bottled water, healthful salad dressing and popcorn as a snack). The study identified patterns of preference of marketing statements in the areas of health information, sensory characteristics, emotional benefits and endorsements. Conjoint utility values generated by both Hispanics and non‐Hispanic respondents correlated highly, suggesting that their food attitudes are quite similar for“non‐signature”products despite the differences in their original cuisines.     

Intake and Biomarkers of Folate and Risk of Cancer Morbidity in Older Adults,NHANES 1999-2002 with Medicare Linkage

Background

After the 1998 mandatory folic acid fortification of enriched cereal-grain products in the U.S., safety concerns were raised that excess consumption of folic acid and high blood folate biomarkers detected in adults may increase the risk of certain types of cancer.

Methods

Baseline data from about 1400 participants in the National Health and Nutrition Examination Survey (NHANES) 1999–2002, aged ≥ 57 years were linked to Medicare and mortality files through December 31, 2007. Using cox proportional hazards regression models, we assessed associations between dietary folate equivalents, folate biomarkers, the presence of unmetabolized folic acid and, overall cancer incidence.

Results

With 8,114 person-years of follow-up (median follow-up, 6.3 years), about 125 cancer cases were identified. After adjusting for confounders, the hazard ratios of the highest quartile versus the second quartile of RBC folate and dietary folate equivalents were 0.54 (95% CI: 0.31–0.93) and 0.54 (95% CI: 0.30–0.95), respectively. Additionally, serum and RBC folate as continuous variables were inversely and significantly associated with cancer incidence (p<0.01). No significant associations were observed between the presence of unmetabolized folic acid, intake of naturally-occurring food folate or folic acid separately, and cancer incidence.

Conclusions

High total folate intake and biomarkers in older adults appear to be protective against cancer in post-folic acid fortification years. This study does not show a negative impact of current level of folic acid fortification on cancer risk. As this is one of the few studies to examine the association between unmetabolized folic acid and cancer outcome, a study including a larger nationwide representative sample of the U.S. population is needed.     

Tracking the prevention of folic acid-preventable spina bifida and anencephaly

BACKGROUND: The fortification of wheat flour with folic acid prevents most cases of spina bifida and anencephaly by raising serum folate levels among women capable of bearing children, as does encouraging women to consume folic acid supplements prior to pregnancy. Unfortunately, surveillance is conducted in few countries where the need is greatest. METHODS: A method for assessing the prevention of these birth defects is presented that combines fortification program information with country case prevalence estimates. RESULTS: This approach suggests that about 70% of all cases could be prevented within a year of implementation of fortification programs, were it not for the inertia of regulatory agencies. CONCLUSIONS: Professional researchers and clinicians can help combat this situation by becoming advocates for child health in their respective countries.     

Salt and the glycaemic response.

The possibility that salt increases plasma glucose and insulin responses to starchy foods was investigated. Six healthy adults took four morning test meals randomly: 50 g carbohydrate as cooked lentils or white bread, with or without 4.25 g of added salt (an amount within the range of salt found in a meal). When salt was added to the lentils the incremental area under the three hour plasma glucose curve was significantly greater than that for lentils alone (43.2 mmol.min/l v 11.1 mmol.min/l (778 mg.min/100 ml v 200 mg.min/100 ml]. When salt was added to bread the peak glucose concentration was significantly higher than that for unsalted bread (6.96 mmol/l v 6.35 mmol/l (125 mg/100 ml v 114 mg/100 ml], and this was followed by relative hypoglycaemia. Plasma insulin concentrations at 45 minutes were higher after a meal of salted lentils and salted bread than after the unsalted foods (p less than 0.05). The high insulin concentration after salted bread was sustained for one hour after the meal, thus the mean area under the three hour curve was 39% greater than that for unsalted bread (p less than 0.05). Salt may increase the postprandial plasma glucose and insulin responses to lentils and bread by accelerating the digestion of starch by stimulating amylase activity or accelerating small intestinal absorption of the liberated glucose, or both. The findings of this preliminary study, if confirmed by others, would support the recommendation that diabetics, as well as the general population, should reduce their intake of salt.     

