Real-World Cost Effectiveness of Mandatory Folic Acid Fortification of Bread-Making Flour in Australia.

BACKGROUND: In 2009, mandatory folic acid fortification of bread-making flour was introduced in Australia to reduce the birth prevalence of preventable neural tube defects (NTDs) such as spina bifida. Before the introduction of the policy, modelling predicted a reduction of 14-49 NTDs each year. OBJECTIVE: Using real-world data, this study provides the first ex-post evaluation of the cost effectiveness of mandatory folic acid fortification of bread-making flour in Australia. METHODS: We developed a decision tree model to compare different fortification strategies and used registry data to quantify the change in NTD rates due to the policy. We adopted a societal perspective that included costs to industry and government as well as healthcare and broader societal costs. RESULTS: We found 32 fewer NTDs per year in the post-mandatory folic acid fortification period. Mandatory folic acid fortification improved health outcomes and was highly cost effective because of the low intervention cost. The policy demonstrated improved equity in outcomes, particularly in birth prevalence of NTDs in births from teenage and indigenous mothers. CONCLUSIONS: This study calculated the value of mandatory folic acid fortification using real-world registry data and demonstrated that the attained benefit was comparable to the modelled expected benefits. Mandatory folic acid fortification (in addition to policies including advice on supplementation and education) improved equity in certain populations and was effective and highly cost effective for the Australian population.

Bread-derived 3D macroporous carbon foams as high performance free-standing anode in microbial fuel cells.

Microbial fuel cells (MFCs) are a promising clean energy source to directly convert waste chemicals to available electric power. However, the practical application of MFCs needs the increased power density, enhanced energy conversion efficiency and reduced electrode material cost. In this study, three-dimensional (3D) macroporous N, P and S co-doped carbon foams (NPS-CFs) were prepared by direct pyrolysis of the commercial bread and employed as free-standing anodes in MFCs. As-obtained NPS-CFs have a large specific surface area (295.07 m2 g-1), high N, P and S doping level, and excellent electrical conductivity. A maximum areal power density of 3134 mW m-2 and current density of 7.56 A m-2 are generated by the MFCs equipped with as-obtained NPS-CF anodes, which is 2.57- and 2.63-fold that of the plain carbon cloth anodes (areal power density of 1218 mW m-2 and current density of 2.87 A m-2), respectively. Such improvement is explored to mainly originate from two respects: the good biocompatibility of NPS-CFs favors the bacterial adhesion and enrichment of electroactive Geobacter species on the electrode surface, while the high conductivity and improved bacteria-electrode interaction efficiently promote the extracellular electron transfer (EET) between the bacteria and the anode. This study provides a low-cost and sustainable way to fabricate high power MFCs for practical applications.

The Availability and Nutritional Adequacy of Gluten-Free Bread and Pasta.

Management of coeliac disease (CD) requires the removal of gluten from the diet. Evidence of the availability, cost, and nutritional adequacy of gluten-free (GF) bread and pasta products is limited. GF flours are exempt from UK legislation that requires micronutrient fortification of white wheat flour. This study surveyed the number and cost of bread and pasta products available and evaluated the back-of-pack nutritional information, the ingredient content, and the presence of fortification nutrients of GF bread and pasta, compared to standard gluten-containing equivalent products. Product information was collected from four supermarket websites. Standard products were significantly cheaper, with more products available than GF (p < 0.05). GF bread products were significantly higher in fat and fiber (p < 0.05). All GF products were lower in protein than standard products (p < 0.01). Only 5% of GF breads were fortified with all four mandatory fortification nutrients (calcium, iron, niacin, and thiamin), 28% of GF breads were fortified with calcium and iron only. This lack of fortification may increase the risk of micronutrient deficiency in coeliac sufferers. It is recommended that fortification legislation is extended to include all GF products, in addition to increased regulation of the nutritional content of GF foods.

Gluten-Free Foods in Rural Maritime Provinces: Limited Availability, High Price, and Low Iron Content.

