Missing Ingredient?

Obviously, one ingredient missing from gluten free bread is the gluten.  But there's something else that might be missing too - folic acid.  

Folic acid is the synthetic form of folate, an essential B vitamin.[1]  Inadequate folate intake can result in a particular type of anemia, increased blood homocysteine levels (associated with increased risk of heart disease), and - especially important to women in their child-bearing years - increased risk of neural tube defects (NTDs) in newborns.[1]  The U.S. RDA for adults is 400mcg, and increases to 600mcg for women who are pregnant.[2] 

Since 1998, folic acid fortification of "enriched cereal-grains" has been mandatory in the US.[3],[4]  The impetus of folate fortification was a desire to "increase the folate intake of women of childbearing age to assist them in reducing their risk of having a NTD-affected pregnancy."[3],[4]  61 Federal Register 151 (5 Mar. 1996), pp. 8782.  As a result, many products made from refined grains, including flours, breads, crackers, pastas, and cereals, contain added folic acid.[5] 

But why fortification, as opposed to supplementation?  NTDs are defects in the brain, spine, and/or spinal cord.[4],[6]  A fetus's brain, spine, and spinal cord develop in the first few weeks of pregnancy, before most women are aware they are pregnant.[4],[6]  So by the time a pregnant woman first sees her doctor to confirm her pregnancy, the NTD ship has sailed.  As stated in the regulations regarding fortification, 

"[f]ood fortification...has the advantage of reaching a great number of women 

in the target population before conception and during early pregnancy.  It also has the 

advantage of providing folic acid in a continuous and passive manner and, thus, 

represents a potentially effective means for improving the folate nutriture 

of women throughout their childbearing years."[4]

61 Federal Register 151 (5 Mar. 1996), pp. 8782.

Relying on supplementation to meet the same goal would require significant educational efforts and could be prohibitively expensive for some women.

So back to that missing ingredient.  If you check out the ingredient list to that gluten free bread in your pantry or freezer, you probably won't see folic acid.  Why?  Because most gluten free products aren't required to be fortified.  This article provides a fairly concise explanation as to why (so you don't need to resort to reading the fortification regulations).

I took a quick survey of the gluten-free foods in my pantry, and none (including bread, two brands each of crackers and pasta, corn tortillas, and breadcrumbs) was folic acid fortified.  In fact, the only folic acid fortified product I've purchased in recent memory was white rice, which I typically eschew in favor of whole grain brown rice.  

Granted, folate is naturally present in foods other than fortified breads and pastas, including leafy greens, fruits and fruit juices, nuts, beans, grains, dairy, meat, seafood, and poultry.[1]  Unfortunately, folate is less available to our bodies than folic acid,[1] so just loading up on kale chips may not be enough.  In fact, a recent study by researchers at Columbia University's Celiac Disease Center found that a group of patients following a gluten free diet had significantly lower blood folate levels than a comparison group.[7]  The study focused on patients who did not have celiac disease,[7] which implies that the lowered folate levels were not the result of celiac disease's characteristic intestinal villi damage and, therefore, more likely tied to diet.

Whatever your personal stance on fortification (there are those who advocate for less processing of our food, even when that processing involves adding back nutrients), those of us in our child-bearing years would do well to think about - and maybe talk to our doctors or dietitians about - whether we're getting sufficient folate in our gluten free diets.  

For more information about:

Folate generally, see 

[1] National Institutes of Health Folate Fact Sheet

Folic Acid Awareness Week 2014

RDAs for folate, see 

[2] Dietary Reference Intakes

NTDs and Spina Bifida, and the link to folate, see 

[6] Medline Plus: Neural Tube Defects

[5] Spina Bifida Association: Status of Folic Acid Fortification

History of Folate Fortification in the U.S., see 

[3] FDA - Folic Acid Fortification

Blood Folate Levels in Gluten Free Patients, see

[7] Characteristics of Patients Who Avoid Wheat and/or Gluten in the Absence of Celiac Disease

Final Rule requiring folic acid fortification, see

[4] Final Rule, 61 Fed. Reg. 151