CHAPTER FIVE

Recent Developments
in Folate Nutrition
Nassim Naderi*,†, James D. House*,1
*Department of Food and Human Nutritional Sciences, University of Manitoba, Winnipeg, MB, Canada
†
Institute of Nutrition and Functional Foods (INAF), Universit
e Laval, Quebec City, QC, Canada
1
Corresponding author: e-mail address: [email protected]

Contents
1. Introduction 196
2. Folate and Folic Acid 196
2.1 Terminology and Chemical Structures 196
2.2 Historical Perspective 198
2.3 Functional Bioefficacy 199
2.4 Stability of Folates 201
2.5 Absorption and Folate Metabolism 201
2.6 Folate and Health 203
2.7 Folate Fortification 204
2.8 Adverse Effects of Folic Acid Food Fortification and Supplementation 205
2.9 Replacing Synthetic Folic Acid With Natural Folate 206
3. Summary 208
References 209
Further Reading 213

Abstract
The term folate (vitamin B9) refers to a group of water-soluble compounds that are
nutritionally essential for the support of optimal human health and development.
Folates participate in numerous one-carbon transfer reactions, including the methyla-
tion of important biomolecules (lipids, amino acids, DNA). A deficiency of folate leads to
pathological outcomes including anemia and impairments in reproductive health and
fetal development. Due to the linkage of impaired folate status with an increased prev-
alence of neural tube defects (NTDs) in babies, several jurisdictions required the fortifi-
cation of the food supply with folic acid, a synthetic and stable form of folate. Data from
the postfortification era have provided strong evidence for the reduction of NTDs due to
folic acid fortification. However, concern is now growing with respect to the amount of
synthetic folic acid within the human food supply. Excess folic acid intake has been
linked to a masking of vitamin B12 deficiency, and concerns regarding the promotion
of folate-sensitive cancers, including colorectal cancer. New strategies to ensure the
supply of optimal folate to at-risk populations may be needed, including the use of bio-
fortification approaches, in order to address recent concerns.

Advances in Food and Nutrition Research, Volume 83 # 2018 Elsevier Inc. 195
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196 Nassim Naderi and James D. House

1. INTRODUCTION
Folate (vitamin B9) represents the collective term for a class of com-
pounds (vitamers) belonging to the water-soluble family of vitamins. Col-
lectively, the folate vitamers play important roles in one-carbon
metabolism, including their involvement in the biosynthetic pathways for
key amino acids and nucleic acids (Institute of Medicine, 1998). As such,
folate is a key factor in cell replication and intermediary metabolism.
A deficiency of folate has been linked to a variety of disorders (Iyer &
Tomar, 2009), including anemia and neural tube defects (NTDs). While
animal cells can interconvert the various vitamin forms, they do not possess
the ability to synthesize the foundational pteroylglutamic acid structure, and
thus rely on exogenous sources of this important nutrient (Molloy, 2005).
Exogenous supply can come in the form of naturally occurring folates in
the food supply and via folate synthesized by commensal microorganisms
within the large bowel. Additionally, synthetic crystalline folic acid is rou-
tinely used to fortify foods and as a constituent of dietary supplements. While
supplemental folic acid has proven effective in addressing critical public
health issues, including the reduction of the incidence of NTDs, there is
growing evidence that the human food supply is now overfortified with folic
acid, and this might pose health risks, including the increased risk of devel-
oping colorectal cancer and the masking of vitamin B12 deficiency (Kim,
2004). The risk appears linked to crystalline folic acid, and not the naturally
occurring forms of folate. As such, there is interest in positioning alternative
sources of folate for use in supplements and to fortify the food supply. This
chapter will further discuss recent advances in our understanding of folate
nutrition, particularly with respect to addressing alternative approaches to
ensure adequate folate intakes in target populations.

