Research from the Universitat Rovira i Virgili adds to the debate surrounding the need to fortify staple foods such as flour with vitamins.

Folate, also known as vitamin B9, is an essential micronutrient contained in green leaved vegetables, legumes and some nuts. It plays a fundamental role in the synthesis of genetic material, cellular division, neurological development and foetal development during pregnancy. For these reasons, the World Health Organisation (WHO) recommends that pregnant women or those planning a pregnancy— complement their diet with folic acid supplements to significantly improve their folate status and reduce the risk of grave pregnancy complications such foetal malformations.

In the late 1990s, when faced with evidence of systemic folate deficiency in the population, countries such as the USA and Canada introduced the mandatory fortification with folic acid of staple foods such as flour or cereals. More than 60 countries around the world have since implemented similar legislation, but overall European countries have failed to follow suit. In the ongoing debate among nutritional experts, many still hold the view that a diverse and balanced Mediterranean diet provides sufficient folate to meet the body’s requirements. Recently, the British Government has decided to introduce mandatory fortification of flour with folic acid from 2026 and in doing so has reopened the debate in Europe. The questions facing experts are 1) does a good diet guarantee sufficient folate to meet the body’s requirements? and 2) is mandatory fortification necessary in the Mediterranean region?

To answer these questions, a research team from the Universitat Rovira i Virgili has studied Mediterranean Diet Adherence, dietary folate intake and blood folate status in the general population in the Tarragona province. They analysed data regarding dietary habits in 740 people, collected between 1998 and 2002, and complemented this with a health check-up and an analysis of the concentrations of folate and other vitamins in the blood. Michelle Murphy, researcher from the Department of Basic Medical Sciences of the URV, explained that dietary habits at that time adhered more closely to the Mediterranean diet than those of today, therefore making them relevant to the issue at stake.

Low Mediterranean diet adherence

The results showed that contrary to popular belief, only a small part of the population studied (17.5%) adhered closely to a Mediterranean diet. Even in those that did, 15% did not meet the folate intake requirements established by the European Food Safety Authority and 8.5% had blood concentrations of folate that were below the WHO recommendations. In the case of participants with low Mediterranean diet adherence, the prevalence of vitamin B9 deficiency shot up, with 71% not obtaining sufficient folate through dietary intake and 25% showing folate deficiencies in their blood. Furthermore, the study also reported deficiencies in other important vitamins such as Vitamin B6, which is essential for the development and functioning of the nervous and immune systems.

In short, the results show that good adherence to a rich and balanced Mediterranean diet is associated in most cases with sufficiently high folate levels; however, they also show that even good adherence to the Mediterranean Diet does not guarantee this. Furthermore, bad Mediterranean diet adherence is associated with a drastic drop in folate levels in 82.5% of the Mediterranean population studied. This has led to the study’s most important conclusion; namely that the majority of the population is at risk of having deficiencies in folate and other essential vitamins.

Paving the way to generalised fortification

On the basis of her work in the laboratory, Murphy has for some time been stressing the importance of campaigns to raise awareness in the population, especially among pregnant mothers,  regarding the need to take supplements, in particular those containing folic acid and vitamin B12. However, given that these latest findings highlight possible systemic deficiencies in the Mediterranean population, the research team is now emphasising the need to at least reopen the debate regarding the mandatory fortification of staple foods such as flour: “We’re talking about a public health measure that can prevent complications in foetal development that have lifelong consequences, such as spina bifida. At first glance it would seem to be common sense to take measures to prevent this” said the researchers.

However, they also stress that to consider such a measure, more data on diet and vitamin uptake by the population is required, and this means doing further research: “Without further data, we cannot unequivocally recommend these measures. We suggest carrying out further research and reigniting the scientific and political debate regarding this topic”, states Murphy. The team stresses that policies to improve the population’s diet by promoting the consumption of fresh and varied foods are essential.