The folate debate

Panacea or public health experiment? Kellie Bisset finds some experts worried that adding folate to bread may bring health dangers

Professor Fiona Stanley is a patient woman. The child health expert and former Australian of the Year has been campaigning to have bread products fortified with folic acid for nearly four years. It's a grand plan that aims to reduce the rate of babies born with neural tube birth defects such as spina bifida. And evidence shows that the B group vitamin - known as folate in its natural form - can reduce the incidence of these defects by as much as 70 per cent. Stanley has watched for the best part of a decade as other countries have made folate fortification mandatory. She's looked on as the rate of neural tube defects has plummeted by between 30 per cent and 50 per cent in the US, Canada and Chile. She's lowered her expectations on how much folic acid we should add to bread, just to keep the idea alive. And she's hoping that finally, recommendations from Food Standards Australia New Zealand (FSANZ) supporting fortification will be adopted by federal, state and territory governments. But the scheme to have all Australians eating fortified bread has hit some turbulence, despite the fact that it could save the health system more than $120 million a year.

Not only is the food industry opposed to the plan, consumers are also sceptical. And to further complicate things, there are voices of alarm being raised within health circles about the potential risks of mass supplementation. "This is effectively a population-wide experiment," says Mark Lawrence, a senior lecturer in public health and nutrition at Deakin University. "The whole thing seems to be being rushed through." Lawrence and leading nutritionist Rosemary Stanton are both concerned about recent evidence suggesting a link between folate and colorectal and breast cancers. "The evidence is by no means conclusive, but if there is any chance of any danger then we need to move carefully," Stanton says.

Neither believes enough weight has been given to several studies published this year suggesting there are health risks associated with higher folate levels. One, published in the American Journal of Clinical Nutrition, said a high intake could increase breast cancer risk in postmenopausal women (2006;83:895-904). Another in Gut (2006;55:1461-66) said those with lower folate levels had a decreased risk of colorectal cancer. In its final report on mandatory fortification, FSANZ says that because of uncertainty over potential health risks, fortification should be set to a conservative level of 80 to 180 micrograms (mcg) per 100g of bread. But it says the recent research does not alter its conclusion that folate intakes do not increase the risk of breast or colorectal cancer, or indeed pose any public health risk.

Elizabeth Milne supports this position. The senior research fellow at the Telethon Institute for Child Health Research in Perth was responsible for reviewing all available evidence on folate and cancer for FSANZ last year. She has also reviewed the more recent studies, and says the great weight of evidence is in favour of folate having a protective effect against colon and breast cancer. The Journal of Clinical Nutrition study was not population based, but in women taking part in a cancer screening trial who had "very high" folate levels in their system, and Milne says its results should be interpreted with caution. As for colorectal cancer, the Gut study was small and didn't control effectively for aspirin or alcohol use - both of which react with folate in the body. According to Milne the recent findings "would need to be replicated in well-designed studies before there would be justification for changing the decision to fortify".

The FSANZ final report on fortification discusses other potential health risks of a widespread increase in folic acid intake, such as multiple births, but says evidence on this is inconclusive. There has also been a suggestion that high intakes could mask Vitamin B12 deficiency in older people, although the report says levels would need to be more than 1000 micrograms a day for that to happen.

What has raised a few eyebrows though, is the report's admission that children are more likely to exceed the upper level for folic acid if staple foods are fortified. The recommended daily intake of folic acid in children is only 150 micrograms, whereas pregnant women, or those planning a pregnancy, need to take 400. The report says under the levels of fortification currently proposed, 7 per cent of 2-3 year-olds are expected to exceed the upper level of intake for folic acid. But despite acknowledging this as "undesirable" it doesn't believe it is a health risk.

Director of Food and Nutrition Australia Sharon Natoli concurs, arguing that most children don't eat enough fruit and vegetables anyway, so their natural levels of folate are unlikely to be high to begin with.

But Lawrence argues the long-term effects on children are a big unknown: "When you are talking about children you are talking about many years of raised levels." He says at the very least, folic acid should be removed from children's breakfast cereals to minimise the risk of them overdosing if mandatory fortification of bread is brought in. There is currently a voluntary fortification system operating nationally, and breakfast cereals have been targeted by manufacturers. In the US, between 15 per cent and 25 per cent of children under eight are estimated to have folic acid intakes above the upper level since fortification was introduced eight years ago. While no negative effects have been reported, FSANZ says it isn't clear if any surveillance is being done, since there was no commitment to monitor adverse health outcomes when the policy was launched.