White blood cell global methylation and IL-6 promoter methylation in association with diet and lifestyle risk factors in a cancer-free population

Altered levels of global DNA methylation and gene silencing through methylation of promoter regions can impact cancer risk, but little is known about their environmental determinants. We examined the association between lifestyle factors and levels of global genomic methylation and IL-6 promoter methylation in white blood cell DNA of 165 cancer-free subjects, 18–78 years old, enrolled in the COMIR (Commuting Mode and Inflammatory Response) study, New York, 2009–2010. Besides self-administrated questionnaires on diet and physical activity, we measured weight and height, white blood cell (WBC) counts, plasma levels of high sensitivity C-reactive protein (hs-CRP), and genomic (LINE-1) and gene-specific methylation (IL-6) by pyrosequencing in peripheral blood WBC. Mean levels of LINE-1 and IL-6 promoter methylation were 78.2% and 57.1%, respectively. In multivariate linear regression models adjusting for age, gender, race/ethnicity, body mass index, diet, physical activity, WBC counts and CRP, only dietary folate intake from fortified foods was positively associated with LINE-1 methylation. Levels of IL-6 promoter methylation were not significantly correlated with age, gender, race/ethnicity, body mass index, physical activity or diet, including overall dietary patterns and individual food groups and nutrients. There were no apparent associations between levels of methylation and inflammation markers such as WBC counts and hs-CRP. Overall, among several lifestyle factors examined in association with DNA methylation, only dietary folate intake from fortification was associated with LINE-1 methylation. The long-term consequence of folate fortification on DNA methylation needs to be further evaluated in longitudinal settings.     

White blood cell global methylation and IL-6 promoter methylation in association with diet and lifestyle risk factors in a cancer-free population

Altered levels of global DNA methylation and gene silencing through methylation of promoter regions can impact cancer risk, but little is known about their environmental determinants. We examined the association between lifestyle factors and levels of global genomic methylation and IL-6 promoter methylation in white blood cell DNA of 165 cancer-free subjects, 18–78 years old, enrolled in the COMIR (Commuting Mode and Inflammatory Response) study, New York, 2009–2010. Besides self-administrated questionnaires on diet and physical activity, we measured weight and height, white blood cell (WBC) counts, plasma levels of high sensitivity C-reactive protein (hs-CRP), and genomic (LINE-1) and gene-specific methylation (IL-6) by pyrosequencing in peripheral blood WBC. Mean levels of LINE-1 and IL-6 promoter methylation were 78.2% and 57.1%, respectively. In multivariate linear regression models adjusting for age, gender, race/ethnicity, body mass index, diet, physical activity, WBC counts and CRP, only dietary folate intake from fortified foods was positively associated with LINE-1 methylation. Levels of IL-6 promoter methylation were not significantly correlated with age, gender, race/ethnicity, body mass index, physical activity or diet, including overall dietary patterns and individual food groups and nutrients. There were no apparent associations between levels of methylation and inflammation markers such as WBC counts and hs-CRP. Overall, among several lifestyle factors examined in association with DNA methylation, only dietary folate intake from fortification was associated with LINE-1 methylation. The long-term consequence of folate fortification on DNA methylation needs to be further evaluated in longitudinal settings.     

Radiation from mobile phone systems: Is it perceived as a threat to people's health?

The aim of this study was to explore the prevalence, nature and determinants of concerns about mobile phone radiation. We used data from a 2006 telephone survey of 1004 people aged 15+ years in Denmark. Twenty‐eight percent of the respondents were concerned about exposure to mobile phone radiation; radiation from masts was of concern to about 15%. In contrast, 82% were concerned about pollution. Nearly half of the respondents considered the mortality risk of 3G phones and masts to be of the same order of magnitude as being struck by lightning (0.1 fatalities per million people per year) while 7% thought it was equivalent to tobacco‐induced lung cancer (～500 fatalities per million per year). Among women, concerns about mobile phone radiation were positively associated with educational attainment, perceived mobile phone mortality risk and concerns about unknown consequences of new technologies. More than two thirds of the respondents felt that they had received inadequate public information about the 3G system. The results of the study indicate that the majority of the population has little concern about mobile phone radiation while a small minority is very concerned. Bioelectromagnetics 30:393–401, 2009. © 2009 Wiley‐Liss, Inc.     

Wholemeal versus wholegrain breads: proportion of whole or cracked grain and the glycaemic response.

STUDY OBJECTIVE--To determine the effect on the glycaemic response to bread of the ratio of whole cereal grains to milled flour. DESIGN--Randomised assignment of groups of diabetic volunteers to test and control meals, taken after an overnight fast. Test foods were also analysed for in vitro digestion with human saliva. SETTING--Tertiary care centre. PATIENTS--Groups of six drawn from pool of 16 volunteers with diabetes mellitus (11 men, five women; mean age 64 (SE 3); 10 taking insulin, five taking oral agents, one controlled by diet; other characteristics comparable). INTERVENTIONS--All patients took standard white bread control meals on three occasions spanning the study and on different mornings took test meals containing varying ratios of whole cereal grains (barley or cracked wheat) to milled flour (75:25, 50:50, 0:100). All meals contained 50 g available carbohydrate and were eaten in 15 minutes. Capillary blood samples were taken for determination of glucose concentrations every 30 minutes for three hours. END POINT--Glycaemic index of foods (= increase in area under blood glucose concentration curve for test food divided by increase in area under curve for white bread control X 100). MEASUREMENTS AND MAIN RESULTS--Significant trend to lower glycaemic index with increasing proportion of whole cereal grains in test bread (p less than 0.05) and lower in vitro digestibility (p less than 0.001). Breads containing up to 75% whole grain were considered palatable. CONCLUSIONS--Breads containing a high proportion of whole cereal grains may be useful in reducing the postprandial blood glucose profile in diabetics because they are more slowly digested. These breads should be called "wholegrain" in distinction to "wholemeal" breads made from milled flour.     

