The Food, Inc. movie trailer:

I saw this movie today with a group of food writers. It’s not fun to watch – I shut my eyes a few times. But if you eat food, you need to see it.

In September this year all bread in New Zealand and Australia, except organic bread, will have folic acid added to it. “About time too”, most nutritionists would say, with some even going so far as to say the government has been ‘morally negligent’ in not introducing folate fortification sooner.

Why? Because folate reduces the risk of neural tube defects (NTD’s) such as spina bifida. In the USA and Canada, where bread has been fortified with folic acid since 1998, there has been a 15-50% drop in NTD’s. And Chile, which used a higher dose of folic acid, reported a 40% drop in NTD’s. In addition, a study on babies in Quebec noted a 6% reduction in the prevalence of congenital heart defects in the seven years after fortification compared to no change during the nine years before fortification.

But some people are concerned about media reports that there could be problems with fortification – (See kiwiblog post with NZ Herald excerpts and some fairly heated comments: “…if any government decides to mass-medicate every bread-buying New Zealander with a certain additive, it has to be very sure that the costs to the community don’t outweigh any health benefits…”).

I had a chat with one of them – an imaginary aussie  bloke called Bruce who grew up in Australia and now lives in New Zealand…

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Bruce: Yeah, gidday. So exactly how many babies will fortification save in New Zealand?

Cindy: In New Zealand  20-30 babies are born with spina bifida each year. It’s been estimated that folic acid fortification would save 4-14 babies a year from these NTDs (neural tube defects).

B: So we are going to mass medicate 4 million people to try to prevent 4 –14 cases? Seems a bit skewed unless you are the parents of one of those babies. Can’t you try anything else?

C: Up until now we have told women of child-bearing age to take a folic acid supplement and to eat foods rich in folate, including those that are already fortified such as some breakfast cereals. But not enough are following this advice. Even if they start taking a folic acid supplement as soon as they know they are pregnant it’s probably too late – it’s needed in the first month of pregnancy.

B:What about food? Don’t you nutritionists always tell us the best way to get nutrients is from your food?

C:Food is definitely the best source as the folate is in a natural form that the body is designed to handle. Folate is naturally high in green leafy vegetables like spinach and broccoli but it is destroyed by cooking. Liver, chickpeas, lentils and citrus fruit like oranges are also high in folate. New Zealanders eat on average 250 micrograms of folate a day but the recommended amount is 400 micrograms a day – and 600 micrograms in pregnancy.

B:I’m not into raw spinach, liver or lentils, and I can’t be bothered peeling oranges. Hummus is OK – it’s made from chickpeas – but I’d probably need to eat it for breakfast, lunch and dinner!

C:Exactly! That’s why they want to add folic acid to bread. Everyone eats it.

B: So how much will we get in our bread?

C: We will get about 140 micrograms folic acid from two or three slices of bread, depending on the thickness. If you add that to the 250 micrograms folate you are already getting from food, you have your recommended daily requirement.

B: Sounds simple. But I eat more like eight slices of bread a day: two pieces of toast for breakfast plus a huge bowl of cereal that’s probably already fortified with folic acid, two big sandwiches for lunch and usually a couple of slices at night after training. So I could be getting four or five times the amount. Is that a problem?

C: If it was from foods, in the natural folate form, it wouldn’t be a problem. In fact eating lots of folate from foods is a great idea. Apart from reducing the risk of NTD’s over 30 studies have found that people who eat lots of folate (the natural stuff) have about 40-60% less colon cancer. It also helps reduce homocysteine which is a risk factor for heart disease. And in the Nurses Health Study people who ate the least folate had more breast, colon and pancreatic cancer.

B: But what about folic acid – the synthetic stuff that’s in supplements and that they plan to shove in the bread? I’ve heard it might cause cancer!

C: No-one is saying folic acid causes cancer but some researchers think if you already have some cancerous cells it may make them grow. As Joel Mason, Associate Professor at the Friedman School of Nutrition Science and Policy at Tufts University, said in a  paper published in 2007, “There is a compelling body of scientific evidence suggesting that habitually high intakes of dietary folate are protective against colorectal cancer” but “we may have inadvertently created the opposite effect with folic acid fortification”.

B: How does that work?

C: Professor Mason suggests two possible reasons. 1. Folate is important in making DNA so it could act as a growth factor for cancerous cells. 2 The body has to convert synthetic folic acid to folate. If you are eating lots of folic acid, the conversion mechanism may become saturated leaving left-over folic acid in the circulation. This is not normal for the body.

B: How bad is it? How many Kiwis might get colon cancer from eating all this extra folic acid?

C: Since mandatory fortification in 1998 the USA and Canada have had 4-6 extra cases of colorectal cancer per 100,000 people per year. Chile has reported a similar increase in the European Journal of Gastroenterology & Hepatology but the one of the journal’s editors says it is a “weak, indirect indication of a causal relationship”.

B: So let’s work out 4-6 extra cases per 100,000 in New Zealand’s population of roughly 4 million. That’s potentially 160-240 more people with colon cancer for the sake of 14 less babies with NTD’s. Yeah, I know that sounds pretty callous – sorry.

C: It’s not that simple because we don’t yet have any proof. These results are just associations – like saying that people who drive expensive cars visit the doctor more than people with cheap cars. Does that mean they are less healthy, or that somehow the car makes them sick?  There are all sorts of reasons why colon cancer rates may have increased – more obesity or even better diagnosis which means more cases are reported. But it is causing some public health people to be cautious about rushing into fortification.

