Expanding Fortification with Folic Acid: Thinking Outside the Cereal-Grain Box

Area of Science:

• Public Health
• Food Science
• Nutrition

Background:

• Folic acid fortification of maize and wheat flour reduces neural tube defects (NTDs).
• Alternative food vehicles are needed as maize and wheat are not universally consumed.
• Identifying these vehicles can further reduce NTD-affected births globally.

Purpose of the Study:

• To identify potential alternative food vehicles for folic acid fortification in low- and lower-middle-income countries (LILMICs).
• To assess the population coverage of potential alternative food vehicles using dietary intake data.
• To review existing research on the technological feasibility of fortifying alternative foods with folic acid.

Main Methods:

• Identified 81 LILMICs based on World Bank income classifications.
• Reviewed national surveys from 1997-2018 for dietary intake and apparent consumption data.
• Conducted a systematic literature review to identify research on alternative food fortification.

Main Results:

• Oil, sugar, and salt showed high population coverage (33.2–95.7%, 32.2–98.4%, and 49.8–99.9%, respectively) in 18 surveyed LILMICs.
• Dairy products (10 studies), salt (6 studies), and fruit juices (5 studies) were most researched for folic acid fortification.
• Limited research exists on the technological feasibility of fortifying oil and sugar with folic acid.

Conclusions:

• Oil, sugar, and salt are promising alternative food vehicles for large-scale folic acid fortification due to high consumption rates.
• Further research is crucial to evaluate the technological feasibility of fortifying oil and sugar.
• Salt fortification with folic acid is a viable option with existing research.