We investigated the price difference between gluten-free (GF) and gluten-containing (GC) foods available in rural Maritime stores. GF foods and comparable GC items were sampled through random visits to 21 grocery stores in nonurban areas of Nova Scotia, New Brunswick, and Prince Edward Island, Canada. Wilcoxon rank tests were conducted on price per 100 g of product, and on the price relative to iron content; 2226 GF foods (27.2% staple items, defined as breads, cereals, flours, and pastas) and 1625 GC foods were sampled, with an average ± SD of 66 ± 2.7 GF items per store in rural areas and 331 ± 12 in towns. The median price of GF items ($1.76/100 g) was more expensive than GC counterparts ($1.05/100 g) and iron density was approximately 50% less. GF staple foods were priced 5% higher in rural stores than in town stores. Although the variety of GF products available to consumers has improved, higher cost and lower nutrient density remain issues in nonurban Maritime regions. Dietitians working in nonurban areas should consider the relative high price, difficult access, and low iron density of key GF items, and work together with clients to find alternatives and enhance their food literacy.

Assessment of Nutritional Adequacy of Packaged Gluten-free Food Products.

PURPOSE: There is concern about the nutritional quality of processed gluten-free (GF) products. The aim was to investigate the nutrient composition and cost of processed GF products compared with similar regular products. METHODS: Product size, price, caloric value, and macro- and micronutrient composition were compared between foods labeled "Gluten-free" and comparable regular products in 5 grocery stores in 3 Canadian cities. Data were calculated per 100 g of product. RESULTS: A total of 131 products were studied (71 GF, 60 regular). Overall, calories were comparable between GF and regular foods. However, fat content of GF breads was higher (mean 7.7 vs. 3.6 g, P = 0.003), whereas protein was lower (mean 5.0 vs. 8.0 g, P = 0.001). Mean carbohydrate content of GF pasta was higher (78 vs. 74 g, P = 0.001), whereas protein (7.5 vs. 13.3 g, P < 0.001), fibre (3.3 vs. 5.8 g, P = 0.048), iron (9% vs. 25%DV, P < 0.001), and folate content (5% vs. 95%DV, P < 0.001) were lower. Mean price of GF products was $1.99 versus $1.23 for regular products (P < 0.001). CONCLUSIONS: Some commonly consumed packaged GF foods are higher in fat and carbohydrates and lower in protein, iron, and folate compared with regular products. GF products are more expensive. Dietitians should counsel patients on the GF diet regarding its nutritional and financial impact.

Chicken eggshell as suitable calcium source at home.

AIM: Taken into consideration that the deficiency of calcium (Ca) in the diet is a common problem, the aim of this work was to study the chicken eggshell as Ca source at home. It was evaluated: (1) different mechanisms to process eggshells and find an easy way to determine the required amount of Ca at home and; (2) the flavor and the texture for eggshell fortified food. METHODS: Chemical and mechanical methods of eggshell processing were evaluated. Changes in flavor and texture were evaluated in volunteers coordinated by a professional chef. RESULTS: A single eggshell contains 2.07 ± 0.18 g of Ca; therefore half an eggshell could provide the amount of Ca needed by adult human beings per day. The best way to use chicken eggshell as Ca dietary supplement is powdered to add to bread, pizza or spaghetti as there were small changes in texture and no changes in flavor.

The cost-effectiveness of mandatory folic acid fortification in Australia.

The Australian government recently introduced mandatory folic acid fortification of bread to reduce the incidence of neural tube defects (NTDs). The economic evaluation of this policy contained a number of limitations. This study aimed to address the limitations and to reconsider the findings. Cost-effectiveness analysis was used to assess the cost and benefits of mandatory versus voluntary folic acid fortification. Outcomes measures were quality-adjusted life-years (QALYs), life-years gained (LYG), avoided NTD cases, and additional severe neuropathy cases. Costs considered included industry costs and regulatory costs to the government. It was estimated that mandatory fortification would prevent 31 NTDs, whereas an additional 14 cases of severe neuropathy would be incurred. Overall, 539 LYG and 503 QALYs would be gained per year of mandatory compared with voluntary fortification. Mandatory fortification was cost-effective at A$10,723 per LYG and at A$11,485 per QALY. Probabilistic sensitivity analysis showed that at A$60,000 and A$151,000 per QALY, the probability that mandatory fortification was the most cost-effective strategy was 79% and 85%, respectively. Threshold analysis of loss of consumer choice indicated that with a compensation value above A$1.21 [assuming a willingness to pay (WTP) threshold of A$60,000 per QALY] or A$3.19 (assuming a WTP threshold of A$151,000 per statistical life-year) per capita per year mandatory fortification would not be cost-effective. Mandatory fortification was found to be cost-effective; however, inclusion of the loss of consumer choice can change this result. Even with mandatory fortification, mean folate intake will remain below the recommended NTD preventive level.

Selenium levels in breads from Sakarya, Turkey.

