Colorectal cancer incidence in Australia before and after mandatory fortification of bread flour with folic acid

Biological, dietetic and pharmacological properties of vitamin B9

Humans must obtain vitamin B9 (folate) from plant-based diet. The sources as well as the effect of food processing are discussed in detail. Industrial production, fortification and biofortification, kinetics, and physiological role in humans are described. As folate deficiency leads to several pathological states, current opinions toward prevention through fortification are discussed. Claimed risks of increased folate intake are mentioned as well as analytical ways for measurement of folate.

The use of nutrigenomics and nutritional biomarkers with standard care of long-term recurrent metastatic rectal cancer: a case report

Introduction

Distant metastases following standard treatment for locally advanced rectal cancer (LARC) are typically associated with poor disease-free survival. We report on a 52-year-old Australian male of Dutch ancestry with no family history of colorectal cancer or significant medical history who experienced bleeding per rectum for several months prior to a colonoscopy in July 2010. He was subsequently diagnosed with Stage IIb LARC.

Case presentation

Despite treatment with curative intent, a distant recurrence to his left lung was detected in May 2012, upstaging him to Stage IV rectal cancer. He had repeated distant metastatic recurrences over the next 8 years, and treatment included multiple surgeries, chemotherapies, radiation treatments, a "watch and wait" period of 20 months, and personalised dietary management. Genetic and nutrigenomic testing identified that the case had KRAS and MTHFR mutations. As part of his dietary management, the case also had his levels of folate, vitamin B12, and vitamin D regularly monitored because of his genetic predisposition and history of deficiency for these key nutrients. Apart from changes in his CEA levels, sudden increases in the patient's folate levels, inconsistent with dietary exposures preceded detection of each new distant recurrence, with significant decreases in the levels at the next follow-up measurement.

Conclusion

A multimodal approach to this patient's management appeared to contribute to his long-term survival of nearly 10 years from the initial diagnosis. Multidisciplinary management, including the use of additional biomarkers, may enhance survival rates in other similar cases with advanced disease resistant to differing therapies, and with potentially poor prognosis.

An evaluation of adherence to folic acid supplementation in pregnant women during early gestation for the prevention of neural tube defects

OBJECTIVE

Neural tube defects (NTD) are potentially preventable by periconceptual folic acid supplementation. Women with obesity are at higher risk of NTD, therefore, are recommended a higher dose of 5 mg folic acid to mitigate this risk. The aim of this study was to evaluate maternal practice of folic acid supplementation amongst the antenatal population in relation to maternal obesity status.

DESIGN

Prospective observational study.

SETTING

Women ≤18 weeks' gestation at their first antenatal appointment attending University Maternity Hospital Limerick (Ireland) were recruited. Maternal height and weight were measured. Obesity was defined at a threshold of ≥30·0 kg/m2 and ≥27·5 kg/m2 when adjusting for ethnicity. A two-part questionnaire captured maternal characteristics and assessed supplementation compliance, commencement and dosage. Fisher's exact test for independence analysed differences in variables. A P value of <0·05 was considered significant.

PARTICIPANTS

A total of 328 women participated over a duration of 6 weeks.

RESULTS

Mean gestational age was 12·4 ± 1·4 weeks and mean BMI 26·7 kg/m2 ± 5·2 kg/m2. 23·8 % (n 78) were classified as obese. 96·5 % (n 315) were taking folic acid and 95·7 % (n 314) supplemented daily. 30·2 % (n 99) commenced supplementation 12 weeks prior to conception. Overall, 57·9 % (n 190) of women met folic acid supplementation dose requirements. 89·1 % (n 55) of women with obesity did not. Women with obesity were less likely to meet the higher folic acid supplementation dose requirements (P =< 0·001).

CONCLUSION

Folic acid supplementation practices within this cohort were suboptimal to prevent their risk of NTD. This study showed inadequate compliance of folic acid supplementation, and inadequate dosage for women with obesity. Increased patient education and awareness are needed within the antenatal period of pregnancy to bring folic acid supplementation practices in line with best practice guidelines.

Folic Acid and the Prevention of Birth Defects: 30 Years of Opportunity and Controversies

For three decades, the US Public Health Service has recommended that all persons capable of becoming pregnant consume 400 μg/day of folic acid (FA) to prevent neural tube defects (NTDs). The neural tube forms by 28 days after conception. Fortification can be an effective NTD prevention strategy in populations with limited access to folic acid foods and/or supplements. This review describes the status of mandatory FA fortification among countries that fortify (n = 71) and the research describing the impact of those programs on NTD rates (up to 78% reduction), blood folate concentrations [red blood cell folate concentrations increased ∼1.47-fold (95% CI, 1.27, 1.70) following fortification], and other health outcomes. Across settings, high-quality studies such as those with randomized exposures (e.g., randomized controlled trials, Mendelian randomization studies) are needed to elucidate interactions of FA with vitamin B12 as well as expanded biomarker testing.

Whole Grain Intakes Are Associated with Healthcare Cost Savings Following Reductions in Risk of Colorectal Cancer and Total Cancer Mortality in Australia: A Cost-of-Illness Model

Whole grain consumption has been associated with the reduced risk of several chronic diseases with significant healthcare monetary burden, including cancer. Colorectal cancer (CRC) is one of the most common cancers globally, with the highest rates reported in Australia. Three servings of whole grains provide a 15% reduction in total cancer and 17% reduction in CRC risk; however, 70% of Australians fall short of this level of intake. The aim of this study was to assess the potential savings in healthcare costs associated with reductions in the relative risk of CRC and total cancer mortality following the whole grain Daily Target Intake (DTI) of 48 g in Australia. A three-step cost-of-illness analysis was conducted using input parameters from: (1) estimates of current and targeted whole grain intakes among proportions (5%, 15%, 50%, and 100%) of the Australian adult (≥20 years) population; (2) estimates of reductions in relative risk (with 95% confidence intervals) of CRC and total cancer mortality associated with specific whole grain intake from meta-analysis studies; and (3) estimates of annual healthcare costs of CRC and all cancers from disease expenditure national databases. A very pessimistic (5% of population) through to universal (100% of population) adoption of the recommended DTI in Australia were shown to potentially yield savings in annual healthcare costs equal to AUD 1.9 (95% CI 1.2-2.4) to AUD 37.2 (95% CI 24.1-48.1) million for CRC and AUD 20.3 (95% CI 12.2-27.0) to AUD 405.1 (95% CI 243.1-540.1) million for total cancers. As treatment costs for CRC and other cancers are increasing, and dietary measures exchanging whole grains for refined grains are not cost preclusive nor does the approach increase energy intake, there is an opportunity to facilitate cost-savings along with reductions in disease for Australia. These results suggest specific benefits of encouraging Australians to swap refined grains for whole grains, with greater overall adherence to suggestions in dietary guidelines.