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Rapid Responses: Rapid Responses published:
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Awareness regarding use of folic acid among health care providers
- anju aggarwal (16 May 2003)
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Folic Acid and Public Health
- Kevin McLaughlin (18 May 2003)
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Fortification of food with folate to reduce cardiovascular risk
- Dietmar Fuchs, Katharina Schroecksnadel, Barbara Frick (2 June 2003)
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Resisting Inertia
- Morton Satin (4 June 2003)
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Dietary Folates are not enough
- Elisa Calzolari, Amanda J Neville and Guido Cocchi (27 June 2003)
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anju aggarwal, Lecturer Pediatrics University College of Medical Sciences and Guru Tegh Bahadur Hospital ,New Delhi. India
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There is documented evidence that folic acid prevents upto 70% recurrence of neural tube defects.Many health care providers are aware of this. But the fact that it is to be given preconceptionally is known only to few. Efforts are required to include this in the undergraduate curriculum in th must know area of learning objectives. In the community use of supplemental folic acid at the right time inright doses can be increased through media. This should be a part of marriage counselling Though fortification will take care of most of folic acid requirment but it may not be possible in many countries.As we discover role of different micronutrients and vitamins how are we going to supplement these in the right quantity for different individuals. "Food for thought" -ultimately healthy eating habits, good quality natural food, awareness and selective supplementation is the answer for such problems.If we supplement iron, zinc , folic acid etc together will it be possible? Will the food be palatable? Won't they interfere with each others absorption. Competing interests: None declared |
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Kevin McLaughlin, PhD Cand. University Of New England NewFoundland Center For Integrative Medicine
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I agree with Dr Ellis and I feel the widespread use of folic acid as a supplement or in food fortification could effectively circumvent a growing public health care issue. Folic acid, especially combined with other B-Nutrients has been continuously shown to lower the risk of developing a host of diseases such as atherosclerosis, cervical dysplasia, NTD, colon cancer,and maybe even Alzheimer's. Certainly the data assessing the impact this inexpensive vitamin has upon the development of heart disease, stokes, peripheral vascular disease and NTD should compell all providers to fully endorse the use of this preventative strategy. Competing interests: None declared |
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Dietmar Fuchs, University of Innsbruck A-6020 Innsbruck, Austria, Katharina Schroecksnadel, Barbara Frick
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With interest we read the considerations by A. Ellis, who criticized the inertia of the UK government regarding fortification of food with folate. Whereas it is well established that folate is effective in preventing neural tube defects in pregnancy, the statement that thousands of unnecessary deaths due to cardiovascular disease could have been prevented by folic acid supplementation, is still rather speculative. In this context the protective role of folate against vascular dysfunction was based primarily on its efficacy to lower homocysteine in hyperhomocysteinaemic and normohomocysteinaemic individuals. However, data that homocysteine by itself induces vascular damage by enforcing oxidative stress are mainly derived from in vitro experiments, applying much higher homocysteine concentrations than detectable in the blood of patients. Moreover, gene expression studies indicate that homocysteine itself is unable to elicit an oxidative stress response in vitro, rather it is able to enhance it once established (1). Although folate administration efficiently lowers homocysteine concentrations and in parallel ameliorates vascular function (2), a causal relationship remains to be elucidated. E.g., a recent study shows (3), that endothelial function already improved within 2-4 hours after folate administration, rather independently from changes of homocysteine concentrations which declined with some delay. Studies demonstrating folate administration to inhibit the progression/development of coronary artery disease are still scarce, and larger clinical trials are needed to confirm that folate is the key player preventing this process. Notably, not only folate administration but also supplementation with other vitamins, e.g. antioxidants vitamin C and E, can be beneficial to reduce lipid peroxidation (4). Immune activation is deeply involved in the pathogenesis of several chronic disorders, like neurodegenerative, autoimmune and malignant diseases in addition to cardiovascular disease. Overwhelming production of antimicrobial and cytocidal compounds may cause oxidative stress and enhance the demand for vitamins in patients with so-called “consuming diseases” (5). Thus, vitamin supplementation in general could effectively slow-down the long- term consequences of chronic immune system activation in patients, compensate for enhanced vitamin consumption thereby reducing, e.g., vascular complications. Also anti-inflammatory medication like aspirin could be of benefit for patients, as the protective role of non-steroidal anti-inflammatory drugs has already been established in many diseases associated with immune chronic immune activation like cardiovascular and neurodegenerative diseases. To conclude, additional vitamins will certainly be beneficial in chronic disorders going along with immune activation and oxidative stress. One the one hand, this does not necessarily allow the conclusion that vitamin supplementation is also of benefit in “healthy” individuals. On the other hand, a more specific role of homocysteine and folate still remains to be unequivocally demonstrated. Schroecksnadel Katharina, Frick Barbara, Dietmar Fuchs