2. FOLATE AND FOLIC ACID

2.1 Terminology and Chemical Structures
Folate, also known as folacin or vitamin B9, refers to a family of chem-
ically and functionally related compounds that exhibit a common vitamin
activity based on the parent structure of folic acid (Selhub & Rosenberg,
1996). The synthetic folic acid (pteroylglutamate) is the most oxidized and
stable form of folate. Folic acid (molecular weight ¼ 441.4 (g/mol)) is
Recent Developments in Folate Nutrition 197

odorless, slightly soluble in cold water, with more solubility in aqueous

alkali, acetic acid, phenol, pyridine, and other basic solvents. Folic acid
is fully oxidized and, in neutral solution, has a maximum absorption at
298 nm. Synthetic folic acid lacks coenzyme activity and must be reduced
to the metabolically active tetrahydrofolate (THF) form within the cell.
Due to its chemical stability and greater commercial availability compared
to natural form of folate, folic acid is the most commonly used form in
supplements and food fortification. Both natural folate and synthetic folic
acid after intakes are converted to 5-methyltetrahydrofolate (5-MTHF),
and this is the predominant folate form usually found in blood plasma
(Wien et al., 2012).
The basic structure of folate comprises a pteridine ring attached to
p-aminobenzoic acid through a methylene group, an L-glutamic acid residue
is linked to p-aminobenzoic acid (Fig. 1). The terms folate and folic acid are
often used interchangeably for this vitamin. The pteridine ring of folic acid is
fully oxidized, while natural folates occur as dihydro- or tetrahydrofolates
(H4folate) with different one-carbon substituents linked at the N5- and/
or N10-position (Fig. 2; Lavoisier, 2008).
The folates in food and feedstuffs are typically in a reduced form as poly-
glutamyl derivatives of tetrahydrofolic acid. The polyglutamated form of
5-MTHF is recognized as the predominant form of dietary folate and is nat-
urally found in fresh food sources (Lucock, 2000). The 5-MTHF vitamer has
the chemical formula C20H25N7O6 (molecular weight of 459.5 g/mol) and
possesses intermediate oxidative stability relative to folic acid. The

Pterin para-aminobenzoic L-glutamic acid

acid
Fig. 1 Chemical structure of crystalline folic acid.
198 Nassim Naderi and James D. House

5-methyl- 5-formyl- 10-formyl-

5,10-methylene- 5,10-methenyl- 5-formimino-

Fig. 2 One-carbon moieties linked at either the N5- and/or N10-position of the folate
structure.

compound can be isolated as a white powder; however, in solution it

requires ascorbate or another reducing substance to achieve medium-term
stability. At neutral pH, it has an absorption maxima of 290 (Scott & Weir,
1993). A calcium salt of L-5-methyltetrahydrofolic acid (C20H23CaN7O6;
MW ¼ 497.5 g/mol) has been synthesized (Ginting & Arcot, 2004) and
shown to possess comparative physiological activity, bioavailability, and
absorption at equimolar doses to the naturally occurring form (Pietrzik,
Bailey, & Shane, 2010).

2.2 Historical Perspective

The natural form of folate was first discovered by Lucy Wills over 80 years
ago as a component of yeast with documented abilities to both prevent
and cure macrocytic anemia. The structure of polyglutamate folate was
determined in the mid-1940s. The chronology of folate discovery is sum-
marized in Table 1. Later in 1943, the monoglutamate form of folate was
synthesized in pure crystalline form, and this discovery proved that folic
acid is composed of a pteridine ring, p-aminobenzoic acid, and glutamic
acid. Afterward, it became evident that natural folates usually differed
from pteroylglutamic acid. Today, folic acid refers to the fully oxidized
chemical compound which does not exist in natural foods. The term
“folate” is designated to the large group of compounds having the same
vitamin activity and includes natural folates and folic acid (Hoffbrand &
Weir, 2001).
Recent Developments in Folate Nutrition 199

Table 1 The Chronology of Folic Acid Discovery From Ulrich and Potter (2006)