Selenium (Se) is an important trace element for human and animal health. It accumulates in wheat and corn, which is consumed mostly as bread. The Turkish population consumes mainly white wheat, whole wheat (brown bread) and corn breads. In this study, samples of these breads were collected from six different bakeries in the city of Sakarya, and their selenium levels were determined by ICP-OES after a chemical digestion. It was found that average selenium levels in white wheat, whole wheat and corn breads were 1149, 1204 and 2023 µg/kg, respectively. The results are compared with daily recommended intake and upper tolerable levels for selenium.

Optimization of iodine intake in Belgium.

Mild iodine deficiency (MID) is a long-standing problem in Belgium and was recognized only recently as public health issue by the Ministry of Health (MOH). The main MID-related health problems in Belgium are a high prevalence of thyroid nodules and multinodular goiter. The economic cost of thyroid nodular disease only in Belgium was estimated at about €40 millions per year. The Belgian health authorities adopted a selective strategy to optimize iodine intake through the fortification of bread with iodized salt. A progressive, step-by-step increase of the iodine content of salt was chosen in order to minimize the incidence of hyperthyroidism. MOH monitors this strategy by assessing periodically the urinary iodine concentration in school-aged children and pregnant women, as well as by a yearly follow-up of TSH concentrations in all Belgian newborns. Although the implementation of this strategy was an important step, the main drawback of the current situation is the absence of a legal framework to support the strategy. The utilization of iodized salt in bread on a voluntary basis was endorsed by the bakery industry and MOH. However a legal framework is required to assure the effectiveness and continuity of the program and to avoid a higher than optimal iodine intake in the population.

Accounting for the contribution of vitamin B to Canada's WWII effort.

Canada began to fortify its flour and bread with vitamin B when it entered the Second World War. The decision was informed by the biology of vitamin B and therefore I suggest that the complexity of this political maneuver can best be understood by considering the specificity of the biochemistry of vitamin B. In this paper I will show that the specific biology of vitamin B allowed the Canadian government the possibility of a healthier population under wartime conditions but also allowed the government a variety of means by which to develop and organize food processing practices to this end.

Effect of flaxseed gum on reduction of blood glucose and cholesterol in type 2 diabetic patients.

The effects of ingestion of flaxseed gum on blood glucose and cholesterol, particularly low-density lipoprotein cholesterol, in type 2 diabetes were evaluated. Flaxseed gum was incorporated in wheat flour chapattis. Sixty patients of type 2 diabetes were fed a daily diet for 3 months, along with six wheat flour chapattis containing flaxseed gum (5 g), as per the recommendations of the American Diabetic Association. The control group (60 individuals) consumed an identical diet but the chapattis were without gum. The blood biochemistry profiles monitored before starting the study and at monthly intervals showed fasting blood sugar in the experimental group decreased from 154 ± 8 mg/dl to 136 ± 7 mg/dl (P=0.03) while the total cholesterol reduced from 182 ± 11 mg/dl to 163 ± 9 mg/dl (P=0.03). Results showed a decrease in low-density lipoprotein cholesterol from 110 ± 8 mg/dl to 92 ± 9 mg/dl (P=0.02). The study demonstrated the efficacy of flax gum in the blood biochemistry profiles of type 2 diabetes.

Panis populi--bread and public health in Australia.

The 'standard loaf, 680 gm, white, supermarket-purchased' as expressed in the Consumer Price Index, is but the basic form of bread sold to the Australian public. In the public health context, three themes have been intimately associated with bread--quality control, price control and bread used as a vehicle for supplementary nutritive agents important in preventive medicine. Price control, through assizing, has been a feature of bread marketing in western communities for seven centuries; and bread remains the last item on which price control (although seldom enforced) exists in Australia. Quality control, for public health, is determined both by regulation and by the force of increasingly literate consumers, of whom women occupy the most important determinant. From the preventive medicine point of view, important themes in bread quality, such as its use to reduce laxative sales on the one hand and to reduce the demographic incidence of colonic cancer on the other, remains outside formal regulation. Australia is a relatively conservative nation in the context of nutritional additives. It was not until 1953 that the National Health and Medical Research Council approved the addition of extra B vitamins to bread. Currently, folic acid is added as a discretion to selected high-premium breakfast cereals in Australia in one attempt to reduce the incidence to neural tube defects. The addition of such ingredients to bread remains an unrealised, but potentially important aspect of preventive medicine in Australia.