IntroductionFolic acid is a coenzyme that is essential for DNA synthesis and methylation pathways. The implication of folate fortification in wheat flour has been hugely studied. Some studies are demonstrating its positives while others are elucidating the adverse effects (Hertrampf and Cortes 2004). This paper focuses on the evidence for and against folic acid incorporation in wheat flour, and ethical considerations arising from such interventions.

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Evidence Supporting Fortification of Folic Acid in Wheat Flour
Prevention of Neural Tube Defects
A huge body of evidence exists that suggests wheat flour fortified with folic acid prevents neural tube effects (Kondo et al. 2017). These are congenital anomalies of the brain and spine, and it can range from spina bifida occult to anencephaly. Despite the available studies being cross-sectional and pre-post fortification analyses, reduced prevalence of brain and spinal cord congenital abnormalities is in tandem with across research and feasible. Considerate is put on the available evidence from the randomized control clinical trials and cohort studies on decreased prevalence of brain and spinal cord congenital abnormalities with incorporation of folic acid food.

Decreased concentrations of folate reduce the number of –CH3 groups that are essential in DNA replication and methylation (Kondo et al. 2017). Research suggests that in parents whose pregnancy outcome is complicated by neural tube defects, they are more likely to carry a variant in the gene that encodes for an enzyme known as methylenetetrahydrofolate reductase. The enzyme plays a crucial role in the regulation of homocysteine and folate levels. Lower concentrations of folate occur in individuals who are homozygous for this gene mutation. It also limits the process of converting homocysteine and methionine which raises the occurrence of spina bifida and anencephaly (Atta et al. 2016). Folic acid supplementation through fortification of foods plays a crucial role in limiting the effects of this mutated gene, therefore increasing the utilization of methionine.

Improves Folate Status
Fortification of folic acid in wheat has been shown to improve folate status. Substantial evidence exists worldwide that folic acid fortified in wheat flour has the potential of increasing blood folate concentrations and decreasing the incidence of folate deficiency. Despite most of the studies being cross-sectional, the study outcome is consistent across all studies. Improving folate concentrations is also justified by the evidence from the limited efficacy wheat flour fortified with folic acid and its supplementation to enhance blood folate concentrations.

Prevention of Folate Deficiency Anemia
Fortification plays a crucial role in preventing megaloblastic anemia or folate deficiency anemia. Folic acid plays an instrumental role in the synthesis of nucleotides needed in DNA replication. Low folate disrupts the dTMP and methylation pathways essential for DNA replication. Without DNA replication, there will be no cell division making the rapidly multiplying erythroblasts huge hence the name megaloblasts. Accumulation of immature megaloblasts in the bone marrow leads to ineffective erythropoiesis. This leads to megaloblastic anemia. Strong evidence is available worldwide that support the fortification of wheat flour with folic acid since it lays a crucial role in preventing folate deficiency anemia. It is also consistent with folic acid supplementation to improve blood folate concentrations hence preventing anemia due to its insufficiency.

Prevention of Stroke and Heart Disease
Folic acid supplementation has been demonstrated instrumental in prevention cardiovascular diseases and stroke. There is a strong evidence that supports the supplementation of folic acid to prevent the occurrence of primary stroke (Taheraghdam et al. 2016). One study found a 10 percent decreased risk of cerebrovascular accident occurrence, and 4 percent less risk of cardiovascular diseases with folate supplementation (Taheraghdam et al. 2016). However, no evidence supports the fortification of wheat flour to prevent stroke and heart disease.

Evidence against Fortification of Folic Acid in Wheat Flour
Epileptogenic Effects
Fortification of folic acid in wheat has been shown to worsen epilepsy. Despite the fact that folic acid is essential in remedying some neuropsychiatric disorders, it has been demonstrated to exacerbate convulsions (Girotto et al. 2013). High doses of folate in epilepsy causes excitatory effects especially when there is a defect blood-brain barrier mechanism of folate. Despite being putative, the epileptogenic impacts of folate are mediated via blocking GABA mediated inhibition. In an apparent distinction, certain classes of anticonvulsants mechanism of action are to decrease blood folate which is a crucial concern in women of reproductive age.

Increases Risk of Colorectal Cancer
Folic acid fortification has been demonstrated to increase the risk of colorectal cancer. Folate is considered an etiological agent, being a commonly studied disease. Research has demonstrated that high intake of folate increases the risk of colorectal cancer by 40 percent compared to low folate intake (Hirsch et al. 2009). Also, numerous concerns have been raised that link increased folic acid fortification programs with an increased prevalence of carcinoma of the colon and rectum. A study was aimed at studying hospital discharges of patients with colorectal cancer in Chile where folic acid fortification had been implemented. The study found out that the incidence of colorectal cancer increased by 162 percent (Hirsch et al. 2009). This data indicates a strong correlation between carcinoma of the rectum and the colon, and folic acid incorporation in staple food.

Ethical Considerations
The delivery of folic acid fortified food to people experiencing folate deficiency should be guided by the fact that every human being has the right to health. When designing the intervention and its implementation, it is crucial that human rights are put into considerations (Choi et al. 2014). The ethical challenges that usually emerge with fortification of staple food to ensure the community gets maximum benefit, circumvent negative effects and ensure social justice and equity principle is followed to the later. Another ethnically challenging aspect of food fortification that must be put under consideration is whether it should be mandatory or voluntary.
Fortification of wheat flour to prevent neural tube defects poses a significant challenge to other groups of the population that do not have problems with folate levels. Therefore, it brings about moral questions on how to circumvent the negative effects such as colorectal cancer. (Choi et al. 2014). This is significant considering the health hazards of folate concentrations which increases the risk of colorectal cancer and exacerbates epilepsy.

Conclusion
Folic acid fortification in wheat has been demonstrated to decrease the prevalence neural tube defects, reduce folate deficiency anemia and decreases the incidence of primary stroke. It also reduces the risk of overall cardiovascular diseases. However, folate has also been implicated as etiological factor in colorectal cancer and worsens epilepsy. This has led to fear of folate and has raised a lot of ethical questions that must be considered in the design of folic acid intervention and implementation. This is to avoid unnecessary harm to populations who are not affected by folate deficiency.

    References
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  • Choi, J., Yates, Z., Veysey, M., Heo, Y. and Lucock, M. (2014) “Contemporary Issues Surrounding Folic Acid Fortification Initiatives.” Preventive Nutrition and Food Science 19 (4), 247-260
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