1930 Wills and Mehta Yeast extract prevented the dietary anemia in rats
1931 Wills Yeast or marmite prevents macrocytic anemia of
pregnancy
1934 Vaughan and Turnbull Marmite corrects anemia of coeliac disease
1938 Wills and Evans Purified liver extracts do not correct nutritional,
pregnancy, or macrocytic anemia
1940 Snell and Peterson Norit eluate factor—factor absorbed from yeast
or liver is growth factor for Lactobacillus casei
1941 Mitchell, Snell, and The term folic acid coined and shown to be a
Williams growth factor for Streptococcus lactis R (Streptococcus
faecalis)
1943; Fullerton; Watson and Idiopathic steatorrhoea megaloblastic anemia
1946 Castle responds to crude liver extracts or yeast extract
1943 Wright and Welch Enzyme hydrolyzing folate polyglutamates to
monoglutamates folate conjugase
1944 Binkley et al. Yeast extracts effective as a source of vitamin BC
only 2%–5% being active for L. casei. Required
enzymatic digestion to balance activity
1945 Angier et al. Synthesis of folic acid and using the term
pteroylglutamic acid
1945 Day et al. Purified L. casei factor is vitamin M
1946 Pfiffner, Calkins, Naturally occurring folate in liver is a
Bloom, and O’Dell heptaglutamate

2.3 Functional Bioefficacy

The functional bioefficacy of a nutrient refers to the proportion of it that,
once ingested, possesses the ability to perform specific metabolic function
(Brouwer, van Dusseldorp, West, & Steegers-Theunissen, 2001). Since
plasma total homocysteine is a functional index of folate status, by nature
of the role that folate plays in sulfur amino acid metabolism (Fig. 3), changes
in plasma total homocysteine concentration in response to a given intake of
folate or folic acid can be used as a measure of functional bioefficacy. Factors
influencing bioavailability and bioefficacy of folate include: (a) species of
folate, (b) amount of folate and folic acid consumed, (c) food matrix effects
200 Nassim Naderi and James D. House

dUMP

5,10-methylene-
DNA synthesis tetrahydrofolate
MTHFR
Glycine
Serine
dTMP
B6 hydroxymethyltransf
erase
Serine

DHFR DHFR MS
Folic acid H2folate H4folate 5-MTHF
B12
Methionine Homocysteine B6

Cysteine

S-adenosylmethionine S-adenosylhomocysteine

DNA methylation
Fig. 3 Schematic presentation of the main metabolic pathways of folate.

(d) overall nutrient status of the host (e) genetic factors, and (f ) host-related
factors (Gregory, 2001).
Folates and their derivatives occur in nature in forms ranging from
mono- to polyglutamates. Synthetic folic acid exists in the monoglutamate
form and it is fully oxidized at the N5- and N10-positions. The poly-
glutamated forms of natural folates, a form needed for cellular folate reten-
tion, must be hydrolyzed to monoglutamate forms prior to absorption in the
small intestine (see below). The monoglutamate forms of folate, including
folic acid, are transported across the proximal small intestine. During the past
decades, several attempts have been made to assess the bioavailability of
folate polyglutamate compared to monoglutamate form, but the results were
not consistent. It is suggested that bioavailability of ingested monoglutamates
is significantly greater than that of folate polyglutamates apparently because
of the requirement for hydrolysis of the latter (Gregory, 2001; Patanwala
et al., 2014). It has been stated that the bioavailability of dietary folate is ham-
pered by the polyglutamate chain to which most of the natural folate is
attached. The polyglutamate chain must be removed by the enzyme con-
jugase present in the brush border of the small intestine prior to absorption
and transport as a monoglutamate into the portal vein (Melse-Boonstra et al.,
2002). Bioavailability of folate or folic acid is likely to be influenced by the
amount ingested. Uncertainty exists as to the extent of folate bioavailability
from natural food sources, as this is dependent on both host- and food-
Recent Developments in Folate Nutrition 201