1. Outinen PA, Sood SK, Liaw PC, Sarge KD, Maeda N, Hirsh J, et al. Characterization of the stress-inducing effects of homocysteine. Biochem J 1998;332:213-21. 2. Doshi SN, McDowell IF, Moat SJ, Payne N, Durrant HJ, Lewis MJ, et al. Folic acid improves endothelial function in coronary artery disease via mechanisms largely independent of homocysteine lowering. Circulation 2002;105:22-6. 3. Woo KS, Chook P, Chan LL, Cheung AS, Fung WH, Qiao M et al. Long-term improvement in homocysteine levels and arterial endothelial function after 1-year folic acid supplementation. Am J Med 2002;112:535-9. 4. Huang HY, Appel LJ, Croft KD, Miller ER 3rd, Mori TA, Puddey IB. Effects of vitamin C and vitamin E on in vivo lipid peroxidation: results of a randomized controlled trial. Am J Clin Nutr 2002;76:549-55. 5. Fuchs D, Jaeger M, Widner B, Wirleitner B, Artner-Dworzak E, Leblhuber F. Is hyperhomocysteinemia due to the oxidative depletion of folate rather than to insufficient dietary intake? Clin Chem Lab Med 2001;39:691-4. Competing interests: None declared |
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Morton Satin, Retired Executive Director of the International Food and Agribusiness Management Association Rockvile, MD, 20850, USA
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During the ‘70s, I was research director of the Steinberg Corporation in Canada, one of the largest integrated agribusinesses at the time. Not only did we own more than 300 large supermarkets, but the production and processing infrastructure for many of the retail products as well. In the case of bakery products, we had our own flour mill and the largest bakery under one roof in the world. Because the business was family-owned, the relationship to consumers and the commitment to social responsibility were very strong. A great number of the positive actions we took were never advertised because we did not want to turn them into a form of underhanded marketing as is often seen today. During the mid-‘70s, the Nutrition Canada Survey reported a shortfall in folic acid and biotin intakes. We immediately petitioned the Government to allow us to include these two nutrients in all our bread products. We had no intention of making a major issue out of it, but simply intended to list these two ingredients in their proper order on the label ingredient listing. We felt that it was the right thing to do and as the cost of these nutrients were next to nothing in the overall scheme of things, we had no plan to change product pricing. The Government regulators refused to permit us to do this as there was no allowance in the bread standard for these micro-nutrients. However, we felt that the Nutrition Canada evidence was compelling and decided to defy the Government. By 1978, all our bread products were supplemented with folic acid and biotin. The Government wisely decided not to prosecute us. Descriptions of our products containing folic acid were made in a number of trade magazines – two decades before the rest of the world decided to add it. Most of the industry, has long known the nutritional benefits of folic acid supplementation, but refused to do anything about it until compelled. It is a pity, because consumers really deserve a bit more responsibility than that. Morton Satin Competing interests: None declared |
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Elisa Calzolari, Professor and Director, Medical Genetics Unit University of Ferrara, Via L Borsari 46, 44100 Ferrara (FE) Italy, Amanda J Neville and Guido Cocchi
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Dietary folates are not enough The authors, who contributed the Italian data (1) to the WHO/EUROCAT report quoted in the News roundup article, would like to contribute further to the case supporting compulsory folic acid fortification of essential food. In Italy diet has traditionally been considered an adequate source of folates and neural tube defect (NTD) prevalence low compared to Northern European countries. This has placed folic acid supplementation low on the public health agenda. Awareness of the preventative effect of folic acid for birth defects is also low. In a recent study only 3% of pregnant women took FA supplements correctly (2). Data from the Emilia Romagna registry of birth defects (IMER) clearly shows that dietary folates are not enough to prevent (NTD) with a prevalence of 7 per 10,000 as total cases in 2000 (see graph). Legalisation of termination of pregnancy (the registry started collecting data in 1996) shows terminations following prenatal diagnosis of NTD were 6 per 10,000 in 2000 (see graph). The factors underlying this trend are currently under investigation. Demographic change in the region with immigration from countries outside of the European Community could perhaps indicate a socio-economically deprived group. 15 to 18% of births in our region are to immigrants (3). Compulsory folic acid fortification of essential food - cheap, effective and proven - as a primary prevention policy for NTD is required across Europe. Only this policy can prevent socio-economic inequality and ensure birth defect prevention to those who need it most. Reliance on a secondary prevention policy based on the termination of affected pregnancies - a heartbreaking alternative in a wanted pregnancy - is no longer ethical given the body of evidence now available regarding the preventative effects of folic acid. Sincerely E Calzolari
References 1. Calzolari E, Cocchi G, Neville AJ. Report on periconceptional folic acid supplementation for Italy EUROCAT Special Report: Prevention of Neural tube defects by periconceptional Folic acid supplementation in Europe. pp52-55 May 2003 in print. 2. Cocchi G., Gualdi S.,Mammoliti PMA., Piccolo C . Primary prevention of Neural tube defects: lack of information about folic acid in Italy: Emilia Romagna region. Fontiers of Fetal Health Vol 2, pp9-11 Sept. 2000 3. ERMES (statistics regarding the Emilia Romagna region) www.regione.emilia-romagna.it Competing interests: � None declared |
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