Which foods are enriched/fortified with folic acid

The question is, to what effect? On the plus side, a study published in the journal Circulation March 14, found that the rate of stroke deaths fell dramatically in the United States and Canada during the first four years of fortification, compared with the seven preceding years. There was no such improvement and no fall in the rate of neural tube defects in England and Wales, where fortification is not mandatory.

Stroke mortality has gradually declined since , probably because of wider use of statins, aspirin, and other medications, as well as lifestyle changes. But the authors of the study believe the sharp drop between and is probably due to fortification. However, about the time that fortification was mandated, there was also an uptick in colorectal cancer. Researchers at Tufts University, working with large population-based cancer registries, studied trends in colorectal cancer from to in the United States and Canada.

The results, published in the July issue of Cancer Epidemiology Biomarkers and Prevention, showed a year decline that was suddenly reversed in the early fortification years, when average blood levels of folate doubled. As a result, an extra four to six cases of colorectal cancer per , people per year — a total of 16, extra cases — were estimated to have occurred. Although the chronological link between increased colorectal cancer cases and higher blood levels of folate isn't proof of cause and effect, the Tufts researchers think there are biological reasons why extra folic acid may be to blame.

Folic acid and folate play complex roles in the body. There's compelling evidence that high dietary intake of folate may protect healthy cells against colorectal and other cancers. But there's equally strong laboratory and clinical evidence that — under certain circumstances — folic acid can stimulate the growth of cancer cells. That trial took place between and and involved 1, men and women who had all had procedures to remove adenomatous polyps the kind most likely to turn into cancer.

To find out if folic acid would prevent more polyps from developing, researchers assigned subjects to receive either 1, mcg of folic acid per day or a placebo. Colonoscopies performed after three years and again three to five years later found little difference in the incidence of adenomas. But at the second follow-up, the subjects taking folic acid had nearly double the rate of advanced adenomas and were more than twice as likely to have three or more precancerous polyps.

This study doesn't tell us whether folic acid supplements prevent or promote the development of polyps in the first place. But it raises concerns about the effects of excessive folic acid from both supplements and fortification, especially on people ages 50 and over, who are more likely to already have polyps. There's a lot we don't know. Although blood levels of folate have increased in the population as a whole and homocysteine levels have come down, only long-term monitoring can tell us whether fortifying foods with folic acid is a safe or effective public health strategy — and clarify who is more or less likely to benefit.

For cereal bars and toaster pastries, the original folate content data were replaced by the measured folate content. For fortified breakfast cereals, we replaced the original folate content data by the measured folate content that best matched each particular cereal.

The difference between measured folate content of each fortified breakfast cereal, breakfast bar and toaster pastry and this average amount assigned as natural folate was considered to be folic acid. As part of the 5th and 6th offspring cohort examinations, blood samples were obtained from subjects who had fasted for at least 10 h.

We performed our analysis separately for individuals who did and did not use B vitamin supplements, with supplement use defined as taking a multivitamin containing folic acid at least once per week. Total folate, natural folate and folic acid values were positively skewed; thus, square-root transformations were used to normalize these data, and means based on square-root transformations are reported. To estimate the effect of folic acid fortification on folate intake in this cohort, we compared total folate, natural folate and folic acid means between the exposed group and nonexposed groups at baseline and follow-up to assess differences between the groups, and we measured the changes in total folate, natural folate and folic acid within the exposed and nonexposed groups between the two time points baseline and follow-up.

We also calculated a direct estimate of the mean within individual difference for the three measures of folate intake between the baseline and follow-up. The differences in the folate intake measures between baseline and follow-up were normally distributed; thus, no data transformations were required. The resulting mean differences were similar, but not identical to the difference of the mean intakes at follow-up and baseline because these latter means were based on transformed data.