related factors (McNulty & Pentieva, 2004). Limitations related to the host
organism include folate status, health, age, gender, gastrointestinal function,
and the use of medication and alcohol (Melse-Boonstra et al., 2002;
Witth€ oft, 2011).
Food processing can also influence bioavailability by affecting the food
matrix and folate stability, resulting in variable folate losses prior ingestion.
Bioavailability of folates in food stuff has been difficult to assess quantita-
tively, but in general folates from animal products for human appear to
be more bioavailable compared to plant-derived food (McKillop et al.,
2003). By comparing homocysteine and glycine, both sensitive measures
of folate status in the folate depleted–repleted rodent model, it was shown
that the folate present in chicken egg in the form of 5-MTHF monog-
lutamate had the same or slightly greater relative bioavailability as crystalline
folic acid (House, O’Connor, & Guenter, 2003).

2.4 Stability of Folates

Folates are susceptible to oxidative degradation during food processing
which is enhanced by oxygen, light, and heat. Oxidation results in a
splitting of the molecule into biologically inactive forms, of which
p-aminobenzoyl-glutamate is one major form (Strandler, Patring,
J€agerstad, & Jastrebova, 2015).The susceptibility of folate is largely
influenced by the pH of the medium, reducing agents in the buffer, type
of buffer, folate derivatives, and the food system. In most cases, folic acid
shows considerably better stability than the reduced folates. The use of
antioxidant agents such as ascorbic acid can improve considerably the sta-
bility of 5-MTHF (House, Braun, Ballance, O’Connor, & Guenter, 2002).
Folate compounds are susceptible to light which is reported to cause cleav-
age at C9–N10 position. Thereby, folate analysis should be often carried out
in low light and glassware that prevents light penetration (i.e., wrapped
with aluminum foil) (Indrawati et al., 2004).

2.5 Absorption and Folate Metabolism

After consumption of polyglutamate folates and synthetic monoglutamate,
they undergo absorption in the intestinal tract. While folic acid can be
absorbed directly, the polyglutamated forms of folates must be converted
to their monoglutamate form. Within the intestinal tract of humans,
this is principally achieved through the action of glutamate carboxy-
peptidase II (folate conjugase) located on the brush surface of enterocytes
202 Nassim Naderi and James D. House

(Visentin, Diop-Bove, Zhao, & Goldman, 2014). The monoglutamate

forms of folate are then transported across the enterocyte via the action of
specific transporters: (1) the reduced folate carrier or (2) the proton-coupled
folate transporter (PCFT) (Said, 2011). The latter PCFT carrier is postulated
to be the primary mechanism of folate transport in the upper intestinal tract
(Visentin et al., 2014).
Following transport, monoglutamates are reduced to di- and
tetrahydrofolate (THF) by reductase enzymes. THF is the parent compound
of all biologically active form of folate. In next step, the THF is converted to
5,10-methylenetetrahydrofolate and 5-MTHF. From there, they are trans-
ferred to the hepatic portal vein which leads to the liver and systemic blood
circulation and body tissues (Czeizel, Dudás, Paput, & Bánhidy, 2011;
Visentin et al., 2014; Witth€ oft & J€agerstad, 2002).
After reduction to tetrahydrofolate, synthetic folic acid gains metabolic
activity similar to other folate species. The enzyme dihydrofolate reductase is
responsible in reducing folic acid to dihydrofolate (H2folate) and next to
THF (Fig. 3). The main function of folate in the human body system is
the transport of one-carbon moieties, such as methyl and formyl groups.
The 5,10-methylenetetrahydrofolate reductase enzyme is responsible for
converting the THFs to 5-MTHF via 5,10-methylenetetrahydrofolate.
5-MTHF is the methyl donor in the remethylation of homocysteine to
methionine through the action of methionine synthase (MS). Methionine
(essential amino acid) will be converted to S-adenosylmethionine which
is an important intracellular methyl group donor (Fox & Stover, 2008).
Folates act as a cofactor to transport one-carbon units at different oxida-
tion levels (methyl-, formyl-, methylene-) for the biosynthesis of DNA and
for hundreds of methylation reactions. Therefore, folates are important for
all cell replication activities and restoring DNA and RNA. Folates play a role
in regeneration of methionine from homocysteine. This reaction is catalyzed
by MS and requires vitamin B12 as coenzyme. During this reaction, the
methyl group in folate is transferred first from 5-MTHF to the cofactor
to form methylcobalamin, and then the methyl group is ultimately trans-
ferred to homocysteine. Deficiency of vitamin B12 in cells results in the
accumulation of 5-methylated folate, thus forming a block in folate metab-
olism, the “methyl trap” (Scott & Weir, 1993). Thus, vitamin B12 defi-
ciency can create a conditional folate deficiency. Folate deficiency causes
abnormal nuclear maturation in the blood cells which in turn leads to meg-
aloblastic anemia (Aslinia, Mazza, & Yale, 2006).
Recent Developments in Folate Nutrition 203

