Wednesday, December 12, 2007

To Fortify or not to Fortify, that is the question

NYT reports on the ongoing controversy surrounding regulations that would require U.S. flour to be supplemented with folic acid to prevent birth defects.

I have mixed feelings on this because I am not yet convinced that making folic acid a ubiquitous supplement to a universal staple like flour is has side effects benign enough to make it an ethical policy. There are suggestions that folic acid can mask other health problems, like vitamin B deficiency, making such conditions harder to diagnose and subsequently treat.

Ideologically, this outlook is bothersome in the same way as the CDC recommendation (via WaPo) urging that all women be considered "pre-pregnant" - this attitude is a dangerous one to start subscribing to for many reasons, not just because men make up (nearly) half of the population, but also because there are women who do not wish to have children, and to treat them as if they will can be seen as patronizing and insensitive.

From a cost-benefit perspective, there certainly are benefits to be had by ensuring pregnant women have access to folic acid supplements to avoid this easily preventable class of birth defects, and if there were no risk of side effects from folic acid intake for the general population, then increasing the presence of folic acid could make sense. However, the implied paternalistic statement that women are too stupid or incapable to take an easy-to-consume supplement (orange juice) and that that society will take steps to ensure the health of the ZEF (zygote/embryo/fetus) in her with or without her consent carries dangerous implications; why not also ban all women from activities that pose a clear risk to the ZEF as well? Is there a difference between prescribing and proscribing at this level?

A socio-economic perspective questions whether pregnant women would have at least an average likelihood of using this fortified flour in their diets - given that more and more of the economically disadvantaged population don't cook food at home and instead consume pre-made food, and that pregnant women are often more strapped for time than the general population, wouldn't it be more reasonable to fortify some other food source, perhaps one that pregnant women would be more likely to consume? How about adding folic acid supplementation/access to the WIC program, for example? This program is specifically targeted to women, especially lower income women who may be less aware of and less likely to have access to folic acid supplements - not only does it avoid the frustrations of federal governmental regulation (when the FDA can't even keep unapproved GMO crops out of our food system) and paternalism, but it is a more efficient use of existing resources that already target the group of people we hope to help.

Addendum: Upon further reflection, I wanted to emphasize that there is a whole gradient of possibilities to implement a "folic acid promotion" policy - anywhere from working with one flour producer to make a line of flour enriched with folic acid, to requiring at least one line without, to letting the free market determine how many producers would enrich (and be required to label positively or negatively), to everything in between. If a policy wonk actually wants to compare the relative effectiveness of such programs, be my guest.

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