Total folate, natural folate and folic acid intake were adjusted for age, gender, number of cigarettes smoked per day, body mass index and total energy intake. In addition to these factors, the mean differences of the three folate intake measures were also adjusted for their respective baseline intakes. We used the Tukey adjustment to account for multiple comparisons between means.

The prevalence of intakes below the EAR was adjusted by the variables mentioned previously. Because of the small numbers of subjects with folic acid intakes above the UL, we present only the crude prevalence for the intake measures based on the UL. We estimated folate intake in a group of nonusers and users of supplements containing B-vitamins who were not exposed to fortification at follow-up nonexposed group and in another group of nonusers and users of B-vitamin supplements who were exposed to fortification at follow-up exposed group Table 1.

At the time of the 5th examination, the age range of the cohort was between 30 and 80 y and the mean age in each group was between 54 and 56 y. The proportion of women within nonusers and users of B-vitamin supplements was similar between the exposed and nonexposed group, although women were more likely to use B-vitamin supplements than men.

Estimation of folate intake among individuals from the Framingham Offspring Cohort exposed and not exposed to folic acid fortification, according to folic acid supplement use 1. FA, NF and total folate means at baseline and follow-up are based on square root transformations. The difference represents the mean of the within-subject difference between follow-up and baseline and was not transformed. Therefore, the mean difference may not be equal to the difference of the transformed means.

Baseline refers to 5th Framingham Offspring examination, which was completed before the start of FA fortification. Follow-up refers to the 6th examination, which started before fortification was implemented and extended over the time period during which fortification was implemented. Fortification was not in place during the 6th examination at the time the nonexposed group was examined but was in place at the time the exposed group was examined.

The multivariable-adjusted folic acid, natural folate and total folate mean intakes are reported in Table 1 for both groups at baseline and follow-up. Among individuals who did not use B-vitamin supplements, folic acid, natural folate and total folate intakes did not differ between groups at baseline. Among those who used B-vitamin supplements, folic acid, natural folate and total folate intakes were not different at baseline when the exposed and nonexposed groups were compared.

Similar changes occurred in men and women. The effect of fortification on the prevalence of folate intake below the EAR was similar in men and women.

Among those who used supplements and were exposed to fortification at the 6th examination, there were no men and only two women who had intakes below the EAR at baseline and no men or women with intakes this low after fortification. Among those not exposed to fortification, the prevalence of men and women with intakes below the EAR did not change between baseline and follow-up and was similar to the baseline prevalence for those exposed to fortification.

Among those who used B-vitamin supplements, the prevalence of individuals with folic acid intake above the UL was essentially the same at baseline in the nonexposed 2. However, at follow-up, the prevalence of individuals in the exposed group with folic acid intake above the UL increased from 1. In this cohort, the introduction of folic acid fortification appeared to increase folic acid intake by approximately twice as much as expected on the basis of earlier dietary modeling.

For these estimations, it was assumed that enriched cereal-grain products contained the amount of folic acid specified in the applicable regulations. For each product, the measured amount of total folate was compared with the amounts declared in the label and the amounts of folic acid required by regulation. In a considerable number of the food products analyzed, the measured amount of folate was appreciably higher than the folic acid levels required to be added by regulation The folic acid fortification regulation provides for a single level of fortification for some of the products enriched bread, rolls and buns and enriched flour and for a range of levels of fortification for others enriched farina, corn grits, corn meals, rice, macaroni and noodle products.

This provision allows manufacturers of these products some flexibility in the amount of folic acid added to these products to ensure that the amount of folic acid required by the regulations and declared on the labels will be present throughout the shelf-life of the product. The overages observed largely explained our substantially higher estimations of the increase in folic acid intake resulting from the implementation of folic acid fortification.