2.6 Folate and Health

Beyond its role in normal metabolism, folate status has been linked to the
development of chronic diseases, including cardiovascular disease, and
also in reproductive health. Given the involvement of folate with other
water-soluble vitamins in the methionine cycle, principally vitamin B6
and B12, specific roles for folate are often difficult to delineate. Folate
deficiency has traditionally been recognized as a problem in countries
struggling with poverty and malnutrition, with the main risk being mac-
rocytic megaloblastic anemia (Gough, Read, McCarthy, & Waters,
1963). Low intake of folate associated with megaloblastic anemia led to
a higher risk of giving birth to infants with NTDs and possibly other birth
defects (Iyer & Tomar, 2012). With respect to chronic diseases, folate
inadequacy has been linked to cardiovascular diseases (Graham et al.,
1997), depression, Alzheimer’s disease (Kruman et al., 2002), and cancer
(Duthie, 1999). Folate plays a part in many metabolic pathways, including
DNA replication, repair, and methylation, and in the synthesis of nucle-
otides, amino acids, and some vitamins. A dietary supply of this vitamin is
therefore required to prevent nutritional deficiency in humans (LeBlanc,
de Giori, Smid, Hugenholtz, & Sesma, 2007). Traditionally, folate defi-
ciency was more common in populations that had a high intake of refined
cereals and a low intake of green leafy vegetables and fruit. Other risk fac-
tors for folate deficiency include the malabsorption of folic acid, which
can be caused by diseases affecting either intestinal pH or the jejunal
mucosa, or due to genetic defects. Prior to the introduction of mandatory
wheat flour fortification with folic acid in 1998, about 15% of adult
women in the United States had low serum folate levels. Serum folate
level is an indicator of recent dietary folate intake, and the most widely used
method of assessing folate status (Pfeiffer, Caudill, Gunter, Osterloh, &
Sampson, 2005).
The main dietary sources of folate are green leafy vegetables, pulses, liver,
egg, and fortified grain products. As such, the requirement for this vitamin is
supplied mainly via the dietary intake of folates and the use of synthetic folic
acid. Vegetables and pulses are considered as rich sources of folate having
200–600 μg 100 g1. Citrus fruits and cereals are good sources of folate with
concentration of 50–100 μg 100 g1. Egg yolk has high content of folate for
about 90 μg 100 g1. In addition to dietary sources of folate, either from nat-
ural or supplemental/synthetic forms, the human digestive tract harbors
microorganisms capable of synthesizing folate. Evidence is accumulating
204 Nassim Naderi and James D. House

that this source of folate is metabolically available to the host (Aufreiter et al.,
2009). However, the extent of this contribution has not been sufficiently
quantified to date.