B: Well that’s a good thing. I’m not sure about the ethics of a group of ‘experts’ forcing us to take supplements in our food – especially when more than half of us will never get pregnant!

C: So how do you feel about the thiamin (vitamin B1) that’s been added to your bread in Australia for decades?

B: What?!!

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See my follow-up article on Vitamin B12

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References from medical journals:

Eur J Gastroenterol Hepatol. Published online before print February 2, 2009. Abstract
Cancer Epidemiol Biomarkers Prev. 2007; 16:1325-1329
Nutr Rev. 2009,67;206-212
J Natl Cancer Inst. 2009;101:432-435
American Journal of Clinical Nutrition, Vol. 80, No. 5, 1123-1128, November 2004  http://www.ajcn.org/cgi/content/full/80/5/1123

Related media stories:

Kiwiblog – Rich on Food Safety
Katherine Rich: Added risk, any way you slice it – NZ Herald 9/6/09
Bakers furious at ‘mass medication’ of NZ’s bread
Government taking advice on folic acid in bread

I read this on David Farrar’s blog so  have block quoted here. Original piece from Danyl’s Dim-post blog on the current political debate about government funding of nutrition initiatives {… maybe I should have a conversation with myself about the current folate debate … hmmm…}.  Anyway there’s some good satirical writing here if you are into that …

Conversation with myself about obesity

Left Wing Danyl: Corporations that sell high-fat and high sugar products are getting rich by selling people slow acting poisons. And they’re deliberately marketing these toxic food substitutes at children! Shouldn’t we at least pass laws to protect minors from these products? After all, we don’t let them buy cigerettes or alcohol.

Libertarian Danyl: Well that’s your answer to everything isn’t it? Just pass another law, take away a little bit more of our freedom, expand the power of the state. Charge people more taxes so you can furthur limit their choices. People should be free to eat whatever kind of food they want. We have enough problems with the nanny state in this country without politicians telling us what we can and can’t eat for dinner.

Economist Danyl: Hang on a minute there – I agree that people should be allowed to choose what foods to eat – but you have to admit that products like soft drinks and potato chips have massive negative externalities. They contribute to chronic illness like diabetes and heart disease and those have a cost to the public health system that other people end up paying for through their taxes.

Libertarian Danyl: Tax is theft!

Left Wing Danyl: Tax is the price you pay for living in a civilised society.

Libertarian Danyl: Civilised? Ha! To quote Ron Paul . . .

Moderate Danyl: Oh shut up, idiot. So Economist Danyl, are you saying there should be an excise on junk food?

Economist Danyl: Why not? That’s what we do with other products that have negative externalities, like tobacco and alcohol.

Left Wing Danyl: The problem there is that obesity is closely correlated with poverty. A tax on junk food would be a highly regressive tax.

Economist Danyl: Then poor people will act like rational maximisers and respond to the changing conditions of the market by switching to cheaper, healthier options.

Sarcastic Danyl: Right, the way they have with tobacco?

Realist Danyl: There are also huge political barriers to an excise – the food companies aren’t just going to lie back and let you devalue their product. They’ll claim that the science around obesity and nutrition is ‘deeply disputed’, that there is real controversy over whether or not french fries are bad for you . . .

Moderate Danyl: Okay, so regulation of food might be too complicated . . .

Libertarian Danyl: Hallelujah.

Moderate Danyl: How about encouraging exercise?

Libertarian Danyl: How about laws governing bed time?

Selfish Danyl: No wait, I think that’s a good idea. The government could subsidise my gym membership!

Realist Danyl: Sponsored exercise programs have repeatedly failed every time they’ve been trialed. The only people who benefit are those already using a gym, who tend to be disproportionately wealthy. Besides which, obesity is about diet not exercise – the best the gym will do is prevent you from gaining more weight.

Selfish Danyl: I don’t think that’s true – the science around obesity and weight loss is deeply disputed . . .

Moderate Danyl: What about before our wedding? We lost twenty kgs in a couple of months.

Realist Danyl: We were running for two hours almost every morning – that’s not very practical for most people. And we put most of the weight back on when we stopped. You have to change your diet, tubby.

Left Wing Danyl: So what? There’s no solution? It’s hopeless?

Moderate Danyl: Thatcher once said that the problem with being middle class is that you understand everyone’s point of view but have none of your own.

Left Wing Danyl: You’re quoting Thatcher now? What kind of bourgeoisie sell out are you? You’ve changed, man. You used to be so cool.

Realist Danyl: No you didn’t.

Go here to read full post and comments {both are a good read if you have a sense of humour!}

Here are some excerpt choice comments …

Comment by Carlos: Remember when eggs were considered the one way ticket to a heart attack? Ooops no, not as bad as 1st thought.  Remember when the answer was low fat diets, so out with olive oil and in with Nutragrain? Turns out that was a bad idea. Remember when red meat and dairy were declared evil? Only later did we ponder the serious consequences of iron and calcium deficiency. Nutritionists have a poor track record only economists can compete with. And we want to let them loose on our tax system?

{Cindy says: I could defend my profession and blame the media for sensationalising our messages. But it’s true; sometimes we get it wrong – especially when we follow the latest ’studies’ and forget to use our common sense!}

Comment by Gareth: I am fundamentally against subsidising the public mental health services that clearly you will be availing yourself of…

Comment by Matt: I wish more people would force themselves to represent both sides of an argument. Aligning yourself with the “left” or “right” is counter-productive, like Bob Dylan once said “I don’t know left and right, I just know up and down”.