In Australia, the need for ongoing monitoring is something the experts do agree on. "It is very important to monitor folate," Milne says. "As we go ahead someone has to make it happen." FSANZ says monitoring is outside its responsibility and Lawrence believes our weak and abysmal record on these things doesn't auger well for the future. "There is no commitment at a federal level to look at a national system of monitoring levels at all," he says.

The Australian Consumers Association has also raised concerns, saying it's irresponsible to consider any mandatory program without a commitment to monitoring. It has also criticised the lack of detail on how all of this might be communicated to the public.

But Stanley is more optimistic. "I think every state and territory minister is committed to monitoring. When you think of the data, almost all the things we want to monitor are collected anyway." So far, ministers have sent encouraging signs that fortification is imminent. In a communique released last month members of the Australia and New Zealand Food Regulation Ministerial Council reinforced their commitment to mandatory fortification "as quickly as possible". However, they delayed their decision for six months, asking FSANZ to review its plan to add folic acid to bread, rather than bread-making flour - a recommendation that has bread manufacturers fuming.

Despite last month's communique, the federal Government has signalled there might be more to the decision than ironing out these technical hurdles. Parliamentary secretary for health Christopher Pyne says any arguments over ongoing monitoring of folate levels are "jumping the gun" because a decision is yet to be made on fortification. "Some of the jurisdictions have raised concerns about the effectiveness of the policy given the cost to industry of implementing it," he says. "I think it would be inaccurate to say it was done and dusted. "There are other concerns with respect to whether bread is the best method to deliver folate because it would not deliver the daily intake required, and women would still be needing to take supplements."

The fact that women in the target group would not meet their daily requirements from fortified bread alone has been described as a serious flaw by critics of the national plan. They say that, rather than medicating 20 million Australians for the benefit of a small population, targeted education campaigns for women at risk would be a better use of public funds. But Stanley says there are a few holes in this argument. "If you shift the whole population distribution of folate intake you are going to make a difference," she says, even if a woman doesn't reach her recommended daily intake of 400 micrograms through eating bread. And the problem with targeted education campaigns is that they don't get optimal results.

Stanley was involved in a WA campaign to encourage women to eat more folate, but despite also having a policy of voluntary fortification, neural tube defects dropped by 30-40 per cent over 10 years rather than the 70 per cent she knew was possible. "We found it was the groups at highest risk we were not getting to - the Aboriginal women, the poor, the very young and the unplanned pregnancies," she says.

More than 40 countries have introduced mandatory fortification, but there has been resistance in Europe and the UK is expected to make a decision next year. "This is a global issue," Lawrence says. "Is exposing the whole population for the benefit of one target group an appropriate public health response?" Stanley, though, is firmly convinced that the risks are being overblown. "The one thing that worries me about any public health intervention is 'first do no harm'. We would not be pushing this if we were not very happy that this was an important intervention."

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Medicating an entire population for the benefit of one very small subgroup seems a bit loony. And doing it before the research is in is just plain irresponsible. There have already been far too many iatrogenic disasters




Surprisingly "healthy" foods

You might be able to claim virtue according to the prevailing religion yet



Eating healthy may be virtuous, but it just doesn't seem like that much fun. Truth is, most of us prefer the taste of French fries over that of oat bran. A glass of Burgundy sounds more tantalizing than a cup of wheat grass juice. And while a nice piece of fruit is no punishment, chocolate is exceedingly more tempting.

The good news: Not all of those seemingly unhealthy choices actually are. Cheese fries may never be a part of your recommended diet, but Russet potatoes alone are nothing to fear. In fact, they're full of disease-fighting antioxidants. Eating the whole box of chocolates still isn't a good idea. A square a day, however, may help prevent cancer and stave off weight gain.

If you're confused, we're not surprised. There's never been more information available on how to eat right. Books, food labels, Web sites--fast food restaurants even provide nutritional information for their meals. But it's hard to draw any simple conclusions from it all. Are carbs good or bad? How many calories are too many? What causes cancer now? No wonder dieticians say people tend to see healthy choices as too much trouble.