2.6.1 Neural Tube Defects

NTDs (spina bifida, encephalocele, and anencephaly) represent a major
group of birth defects. During fetal development, the neural tube closes
by the third week of postconception in humans. Failure of the neural tube
to close completely results in a neural tube defect or NTD (Czeizel & Dudas,
1992). Maternal nutrition factors contribute significantly to the various eti-
ologies of NTDs. Previous investigation (Smithells, Sheppard, & Schorah,
1976) reported that the diets and postnatal blood of women who had given
birth to babies with an NTD were lacking in several micronutrients, prin-
cipally folic acid. Following two decades of research, it was established that
folic acid supplementation reduces 50%–75% of NTD-affected pregnancies
(Laurence, James, Miller, Tennant, & Campbell, 1981; Scott & Weir, 1993;
Seller & Nevin, 1984; Vergel, Sanchez, Heredero, Rodriguez, & Martinez,
1990). Dietary supplementation with 400 mg of folic acid per day showed
70% prevention of NTD in women with a past history of carrying a fetus
with NTDs and 50% of NTDs in the general population. It was found that
30%–50% of the population is nonresponsive to maternal folate level, dem-
onstrating folate-responsive and nonresponsive individuals in the human
population (Berry & Li, 2002; Czeizel et al., 2011). The latter observations
provided strong evidence that additional folate might provide a public health
benefit, particularly with respect to healthy birth outcomes.

2.7 Folate Fortification

Food fortification refers to addition of micronutrients into processed foods.
It is a valid technology to improve micronutrient levels, as part of food-based
approaches, if access to adequate levels of specific nutrients is limited. Sup-
plementation, on the other hand, refers to the provision of micronutrients in
the form of pills, capsules, or syrups. Typically, supplementation is consid-
ered to be a rapid approach to achieve enhanced intakes of nutrients of con-
cern, in stable and bioavailable forms, in select population groups. However,
with respect to NTDs, given the fact that 3 weeks postconception reflects
the maximum time for the protective effect of folate, challenges to the effi-
cacy of folic acid supplementation for NTD risk mitigation exist. These
include the fact that many pregnancies are unplanned and the usage of sup-
plements by women of child-bearing age is typically below 40%. In a cohort
Recent Developments in Folate Nutrition 205

of young, college-aged women, only 26% of the participants reported taking a

supplement containing folic acid (Shuaibi, House, & Sevenhuysen, 2008).
Supplement usage by women during pregnancy is, however, considerably
higher, with greater than 90% of a cohort of pregnant women in Ontario,
Canada, taking supplements with folic acid (Plumptre et al., 2015). However,
this level of supplement usage may not be NTD-protective given the need for
adequate periconceptional folate status. Fortification of the food supply with
folic acid presented an alternative approach to ensuring adequate intakes.
In 1992, to reduce the number of cases of NTDs, the US Public Health
Service recommended that all women capable of becoming pregnant con-
sume 400 μg of folic acid daily. Three approaches were advocated to increase
folate consumption, including the improvement of dietary habits to ensure
the consumption of foods naturally rich in folate, fortify foods with folic
acid, and promote the use of dietary supplements containing folic acid
(CDC, 1991). However, for reasons discussed above, the governments of
the United States and Canada, along with several other countries, intro-
duced the mandatory fortification of grain products with folic acid (FDA,
1996). Crystalline folic acid (monoglutamate form) was chosen as the form
of folate to use in fortifying foods owing to its availability, cost, and stability.
Mandatory fortification of cereal grain products started in 1998 from
United States and followed by Canada and some Latin American countries
but not in Norway or in the United Kingdom (Wien et al., 2012). There-
after, the results of several studies and surveillance show the number of
NTD-affected pregnancies declined by as much as half. Given the significant
decline in NTD rates, mandatory folic acid fortification became recognized
as a major public health triumph (De Wals et al., 2007). However, in recent
years, concern has been raised that populations within folic acid-fortified
countries might be exposed to excessive levels of this form of folate.

