Folic acid: Prevention or a second best solution?

30 November 2009

Written by: Christopher Scanlon

Hot, steamy and delicious. Mouths water and diets crumble at the sight of the delectable dough. Since the 13th September 2009, our loaves of daily bread have contained folic acid. A controversial new food standard that makes it mandatory to fortify bread flour has its proponents cheering, and its detractors defiant.

“Anything that reduces the likelihood of neural tube defects is a good thing and my understanding is that it is not going to have any significant adverse health effects,” says Katherine Simmons. Simmons is an attractive young woman who sits patiently in her wheelchair, in the manner common to those who are used to waiting for care and attention. The 22 year-old was born with the most severe form of spina bifida rendering her spinal cord development incomplete.

John Simmons is the current president of the Spina Bifida Foundation of Victoria, an organization which provides help and support for its 200 members. The foundation is just one of the 60 community organizations housed in Ross House, a five storey building in Flinders Lane, Melbourne. Simmons has been a member of the foundation since 1987, shortly after his daughter Katherine, was born with spina bifida, a neural tube defect. Although the exact cause of this condition is unknown, the National Institute of Neurological Disorders and Stroke, state that there are both environmental and genetic factors involved.

“There’s been a lot of research into this over the last 20 years, and it is clear that there is a risk when there’s a reduced level of folate in the diet,” explains Simmons. “What we do know, is that if a woman who is planning a pregnancy takes additional folate in her diet at least one month before and three months after there will be a 70% reduction in the rates of spina bifida.”

The tall, middle-aged engineer is proud of the work done by this community group in its campaign to introduce folic acid supplementation for the general community. “We were involved in a cost benefit analysis of bread fortification which found that at doses of 100 micrograms of folic acid per 100 grams of flour, the benefits outweighed the costs.”

Simmons explains that the new food standard to fortify bread was developed by FSANZ or Food Standards Australia New Zealand, the organization which maintains a safe food supply for the populations of Australia and New Zealand. The regulation stipulates that all commercial bread flour with the exception of organic, is to be fortified with folic acid. While Australia commenced its mandatory bread fortification on September 13th, New Zealand has deferred its implementation until 2012, due to consumer concern about the effects of folic acid on human health.

Nutritionist, Rosemary Stanton agrees that there is cause for concern, because for some people, higher levels of folic acid can result in increased cancer cell growth leading to tumours of the colon, breast and prostate. Therefore, she says, taking large amounts of folic acid is not a good thing for the whole nation, and in view of this the regulators have kept the level of folic acid in bread deliberately low. Speaking on 3cr radio, Stanton called for caution but added, “I don’t think we have to jump up and down and think we will all get cancer and that it will be in anyway harmful.”

Most Australian adults consume around 250 micrograms of folate daily with the recommended dose being 400 micrograms each day. Stanton describes the fortification of bread with folic acid as “a second best solution.” Bread was chosen, she explained “because most people eat a couple of slices a day.” “But the problem is that the amount of folic acid  in the bread, will not be enough to make up for the women who don’t eat enough green veggies, so they will still need to take a supplement,” said Stanton. On average 100 grams of bread or around three slices, will only provide about 120 micrograms of folic acid.

Dr. Stanton says that she hesitates to publicly oppose the decision, because “if you say anything against this measure then people accuse you of not wanting to reduce the rate of spina bifida and this is simply not true.” She explains that what she would really like to see is more women eating more vegetables and foods that contain folate, the natural form of the B vitamin.

Stanton is not alone in her criticism and is joined by Professor Leonie Segal, a member of Kevin Rudd’s National Preventative Health Taskforce who recently told The Australian, that ‘mandatory fortification of bread with folic acid risked turning food into pharmacotherapy, when simpler solutions existed’. Stanton has sympathy with this opinion and jokingly adds that she has always had difficulty with the notion that nature depended on humans inventing vitamin factories for our survival. “Ultimately what we should be doing is getting people to eat more vegetables.”

The New Zealand Bakers’ Association is one of the groups who are opposing the adoption of the new food standard. The Association is concerned, that the distribution of folic acid cannot be evenly distributed amongst their products. In Australia, there is mounting opposition coming from the flour millers, whose responsibility it is to add the folic acid. Mark Laucke, who is the managing director of Laucke Flour Mills in South Australia, has stated via email, that although he supports public health initiatives, he believes that the fortification of bread with folic acid, puts the general public at risk. His customers have been informed, that he will not be adding folic acid to his flour. “Since the standard was enacted, scientific research has continued to mount evidence against mandatory folic acid fortification, and proponents have ensured that negative scientific data has been overlooked, ignored or dismissed,” Laucke said.

Of New Zealand’s decision to deter the implementation of the standard, John Simmons is understandably critical. “Although there have been studies to show there are some unexpected side effects, none of these have been conclusive enough to say that it shouldn’t go ahead,” he said. “Governments have a responsibility to proceed with public health measures that reduce significant health problems, and while those with spina bifida are pleased to be alive, they would prefer not to be disabled, incontinent and have ongoing health problems.”

Life has been challenging for Katherine Simmons, who like 85-90% of people with spina bifida has hydrocephalus, the accumulation of cerebro-spinal fluid around the brain. Hydrocephalus results in a number of cognitive and learning disorders, such as problems with concentration and memory. Her difficulties extend to the area of friendships which she finds hard to maintain. “It can be really tough when your friends just scoot off and leave you to take the lifts and the disability accesses alone,” she explains.

Despite these challenges, the young woman sitting in front of me is currently studying legal and dispute studies at RMIT University, Melbourne. I think she is amazing and I tell her. Even so, sitting close to Katherine I can feel her pain. It must be really horrible to have to cope with daily bladder and bowel incontinence about which Katherine laughingly said, “I can tell you all about those if you like.”

Simmons shares a moment of reflection where he wonders what would have happened to Katherine had she been born twenty years earlier. “She would probably have been in a special school and not have had the advantages she has now.” The intense medical care afforded Katherine in her early years has been replaced by the yearly blood tests and renal scans.

The International Federation for Spina Bifida and Hydrocephalus, is an organization that while supporting the fortification of food with folate, seeks to point out that disability does not rule out a meaningful life. The federation challenges the view of disability, that leads to the social acceptance of prenatal testing and termination for babies with neural tube defects, resulting in over 90% of fetuses with the condition, being aborted in western countries. The federation demands that the medical world and governments “support children of all characteristics.”

Katherine Simmons has been fortunate to have been born into a very supportive family who continue to challenge the system, ensuring that she receives the medical care and educational support that she deserves. Even so, discrimination towards the disabled remains, reminding us that it takes more than folic acid to change society’s attitude to those who are considered ‘imperfect’.

Helen Lobato is an emerging journalist based in Melbourne.