We assessed inadequacy of total folate intake estimates using the EAR, which is the parameter suggested by the DRI committee to assess inadequacy of a particular nutrient intake in a group of individuals We also calculated the prevalence of individuals with folic acid intakes above the UL for folate. It is based on folic acid, not total folate, because there was no evidence to indicate that excessive intakes of natural folate caused adverse health effects. The UL was determined on the basis of studies suggesting that large intakes of folic acid could trigger or aggravate neurologic damage in individuals with B deficiency The prevalence of individuals with folic acid intakes above the UL was notable only among individuals who used B-vitamin supplements and were exposed to folic acid fortification Although our preliminary indirect assessment of risk based on high folic acid intakes in association with low vitamin B status found few subjects with both conditions, there has been no direct assessment of risk associated with increased folic acid intake in older individuals, nor has there been any systematic examination of potential adverse effects on children.

Lewis et al. The lack of information on actual folic acid intakes of children and potential for high folic acid intakes in both children and older adults indicates a critical need for further research.

There are several potential sources of imprecision in our estimations of folate intake. The FFQ does not provide a precise estimate of nutrient intake, but it is a relatively inexpensive and simple way in which to assess average long-term intake of a nutrient The semiquantitative FFQ used for this study was validated in the past to assess folate intake, 18 , 19 but it has not yet been validated in the era of fortification.

Our estimation of folic acid in fortified foods, based on the calculated difference between the new measured total folate value and the total folate value for each food in the existing food composition database, may lead to an overestimation of folic acid intake. The limitation of this approach is that the current folate values listed in the food composition database were measured using the traditional method in which the food sample was treated with folate conjugase, whereas the new measured total folate content in fortified foods was determined using a new method that uses trienzyme extraction; this method has been shown to result in higher folate values compared with the traditional approach The traditional method may underestimate total folate content due to incomplete release of folate from the food matrix and incomplete cleavage of the polyglutamate chain However, the values of natural folate in enriched cereal-grain products are very small relative to the folic acid added to these products, and even if there is an underestimation of the current food composition database values of folate in enriched cereal-grain products, it would have little overall effect on our estimations of folic acid in fortified foods.

Our inability to identify the variety of mixed dishes and breaded foods using the FFQ may also lead to underestimation of folic acid.

Another potential limitation of the folate data derives from the fact that our values of measured folate were not based on a systematic study of the U.

Although these products were selected on the basis of market data and represent the top-ranked products covered by the fortification regulations, they comprise a survey of a limited number of foods within enriched cereal-grain categories. Furthermore, these foods were collected in the Washington, DC metropolitan area.

We have no comparable data on foods available in the Southern New England region during the period of this study. The limitations of our estimates of the change in folate intake associated with fortification underscore the critical need for food composition tables that differentiate between natural folate present in foods and folic acid added to foods to allow assessment of total folate and folic acid intake in individuals and populations Which populations are folic acid supplementation and fortification designed to reach?

Folic acid supplementation and fortification are designed to reach women of reproductive age to help prevent neural tube defects. Why do the folic acid recommendations include the use of supplements or fortification?

The use of dietary supplements and consuming fortified foods can provide the amount of folic acid needed for the prevention of neural tube defects. A woman of reproductive age can decide to take a supplement containing folic acid or to eat foods fortified with folic acid, or both, depending on her dietary habits.

What are the differences between supplementation and fortification? A dietary supplement can provide the full recommended amount of folic acid to a woman of reproductive age to help prevent her baby from having a neural tube defect. However, this approach requires remembering to take the supplement every day. Moreover, while they are relatively inexpensive, supplements can be costly for some women. With mandatory fortification of staple foods , a large proportion of the population is getting more folic acid; therefore, getting enough folic acid to prevent neural tube defects does not require behavior change such as taking a daily vitamin.

Additionally, the added cost to the consumer for fortified food products is low How have supplementation and fortification affected the number of babies born each year with neural tube defects? Consuming folic acid from fortified foods and vitamin supplements has been proven to prevent neural tube defects , which can be fatal or cause varying degrees of disability. This is a detailed review of vitamin D toxicity and how much vitamin D is considered too much.

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