UK policy on folate fortification of foods

The UK Food Standards A gency has decided not to recommend fortification of foods with folate, the family of vitamins associated with the prevention of neural tube defects in babies. This is a change in attitude from previous recommendations made by a series of committees and reports in the UK. Notably, it differs from US policy on the matter. The debate may not be over yet, however.     

Folate biofortification in food plants

Folate deficiency is a global health problem affecting many people in the developing and developed world. Current interventions (industrial food fortification and supplementation by folic acid pills) are effective if they can be used but might not be possible in less developed countries. Recent advances demonstrate that folate biofortification of food crops is now a feasible complementary strategy to fight folate deficiency worldwide. The genes and enzymes of folate synthesis are sufficiently understood to enable metabolic engineering of the pathway, and results from pilot engineering studies in plants (and bacteria) are encouraging. Here, we review the current status of investigations in the field of folate enhancement on the eve of a new era in food fortification.     

Public awareness of organ donation.

A telephone survey of public attitudes toward organ donation and transplantation was conducted in a community in southwestern Ontario. The subjects were selected at random; the response rate was 57%. Of the 50 respondents 62% stated that they had signed the organ donor card accompanying their driver''s licence. These respondents were more likely than those who did not sign it to have discussed organ donation with their families. At least 80% of the respondents said they would agree to donate their organs and those of their next-of-kin, and 80% said that the organ donor card should be considered a legal document. Organ transplantation was regarded by all but one respondent as an acceptable medical procedure. Also discussed were concerns about organ donation and possible strategies to improve the availability of organs for transplantation.     

A Novel Approach to Evaluating the Iron and Folate Status of Women of Reproductive Age in Uzbekistan after 3 Years of Flour Fortification with Micronutrients

Background

The Uzbekistan 1996 Demographic Health Survey reported 60.4% of women of reproductive age (WRA) had low hemoglobin concentrations (<120 g/L), and anemia was an important public health problem. Fortification of wheat flour was identified as an appropriate intervention to address anemia due to the ubiquitous consumption of wheat flour. A National Flour Fortification Program (NFFP) was implemented in 2005.

Methodology/Principal Findings

After 3-years of the NFFP, a national survey using large country-lot quality assurance sampling was carried out to assess iron, folate, hemoglobin and inflammation status of WRA; the coverage and knowledge of the fortified first grade UzDonMakhsulot (UDM) flour/grey loaf program; and consumption habits of women to investigate the dietary factors associated with anemia. Estimated anemia prevalence was 34.4% (95% CI: 32.0, 36.7), iron depletion 47.5% (95% CI: 45.1, 49.9) and folate deficiency 28.8% (95% CI: 26.8, 30.8); the effect of inflammation was minimal (4% with CRP >5 mg/L). Severe anemia was more prevalent among folate deficient than iron depleted WRA. Presence of UDM first grade flour or the grey loaf was reported in 71.3% of households. Among WRA, 32.1% were aware of UDM fortification; only 3.7% mentioned the benefits of fortification and 12.5% understood causes of anemia. Consumption of heme iron-containing food (91%) and iron absorption enhancers (97%) was high, as was the consumption of iron absorption inhibitors (95%).

Conclusions/Significance

The NFFP coincided with a substantial decline in the prevalence of anemia. Folate deficiency was a stronger predictor of severe anemia than iron depletion. However, the prevalence of iron depletion was high, suggesting that women are not eating enough iron or iron absorption is inhibited. Fortified products were prevalent throughout Uzbekistan, though UDM flour must be adequately fortified and monitored in the future. Knowledge of fortification and anemia was low, suggesting consumer education should be prioritized.     

Salt Intake and Health Risk in Climate Change Vulnerable Coastal Bangladesh: What Role Do Beliefs and Practices Play?

