Delivering babies is predominantly a source of joy, with just a small fraction of heartbreak, but this heartbreak can be devastating. I recently thought more about devastating outcomes while counseling a patient about her baby’s newly discovered, severe neural tube birth defect (“NTDs”). As a physician with a special interest in Lifestyle Medicine (which focuses on six key pillars of behavioral interventions to improve outcomes or to cure pathology — whole food, plant based nutrition, stress management, avoidance of risky substances, restorative sleep, social connection, and physical activity), I know we need more preventive medicine strategies to help patients focus on nutrition to prevent, heal, or even cure. We know that nutrition can play an essential role with NTDs.
NTDs which can include spina bifida and anencephaly can sometimes be prevented through folic acid consumption in a prenatal vitamin. Nutrition is important too, as folate is present in many foods, such as leafy greens. The FDA mandated folic acid supplementation in all enriched grain products to reduce this birth defect in 1998. Since then, the CDC estimates that NTDs have dropped by up to 35%, showing that though not all NTDs can be prevented through this intervention, food fortification does reduce incidence. Still, there remains a critical oversight, particularly concerning the Latino community: the absence of folic acid fortification in corn masa flour.
According to the CDC, Latinas have the highest risk of NTDs. While there are several reasons to explain this statistic and many are not modifiable, some of the risk may be explained by a heavier reliance on corn masa flour as a staple in their diet. While the FDA approved voluntary folic acid fortification of masa in 2016, it is estimated that only about 10% of manufacturers have complied with the new guidelines. As such, the Latino community may not have benefited from the well-established fortification strategy in existence.
While California has made great strides in reducing morbidity and mortality in maternal and infant health outcomes, there is more work to be done. The mission is clear in public health: to ensure equitable access to essential nutrients and to implement preventive measures for all communities to ensure the best outcomes. The Assembly Bill 1830 introduced by Dr. Joaquin Arambula, co-authored by Assembly Members Mia Bonta and Alex Lee, and sponsored by the American College of Obstetricians and Gynecologists, will do this.
This legislation requires a safe, effective amount of folic acid be added to the masa flour manufactured, sold, delivered, distributed, and held in California. In essence, it will hold corn masa to the same standards as already enriched grain products. Additionally, it requires the nutritional label to include this, so that our patients will know the flour they are using will help aid in a healthy pregnancy. There are some important exceptions to this requirement which allow for cultural preservation of taste in the product.
Health disparities among minority populations persist despite advancements in medical science. As advocates for patients, we must recognize that our duty extends beyond the parameters of clinical settings; it encompasses advocating for policies and practices that promote health equity. Additionally, when possible, we must continuously look for strategies which emphasize prevention rather than treatment after the fact.
Lastly, this bill could impact national health. Since so much of corn masa is consumed in California, manufacturers may find it wise from an economic sense to bring all products up to the standards set by California. Let us together fortify not only our food but also our commitment to serving all patients with dignity, respect, and the highest standard of care. Prevention, after all, can truly be the best medicine.
Shilpa Mathew is a practicing ob/gyn in Sacramento, CA. Prior to that she practiced as an attorney in San Francisco, CA and has a special interest in the intersection between law and medicine. She currently is the Co-Legislative Chair for Legislative Committee of the The American College of Obstetrics and Gynecology in California. Find her on Instagram.
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