"We are in such a hurry, we're so busy multitasking that eating is no longer a solo event," says David Grotto, spokesperson for the Chicago-based American Dietetic Association. "It's an inconvenience. We have hunger, and we need to squash it. We need to wolf down some food. You're lucky if you remember what you ate the day before."

A recent ACNielsen study of how habits of eating and drinking outside the home develop offers a glimpse into what's going on. About 82% of consumers acknowledged that individuals are the most responsible for weight gain in the U.S. population. Only 6% place the biggest blame on fast food joints and 2% on food companies. Of those surveyed, 18% said the main factor leading to weight gain is that modern life is too easy for people to make an effort to be healthy.

Elisa Zied, author of So What Can I Eat?! and a spokeswoman for the American Dietetic Association, says people are frustrated by the conflicting research studies and news reports about what can harm or benefit them. Typically, they just want practical advice on what to eat. They're also unknowingly making bad choices. Most people know that soda and candy contain a lot of sugar. But they don't always realize that low-fat flavored yogurt, salad dressing and Chinese food (think chicken with broccoli), can too. Because of the new obsession with lowering our intake of trans fats, which food labels must now list, some people are consuming more saturated fats, she says.

Deepak Varma, senior vice president of customized research for ACNielsen, says consumers fall into "autopilot" mode, not really thinking about what they're buying or eating until they have a moment of truth in the form of a medical checkup or wanting to get in shape for an upcoming marriage. People also get in the habit of having larger portions because they want to get good value for their money, he says. Unfortunately, there is no cure all when it comes to waking up and taking control of your health. Grotto, who is writing a book about making friends with food, suggests viewing meals as both sources of sustenance and enjoyable experiences. To make that process a little easier, we asked dieticians to recommend a number of foods with surprising health benefits. Chocolate and bruschetta, anyone?

Once you incorporate these tips into your eating habits, try tackling more challenging ones. Jennifer Nelson, director of clinical dietetics at the Mayo Clinic in Rochester, Minn., says another way we can start to change is by asking restaurants for more healthy options and smaller portion sizes. Define value by the quality of your food, not its "supersize." "Small indiscretions can create bigger health issues," Nelson says. "The good news is that small attempts, the more we chip away at it--we can get big results, too."

Click here for the slideshow

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Just some problems with the "Obesity" war:

1). It tries to impose behavior change on everybody -- when most of those targeted are not obese and hence have no reason to change their behaviour. It is a form of punishing the innocent and the guilty alike. (It is also typical of Leftist thinking: Scorning the individual and capable of dealing with large groups only).

2). The longevity research all leads to the conclusion that it is people of MIDDLING weight who live longest -- not slim people. So the "epidemic" of obesity is in fact largely an "epidemic" of living longer.

3). It is total calorie intake that makes you fat -- not where you get your calories. Policies that attack only the source of the calories (e.g. "junk food") without addressing total calorie intake are hence pissing into the wind. People involuntarily deprived of their preferred calorie intake from one source are highly likely to seek and find their calories elsewhere.

4). So-called junk food is perfectly nutritious. A big Mac meal comprises meat, bread, salad and potatoes -- which is a mainstream Western diet. If that is bad then we are all in big trouble.

5). Food warriors demonize salt and fat. But we need a daily salt intake to counter salt-loss through perspiration and the research shows that people on salt-restricted diets die SOONER. And Eskimos eat huge amounts of fat with no apparent ill-effects. And the average home-cooked roast dinner has LOTS of fat. Will we ban roast dinners?

6). The foods restricted are often no more calorific than those permitted -- such as milk and fruit-juice drinks.

7). Tendency to weight is mostly genetic and is therefore not readily susceptible to voluntary behaviour change.

8). And when are we going to ban cheese? Cheese is a concentrated calorie bomb and has lots of that wicked animal fat in it too. Wouldn't we all be better off without it? And what about butter? It is just about pure fat. Surely it should be treated as contraband in kids' lunchboxes! [/sarcasm].

9). For a summary of the weak science behind the "trans-fat" hysteria, see here. Trans fats have only a temporary effect on blood chemistry and no lasting harm from them has ever been shown.

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