BackgroundHigh salt consumption is an important risk factor of elevated blood pressure. In Bangladesh about 20 million people are at high risk of hypertension due to climate change induced saline intrusion in water. The objective of this study is to assess beliefs, perceptions, and practices associated with salt consumption in coastal Bangladesh.MethodsThe study was conducted in Chakaria, Bangladesh between April-June 2011. It was a cross sectional mixed method study. For the qualitative study 6 focus group discussions, 8 key informant interviews, 60 free listing exercises, 20 ranking exercises and 10 observations were conducted. 400 adults were randomly selected for quantitative survey. For analysis we used SPSS for quantitative data, and Anthropac and Nvivo for qualitative data.ResultsSalt was described as an essential component of food with strong cultural and religious roots. People described both health benefits and risks related to salt intake. The overall risk perception regarding excessive salt consumption was low and respondents believed that the cooking process can render the salt harmless. Respondents were aware that salt is added in many foods even if they do not taste salty but did not recognize that salt can occur naturally in both foods and water.ConclusionsIn the study community people had low awareness of the risks associated with excess salt consumption and salt reduction strategies were not high in their agenda. The easy access to and low cost of salt as well as unrecognised presence of salt in drinking water has created an environment conducive to excess salt consumption. It is important to design general messages related to salt reduction and test tailored strategies especially for those at high risk of hypertension.     

Neural tube defect rates before and after food fortification with folic acid

BACKGROUND: Since 1998, enriched cereal grains sold in the United States have been fortified with folic acid, to reduce the incidence of neural tube defects (NTDs). The Centers for Disease Control and Prevention (CDC) recently reported that NTD rates have decreased 26% since fortification, but that additional effort is needed to achieve the national goal of a 50% reduction. However, accurate determination of NTD rates requires counting antenatally detected cases; the CDC study noted that the number of prenatally diagnosed cases was likely underestimated. METHODS AND RESULTS: We examined studies from the United States and Canada that compared rates of NTDs before and after very similar fortification programs were instituted in each country. U.S. studies had incomplete ascertainment of prenatally diagnosed NTD cases, and as a result, underreported the number of NTDs prevented. Canadian studies, in which ascertainment was more complete, showed decreases in NTD rates up to 54%. CONCLUSIONS: There is a strong correlation between the completeness of ascertainment and the percentage decrease in NTD rates. Studies that identify cases best show that folic acid fortification is preventing around 50% of NTDs. The percentage of NTDs that are folate-preventable in the United States is uncertain, but is probably 50-60%. Thus, we may be quite close to achieving the optimum level of protection at current fortification levels.     

Attitudes of general practitioners to prehospital thrombolysis.

OBJECTIVE--To investigate reasons for general practitioners not giving thrombolytic treatment to eligible patients with acute myocardial infarction. DESIGN--Postal questionnaires were sent to 424 general practitioners. SUBJECTS--97 general practitioners who had taken part in the Grampian region early anistreplase trial, 185 whose practices in Scotland were at least 24 km from a district general hospital, and 142 who had attended postgraduate conferences at which thrombolysis had been discussed; 87, 158, and 125 respectively responded. MAIN OUTCOME MEASURES--Answers to questions about readiness to use thrombolytic treatment. RESULTS--Response rate was 87% (370/424). Almost all respondents (350) were convinced of benefits of thrombolysis for acute myocardial infarction, and 277 were convinced that there were additional benefits from its administration in the community at first opportunity. Most doctors working 16 km or more from hospital thought that giving treatment at home would appreciably save time (200/274). Most doctors agreed that they could make time to give thrombolytic treatment (278), and would be willing to record an electrocardiogram (284), and would be able to interpret it (280). Sixty four respondents (17%) reported using thrombolytic treatment in previous year. Among non-users, 150 (49%) were unwilling to use thrombolytic treatment without further training. While many non-users (210 (69%)) were willing to use thrombolytic treatment without encouragement from Department of Health, 184 (60%) were unwilling to use it unless encouraged to do so by their local cardiologist. CONCLUSIONS--The need to become better informed about thrombolysis and lack of encouragement from local cardiologists were important factors preventing wider use of thrombolytic treatment in the community by general practitioners.     

Mandated Reporting of Suspected Animal Harm by Australian Veterinarians: Community Attitudes

ABSTRACT

Research demonstrates that animal abuse is linked with various forms of interpersonal violence and that veterinarians themselves are concerned about this link. However, Australian veterinarians are not currently mandated to report cases of suspected animal abuse (AA), a position outlined by the Australian Veterinary Association under their “Animal Welfare principles and philosophy–Animal Abuse” section. A range of barriers to reporting suspected abuse cases have been identified. Barriers specifically mentioned in the AVA statement regarding the non-mandatory reporting stance were presented to a community sample of 209 participants. While 161 (77%) indicated they were aware that certain professionals were mandated to report animal abuse, notably 76% of these (n=123) indicated (incorrectly) that veterinary professionals in Australia were so mandated. Over half of the participants (n=117, 58%) indicated that “Concerns about the continued welfare of the animal victim” was, in their opinion, the most significant barrier to introducing mandatory reporting for the veterinary profession in Australia. The implications of community opinion regarding veterinarians and mandated reporting, along with acknowledgement of barriers and potential consequences of mandated reporting, are discussed.