For the last 25 years, the U.S. has required that grain and cereal products be fortified with folic acid — and the CDC is now urging manufacturers of products made using corn masa flour to add the B vitamin to minimize the risk of birth defects in the Latino population.
Every year, around 3,000 babies in the United States are born with a Neural Tube Defect (NTD). Most of them have spina bifida or anencephaly, which is a fatal neural tube defect in which the brain and skull don’t develop properly.
The Latino population has the highest rate of neural tube defect impacted pregnancies in the United States.
NTDs are often associated with folate deficiency during pregnancy. Folate is a very important B vitamin — vitamin B9, to be specific.
"Folate is your umbrella term for many different, many different variations of vitamin B9. Naturally occurring folate is what you're going to find in your fruit and vegetables; that healthy diet. Unfortunately, natural occurring folate is very heat sensitive and light sensitive. So as soon as you cook that fruit or vegetable, then you're losing a lot of the natural of folate that that that can be found," said Capt. Jenny Williams, team lead of the Neural Tube Defect Surveillance and Prevention Team at CDC’s National Center on Birth defects and Developmental Disabilities.
She's an expert on folate and pregnancy.
"Folic acid is a manufactured form of vitamin B9 that is stable to heat and light," Williams said. "So it's ideal to put [it] in enriched cereals, and it can survive the cooking process."
It’s difficult for a person to get the amount of folate that reduces the risk of neural tube defects from food alone, so the CDC and pretty much every other organization that offers guidance on health and nutrition recommend that those of childbearing age — whether or not they are planning a pregnancy — consume 400 micrograms of folic acid a day.
They recommend supplements, and since 1998, the Food and Drug Administration has also required that it be added to certain foods.
"So here in the United States, we mandatorily fortify wheat products and rice products that are labeled enriched," Williams said. "So anything that's labeled 'enriched' will have folic acid included in that product."
Breakfast cereals and the bread used to make peanut butter sandwiches and pasta in dinner dishes are all fortified with folic acid.
That has gotten more B9 into the diets of a lot of Americans.
Bread, cereal, wheat flour, pasta — they are staples for a large portion of the population. But not all Americans start their day with Cheerios and end it with spaghetti for dinner.
"When we mandatorily fortified in 1998, corn masa flour was not included in those in those regulations. Corn masa flour is a culturally appropriate staple carbohydrate for many [Latinas]," Williams said.
Food fortification, or adding nutrients to foods, is widely hailed as one of the most successful public health interventions in U.S. history. Folic acid fortification alone is credited by the March of Dimes with preventing serious defects of the spine and brain for roughly 1,300 babies every year.
Research cited by the CDC has found that the birth prevalence of NTDs has decreased by 35% in the United States since mandatory folic acid fortification began.
"[Latinas], unfortunately, have the highest risk of having a neural tube defect affected pregnancy, and that's for a variety of reasons. This population is less likely to take supplements containing folic acid. They have risk factors like some genetic variations are found in the Hispanic population at higher rates than they are in non-Hispanic white people or non-Hispanic Black people," Williams said.
And Latinas don't benefit from wheat flour fortification as much, especially those coming from countries where maize is their staple carbohydrate.
Terri Locke was born with spina bifida. The Latina grew up eating all the delicious foods of her culture.
"We had enchiladas and chilies," she said. "We made a lot of tortillas."
The healthy foods that have sustained countless generations of Latin American families are often made with corn masa flour, which is not included in the FDA mandate.
Locke said she thinks the effort to change that is a good idea.
"Really I think it would help so much to put fortification in foods that the Hispanic community eats more of," Locke said. "It has been established that folic acid reduces the chance of neural tube defects. And so why not? Just do what we can do to try to prevent. If we prevent one child from having spinal bifida, that's huge."
There is some conversation about whether people with certain gene variants impacting folate metabolism should avoid foods that have been fortified with synthetic folic acid.
Williams told TPR that research shows the benefit of fortification outweigh the risks.
"Folic acid safety and its impact on various outcomes has been thoroughly reviewed and continues to be regularly reviewed by a large group of experts from around the world," Williams said. "Based on the extensive body of high-quality studies available, these groups have come to the same conclusions: folic acid fortification dosages are not associated with harms that outweigh the benefits."
Williams said it’s currently unclear how much corn masa flour and how many masa containing products in the United States contain folic acid, but, to her way of thinking, it's not enough. Williams sees it as another unacceptable health disparity.
"[Latinas] have the highest rates of NTDs. We know how to prevent these NTDs, but we need to be able to get that prevention to the people that need it the most," she said.
Next year, CDC is planning research in two markets with large populations of Latinos from Mexico and Central America to determine which stores carry fortified corn masa flour products, the type of products available, and how much shelf space is allocated to them.
In the meantime, the public health agency continues to try to get the word out that supplementing every day, even for people who are not planning for a baby, is essential.
