The bread of life: should we enhance our food?

A new study from the US suggests that folic acid supplements may
substantially reduce the risk of premature birth. This has reinforced
calls for the fortification of flour with folic acid. Although this
reported effect on preterm births is new, there are well documented
public health benefits of folic acid.(1) The food standards agency in
the UK finally decided in May last year that folic acid would be added
to either flour or bread, after years of lobbying.

Supplementing bread and flour is an effective way of providing health
supplements on a population level. But how much should we add to food
staples in the name of public health? Should additives be limited to
those that prevent serious disease, or if available, should we add
things to food that enhance health?

The basis for population interventions to improve health are that they are an effective and efficient way of improving the well-being of members of a community. Vitamin deficiencies in the population have been targeted by adding vitamins to foods. Common childhood illnesses with serious complications have been vastly reduced by widespread immunisation. But if our concern is with the well-being and capacity to flourish of members of the community, we should not necessarily limit ourselves to interventions that prevent disease. Interventions for disease provide benefit only for the small proportion of individuals who suffer that disease. Interventions to improve health have the potential to positively impact a significantly larger proportion of the population

One concern about public health interventions  are that they involve some infringement of personal choice or autonomy. Autonomy concerns can be reduced by allowing people to opt-out. For food additives this simply requires the availability of non-fortified food. From this perspective it would be more sensible to add health-enhancers or disease-preventers to something like bread rather than to the water supply.

The other pervasive concern about additives to food is that the benefits may be exaggerated, or that in fact in the long term such additives may be harmful. There is a need to have good quality evidence before any intervention at a population level, and there is a good case for careful monitoring after supplements are introduced to food.(2)

However it is likely in the not-too-distant future that we will be able to identify dietary supplements that enhance our health and not just prevent disease. If we take the wellbeing of members of our community seriously there is good reason to make these widely available.

Our daily bread may then be able to live up to its reputation as the staff of life.

1. Folic acid supplements reduce the risk of spina bifida and related malformations when taken in early pregnancy. In the US, flour has had folic acid added to it since 1998, and there has been a fall in the incidence of neural tube defects by about 20%

[Edit – footnote 2, added 1/2/08]

2. It occurred to me after I initially wrote this post is that perhaps we need to think about foods that are enhanced (either to reduce disease or enhance health) in the same way that we think about medications. This would require a higher standard of evidence before its introduction, and a higher quality of post-release monitoring – than is currently the case. For example the introduction of omega-3 eggs, or the addition of multiple vitamins to fruit juices has occurred in a largely unregulated and unmonitored environment. When does food count as medicine?

Folic Acid may reduce premature births by 70% Guardian 31/1/08

Food Standards Agency: Folic Acid discussion May 2007

Fact sheet from UK government on folic acid fortification

Neural tube defects decline in the US after folic acid is added to flour BMJ 2001

The Folate debate Pediatrics 2006

Folic acid and the prevention of neural tube defects BMJ 1995

Delaying folic acid fortification of flour BMJ 2002

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