Disparities in Neural Tube Defects leads to new food additive rule…

A PHS 795 student wonders why it took almost twenty years for the FDA to approve folic acid supplementation for corn masa flour, a dietary staple of the US Hispanic population:

Professor Ehrenthal’s lecture on Determinants of Health Across the Lifecourse reminded me of something that I had looked into lately: folic acid. It is a widely known fact that folic acid reduces neural tube defects (NTDs) in newborn babies. Since approximately half of all pregnancies in the U.S. are unplanned, the FDA published relevant regulations in 1996. As of January 1, 1998, folic acid fortification required enriched cereal-grain products (bread, rolls, and buns; wheat flours; corn meals; farina; rice; and macaroni and noodle products) to add folic acid. I understand that it has been a meaningful public health intervention here in the U.S. in promotion of fetal development and infant health, and of course health throughout one’s lifetime. And yet, there was an unintended loophole in the policy, missing out the corn masa – the regular diets of Hispanic Americans. Because the incidence of NTDs among Hispanic Americans did not decline as much as that of the general population, the FDA has approved a food additive petition this year, requesting that folic acid be added to corn masa flour! I found it quite fascinating how the U.S. government followed-up on its public health intervention and came up with a supplementary action in TWENTY YEARS! Here is the FDA website for you to take a look: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm504412.htm

The FDA’s website argues that the delay was in part due to the need to prove that folic acid supplementation of corn masa flour is safe… even though it was already mandated for enriched cereal-grain products). Strains credulity, in my opinion.

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4 thoughts on “Disparities in Neural Tube Defects leads to new food additive rule…

  1. First, this is an extremely interesting public health intervention that I had never heard of before – very similar to water fluoridation. I wonder if it was initially met with any push-back by those who did not understand the benefits/risks. It may have also been a more inconspicuous change than water fluoridation, flying under-the-radar.

    Second, in another class, PHS 780, we recently had a guest speaker come and and talk to us about the disconnect between research and public health intervention, saying that it takes on average 17 years for 14% of research done to actually be incorporated into policies or interventions. If this applies to folic acid fortification, then it might be the case that it took an extreme amount of time for the research done to finally be incorporate into the original 1998 mandate, and then once the food additive petition was established for corn masa flour, another unreasonable delay between research and policy was required to incorporate the addition. 20 years is right around the average time of 17 that the guest lecturer quoted, so given these statistics, it’s almost par for the course that it would take so long to update the mandate.

    I don’t mean to argue that there was no problem with the long delay between folic acid fortification being incorporated into other enriched cereal-grain products before corn masa flour. First of all, if proper inter-cultural studies were done to truly understand all of the cereal-grain products that are most commonly consumed by Americans, corn masa flour would have been incorporated into the original mandate. Second, the 17 year gap between research and intervention (along with the fact that only 14% of the research is used) is an enormous problem in our healthcare progression. There is no real reason to be putting so much funding into research if it is not maximized for translation into improved health outcomes. There are many reasons for this gap, the first being that translation of research into interventions isn’t necessarily incentivized in our publish-or-perish academic system. Unfortunately, Hispanic Americans suffered from this deficiency. I wonder if any work is being done by major research organizations to remedy the issues, or improve the way we look at healthcare research.

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  2. I know it can take a long time for research to produce change, but I am surprised that it would have taken 20 years to determine that folic acid remained stable when added to corn products. They would have already had research models for the other grains, so I imagine that it would take less time to design and implement the study.

    What is especially troubling is that the Latina population would likely have been at greater risk anyway, since a portion of them may not speak English, have insurance, see a provider, and especially if recently immigrated, they may not have income or community. Those encountering these struggles may not have any knowledge of folic acid (that you can take it as a supplement), and may not receive health care services, where they may have been informed of supplements as an option. Either way, poor, recent immigrants would have greatly benefited from corn masa products being fortified. Finally, they will be able to benefit.

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  3. I don’t find this surprising..in fact….in fact this is very much aligned with the treatment of racial/ethnic and poor white populations in this country.

    If you want to know more about Latinx and discrimination read my paper. http://edwardvargas.com/wp-content/uploads/2016/02/SRE-2016-Vargas.pdf

    Annie…I have a few thoughts on your comments “portion of them may not speak English, have insurance, see a provider, and especially if recently immigrated, they may not have income or community,” …..I actually find these comments misguided.

    First, being Latina/o doesn’t equate to being an immigrant. There are Americans of Mexican descent in this country before this space was even the U.S.

    Second, you should also specify if your talking about undocumented immigrants versus legal permanent residents or naturalized citizens (I think your conflating these). Legal status matters when discussing program eligibility and access to social services and health insurance.

    Read this: http://edwardvargas.com/wp-content/uploads/2015/09/SSQ_WIC_Vargas.pdf

    I also disagree that recently arrived immigrants have no income or community. I’m not sure were you got this but figures by PEW and even conservative economists show that over 90 percent of immigrants are employed full time…especially among the undocumented. Moreover, the idea that immigrants have no community goes against all social science research which shows the importance of social networks and familismo in Latinx immigrant populations. The reality is when your marginalized in society all you have is community to survive. .

    Lastly, there is a debate in public health around the Hispanic immigrant paradox which shows that despite undocumented immigrant mothers having low SES they have better birth outcomes relative to white mothers with higher SES. The fact that the federal government doesn’t have enough “cultural competency” is just an excuse and again very much aligned with the historical treatment of racial/ethnic and poor white populations in the country.

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    • Thank you both for your comments on this article. I take Edward’s comments to heart and respect his expertise and perspective on Latinx health disparities. I took Annie’s comments to mean “some” not “all” individuals — but it is useful and positive to address what are likely wide misperceptions on Latinx culture among researchers and practitioners who do not have first hand experience. I appreciate both of your care for this issue!

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