Why tortillas sold in California may be forced to add a new ingredient

Corn chips, tortillas, tamales and pupusas — while all delicious may be missing a key vitamin for women of reproductive age.

Folic acid has long been used to prevent serious birth defects and help babies develop. Medical and public health experts advise daily consumption during pregnancy, but also in the months before becoming pregnant. This B vitamin is so important the federal government requires folic acid in certain foods such as enriched breads and cereals.

Now a California lawmaker is carrying a bill that would require manufacturers of corn masa flour — used to make many classic Latino foods — to also add folic acid to their products. Assemblymember Joaquin Arambula, a Fresno Democrat and physician, is carrying Assembly Bill 1830. The legislation would require that producers add 0.7 milligrams of folic acid to every pound of masa, and that this addition be reflected in the nutrition label. 

Arambula wants to address clear disparities in who gets the necessary amount of folic acid. State public health data show that Latinas are less likely to take folic acid in the early weeks of pregnancy or before becoming pregnant when compared to other racial or ethnic groups. This puts them at higher risk of having children born with birth defects of the brain and spinal cord, most commonly spina bifida and anencephaly.

Folic acid, or synthetic folate, promotes healthy cell growth. Research has shown that when taken before and in the early weeks of pregnancy and in the early weeks, folic acid can help prevent birth defects by as much as 70%. 

“Food is the best way that we can get folic acid into our communities before they’re pregnant,” Arambula told CalMatters. “Oftentimes the prenatal vitamins that we give to pregnant people are too late.” 

That’s because the brain and spine begin to form within the first four weeks of gestation. Many people may not even know they’re pregnant during this time, especially when the pregnancy is unplanned. 

The U.S. Food and Drug Administration followed that rationale when it handed down a mandate in 1998 requiring folic acid fortification in enriched grain products, including cereals, breads, pasta and rice. Since that rule took effect, the proportion of babies born with neural tube defects has dropped by 35% — about 1,300 fewer babies every year — according to the Centers for Disease Control and Prevention. 

The FDA did not include corn masa flour in its folic acid mandate. Continuing to leave it out is “a real oversight,” Arambula said. Culturally, the diets of many Latinos, especially of immigrants and first generation residents, often rely heavily on corn flour. 

Latinas get less folic acid

Dr. Megan Jones sees many high-risk pregnancies among Latina farmworkers as a maternal-fetal medicine specialist on California’s Central Coast.

She sees babies born with neural tube defects, cleft lips and cardiac defects, among other problems. 

“We just had two babies with spina bifida in the last six months, they came kind of back to back. It’s not like I would say this is something we see every month, but a neural tube defect is a big deal,” Jones said. “This impacts the kid’s ability to walk, to be able to use the restroom, orthopedic stuff. This is a huge undertaking for a family. I would say in general, even seeing three or four of these in a year has a big impact on a community.”

And while it’s difficult to pinpoint what exactly is to blame in each case, hypertension, diabetes and folic acid deficiencies can play a significant role, she said. 

The CDC advises that all women of reproductive age get 400 micrograms of folic acid, much of which can be found in prenatal and women’s multi-vitamins. But Latinas and Black women are less likely to be taking these before pregnancy. 

Between 2017 and 2019, the latest years for which state data is available, about 28% of Latinas reported taking folic acid the month before becoming pregnant, according to the California Department of Public Health. That compares to 46% of white women. Women on Medi-Cal, the state’s public health insurance program for low-income people, are also less likely to take folic acid before pregnancy compared to women on private insurance. 

Regionally, women in the San Joaquin Valley and in the very northern part of the state were less likely to take folic acid. 

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Voluntary vs. mandated folic acid in foods

In 2008, Mexico began requiring that corn masa be strengthened with folic acid, but enforcement of that mandate has lagged, according to research conducted by Columbia University and Mexico’s National Institute of Public Health. 

Meanwhile, the U.S. government has long acknowledged the potential benefits of fortifying corn masa with folic acid, but still does not require it. In a 2009 study, the CDC wrote: “Fortification of corn masa flour products could increase folic acid intake by nearly 20 percent for Mexican-Americans, who are at a 30-40 percent higher risk for a number of severe brain and spinal birth defects.”

With mounting data and advocacy, in April 2016 the FDA approved a petition to allow manufacturers of corn masa flour to add folic acid to their products. That was voluntary and producers have been slow to act. Two years after the FDA’s announcement, a study published in the Journal of the American Medical Association found that only 10% of corn masa flour contained folic acid; none of the corn tortillas tested did. 

The Center for Science in the Public Interest, a consumer advocacy organization, did its own survey of hundreds of corn masa products from 2018-2022 and found folic acid in only 14% of corn masa flours and found none in the 476 corn tortilla products analyzed. 

Arambula’s legislation is sponsored by the American College of Obstetricians and Gynecologists. The bill has made it out of its first policy committee, and so far has no registered opposition. 

The March of Dimes, which advocates for maternal and infant health, for years has advocated for folate to be added to corn masa, so that more women can get folic acid through their diets. Advocates there believe California’s decision can have national influence and bring the issue back to the forefront, said David Pisani, director of advocacy and government affairs at March of Dimes.

“Folic acid hasn’t been on the tips of people’s tongues for quite some time,” Pisani said. “You don’t read about it, you don’t hear about it, and I think it’s because there is this misunderstanding that well, isn’t it already in everything most people are consuming? Obviously, the answer is not every product.”

Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

CalMatters is a Sacramento-based nonpartisan, nonprofit journalism venture committed to explaining how California's state Capitol works and why it matters. It works with more than 130 media partners throughout the state that have long, deep relationships with their local audiences, including Embarcadero Media.