2.8 Adverse Effects of Folic Acid Food Fortification and

Supplementation
Despite documented beneficial effects of folic acid fortification on
preventing NTDs, concern has been raised about the amount of population
exposure to crystalline folic acid. The potential for folic acid, enhanced via
food fortification, in masking vitamin B12 deficiency has been raised, as the
latter leads to the progression of irreversible neurological symptoms
(Molloy, Brody, Mills, Scott, & Kirke, 2009). The latter findings were of
particular importance to those individuals who received folic acid from both
supplements and a range of fortified foods because in this situation people
206 Nassim Naderi and James D. House

may exceed the upper limit for folic acid intake (1 mg from folic acid). Fur-
thermore, there are some reports on the relation between folic acid supple-
mentation during pregnancy and risk for miscarriage or an increase in the
occurrence of multiple births (Czeizel & Dudas, 1992).
Another concern that has been raised in relation to increased exposure to
dietary folic acid relates to the potential for increased risk of gastrointestinal
cancer, including colorectal cancer (Kim, 2004). A systematic review found
only prostate cancer to be linked to high folic acid intakes (Wien et al.,
2012). While the latter finding may not translate to specific concerns related
to maternal folate exposure, recent preclinical studies in animals have shown
that high folic acid (and other methyl donor) intakes may lead to epigenetic
changes in offspring, increasing the risk of development of diabetes and
alterations in food intake behavior (Huot et al., 2016). Perhaps it is time
to reevaluate the strategy of fortifying foods with folic acid, taking into
account the impacts to the entire population and not just a subsection at risk
for NTD-affected pregnancies.

2.9 Replacing Synthetic Folic Acid With Natural Folate

The introduction of mandatory folic acid fortification of grain products in
certain jurisdictions, including Canada and the United States, has succeeded
in decreasing the rates of NTD by 20%–50% (Persad, Van den Hof, Dub
e, &
Zimmer, 2002; Ray, 2004). However, in some countries like the Nether-
lands, folic acid fortification is prohibited due to growing debate about the
long-term safety of folic acid consumption by general population (Varela-
Moreiras, Murphy, & Scott, 2009). The debate addresses two main risks
of long-term consumption of high folic acid intake which could promote
the formation of colorectal tumors (Kim, 2004; Mason et al., 2007) and mas-
king the appearance of vitamin B12 deficiency anemia (Morris, Jacques,
Rosenberg, & Selhub, 2007, 2010). Recent studies regarding folic acid for-
tification are rediscovering the harms to the nervous system from long-term
exposure to doses of folic acid between 0.5 and 1 mg in the presence of vita-
min B12 deficiency (Reynolds, 2016). Thereby, it is highly recommended
to review the safe upper intake level of folic acid to prevent the health risk
factors.
As discussed above, synthetic folic acid is absorbed by carrier-mediated
mechanism, and it must be reduced and then metabolized to 5-MTHF in the
human mucosal cell and/or liver in order to be metabolically active. Because
Recent Developments in Folate Nutrition 207

the ability of conversion is limited, unmetabolized folic acid can appear in

the systemic circulation, even after low-dose application (Pietrzik et al.,
2010). Due to the suspected adverse effects of folic acid fortification, atten-
tion has been directed toward other solutions that might help increase pop-
ulation intake of natural folates, which do not carry with them the same
safety concerns as synthetic folic acid, particularly with respect to the mas-
king of vitamin B12 deficiency. As such, other strategies have been inves-
tigated in order to increase population intake of natural folates without
adverse effect of synthetic folic acid. The development of novel foods
enriched with natural folates has been considered as an innovative solution
in nutritional strategies.
One strategy for increasing natural folates in the food supply includes the
development of novel functional foods based on animal products enriched
with natural folate through the addition of high dose of synthetic folic acid to
animal feed (Altic, McNulty, Hoey, McAnena, & Pentieva, 2016; House
et al., 2002). Research has shown that hen eggs can be enriched with folate
by supplementing hen’s diet with folic acid and reaching maximum folate
content of about 2.5 times that of a normal egg (Altic et al., 2016; House
et al., 2002; Sahlin & House, 2006). Natural folates in novel folate-enriched
eggs are highly stable with little or no losses during storage at refrigerator or
room temperature for 27 days (Altic et al., 2016). Studies revealed that the
folate which appears in enriched eggs is in the natural form, mainly as
5-MTHF, and this strategy could offer an efficient solution to increase folate
intake of population, especially where long-term consumption of folic acid-
fortified foods has been criticized (Hoey et al., 2009). This researcher stated
that no polyglutamate forms were present in egg yolk. House et al. (2003)
also reported the relative bioavailability of folate in eggs is higher or equal to
100% compared to folic acid. The 5-MTHF in egg yolk does not oxidize
during cold (4°C) storage for 4 weeks and folate levels remained constant
relative to freshly collected eggs (House et al., 2002).
Compared to green leafy vegetables, folates in animal products including
eggs are also usually more stable during thermal treatment (McKillop et al.,
2003). However, a significant obstacle in egg consuming is the perception
that egg consumption is associated with a rise in blood cholesterol levels.
Food processing techniques such as fractionation methods enable scientists
to fractionate egg yolk in different components with different compositions.
Fractionation of egg yolk by centrifugation techniques can enable us to sep-
arate a low-cholesterol content fraction of yolk which is concentrated with
208 Nassim Naderi and James D. House

5-MTHF (Naderi, House, & Pouliot, 2014). The consumption of these

novel folate-enriched eggs or egg-derived, folate-enriched fractions could
represent alternative and cost-efficient ways of increasing folate intake
and potentially folate status of population in countries that mandatory folic
acid fortification remains nonexistent (Altic et al., 2016). Another way to
introduce a stabilized form of 5-MTHF into the food supply is via direct
encapsulation (Liu et al., 2012), a strategy shown to lead to effective forti-
fication of cereal grain products, including noodles and bakery products
(Liu, Green, & Kitts, 2015; Liu, Green, Wong, & Kitts, 2013).
Another strategy to increasing the supply of natural folates is via
encapsulated probiotics (Divya & Nampoothiri, 2015). The use of folate-
producing food-grade microorganisms has been positioned as a natural alter-
native to fortification with the synthetic folic acid (Laiño, Zelaya, del
Valle, de Giori, & LeBlanc, 2015). Fermented milk bioenriched with folate
was produced from folate-producing lactic acid bacteria, and this product
effectively increased plasma folate concentrations (Laiño et al., 2015). The
latter method represents an approach toward biofortification of foods with
folate. The use of genetically modified biofortified crops offers additional
opportunities. Researchers applied transgenic breeding techniques in order
to enhance vitamin or mineral concentrations in some crops such as Golden
Rice (De Steur, Feng, Xiaoping, & Gellynck, 2013). However, the genet-
ically modified biofortification faces challenges for commercialization, due
to regulatory hurdles and consumer acceptance of genetically modified
foods. Folate biofortification through breeding or metabolic engineering
in rice, tomato, potato, wheat, and cassava was assessed; however, this strat-
egy needs to be developed to enable adequate biofortification of other staples
(Strobbe & Van Der Straeten, 2017).

3. SUMMARY
Folate is a water-soluble vitamin critical for optimal health in humans.
Recent attention has focused on the supply of folic acid to the population,
with particular emphasis on the reduction of the incidence of NTD rates in
newborn infants. Recent evidence is challenging current public health strat-
egies with respect to food fortification, necessitating a review of the current
approaches. Innovative alternative approaches to supplying folate to the
human population include the use of biofortified foods and novel, stabilized
forms of folate.
Recent Developments in Folate Nutrition 209

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FURTHER READING
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