Delaying folic acid fortification of flour
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7350.1348 (Published 08 June 2002) Cite this as: BMJ 2002;324:1348All rapid responses
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Dear Sir,
re: Folic acid supplementation and masking of B12 deficiency.
On behalf of the Society for Research into Hydrocephalus and Spina
Bifida we wish to record our dismay at the decision of the Food Standards
Agency (FSA) against fortification of flower with folic acid. The
Editorial by Oakley (8th June 2002) 1 is timely in reminding us of the
benefits to be gained in the prevention of a severely disabling condition
and the mounting evidence of benefits in reduction of cardiovascular
disease and certain malignancies. We find it regrettable that the FSA in
their public statement on the web refer to ‘hypothesised’ advantages yet
make an unconditional statement that such supplementation would mask the
symptoms and signs of vitamin B12 deficiency. There is no conclusive
evidence that this would happen at the levels of folate intake proposed
and so this statement should also be referred to as an ‘hypothesis’. The
FSA also raise questions about the stability of synthetic folic acid in
cooking to which the answer is known. It is known to be more stable than
the natural product as well as being more bio-available. It is not
difficult to incorporate into flour and is already in many breakfast
cereals. Professor Sir John Krebs 2 in reply to Professors Wald and
Hoffbrand argues that the FSA must make decisions on the basis of
scientific evidence. The evidence is available regarding the benefits in
prevention of neural tube defects but not for the hypothesis that
significant numbers of elderly people would have B12 deficiency masked.
Vitamin B12 can also be added to grain products and already is added to
some foods. If there is such fear of masking B12 deficiency by folate
surely the logical recommendation must be to add both factors, not ignore
the advantages available to our society. We must remember that at present
there is still a significant number of births affected by spina bifida,
but also remember the emotional costs of the bereavement of termination,
quite apart from the medical costs, must be considered.
Miss C M Bannister,
President, Society for Research into Hydrocephalus and Spina Bifida
Miss C Sobkowiak,
Hon Sec, Society for Research into Hydrocephalus and Spina Bifida
Mr A E MacKinnon,
Consultant Paediatric Surgeon, Sheffield Children’s Hospital, Western
Bank, Sheffield S10 TH
e-mail emackinnon@sch.nhs.uk
Correspondence to A E MacKinnon
References:
1. Editorial: Delaying folic acid fortification of flour. BMJ
2002;324:1348-9.
2. Times 3rd June 2002
3. Times 27th May
Competing interests: No competing interests
The excellent editorial by Oakley (1) makes a strong case for the
fortification of flour with folic acid in order to improve the
cardiovascular health of adults. Whilst this angle of attack might easily
be deflected by the Department of Health on the basis of a lack of
watertight evidence to support the view that folate supplementation
reduces cardiovascular disease risk, the assertion that the current
approach to the prevention of neural tube defects is irrefutable.
In a recent study of diet in the first and third trimesters of
pregnancy among 300 women from Northampton (2), we found that uptake of
Department of Health advice to take folate supplements was poor. In
keeping with other studies over the last 5 years we noted that only 43% of
women consumed folate supplements before conceiving and that there were
clearly defined groups of women who failed to comply. These were women
under the age of 21, women who smoked and women from lower income groups.
Importantly we also noted that mean unsupplemented daily intakes of folate
were only 237µg/day and that 25% of the women we studied failed to consume
folate at the RNI value of 300µg/d.
These findings clearly show that the current strategy for preventing
neural tube defects is not working. Although promotion campaigns have
certainly raised womens awareness of the advice (3), young women form poor
social backgrounds remain at risk of NTD associated pregnancy.
The lesson to be learned from the USA is that folate fortification
appears to have major benefits in NTD prevention, with no apparent adverse
effects. The suggestion made by the FSA that fortification should not be
attempted in order to preserve consumer choice is an absurdity. The
projected reduction in the number of children born with spina bifida by 74
cases per year and possibly reductions in the prevalence of
hyperhomocysteinaemia and associated morbidity and mortality, means that
folate fortification is every bit as sensible a policy as other currently
applied strategies, such as the fortification of dairy produce with
vitamins A and D.
1. Oakley GP (2002). Delaying folic acid fortification of flour. BMJ
324, 1348-1349.
2. Langley-Evans SC, Langley-Evans AJ (2002). Use of folic acid
supplements in the first trimester of pregnancy. Journal of the Royal
Society for the Promotion of Health: In Press
3. Raats M, Thorpe L, Hurren C (1999). Womens perceptions of diet, folic
acid and pregnancy. Proceedings of the Nutrition Society 58, 53A.
Competing interests: No competing interests
Dr. Ali Nasir kindly send me an e-mail pointing out that the
fortification level recommended by the UK Committee on Medical Apsects of
Food and Nutrition (COMA) is 240 micrograms (not milligrams as in the
editorial) per 100 g of flour. It is also 2.4 parts per million. I am
thankful to Dr. Nasir for pointing out the error.
Godfrey Oakley
Competing interests: No competing interests
Dr. Sharma's comments are well taken. Iron and folic acid
fortification are both important.
Competing interests: No competing interests
We fully agree with Dr Oakley that fortification of flour with folic
acid should be started without delay to prevent neural tube defects in
newborns. Although this will prevent most cases of neural tube defects, it
can not prevent all the cases as the etiology of neural tube defects is
multifactorial. We reported a cluster of neural tube defects in a district
in Northern India following an epidemic of Dengue fever suggesting it to
be a cause of the defects in some cases at least(1,2). Infact iron
fortification should be of more significance in developing countries with
prevelence of iron deficiency anaemia as high as 80 percent ( Malhotra
& Sharma 1999 unpublished data).
Iron deficiency anaemia continues to
be a major cause of maternal mortality and morbidity in India. There is
very poor iron intake compliance due to side effects. Iron fortification
of wheat flour is a more feasible method of controlling this menace. Hence
along with folic acid, iron fortification should be considered in
developing countries with high prevalence of iron deficiency anaemia in
pregnancy like India.
1. Sharma JB, Gulati N. Potential relationship between dengue fever
and neural tube defects in a northern district of india. Int J Gynecol
Obstet 1992; 39: 291.
2. Sharma JB, Newman MRB, Smith RJ. Folic acid, pernicious anaemia and
prevention of neural tube defects ( letter). Lancet 1994; 343: 923.
Competing interests: No competing interests
Sir:
Attention is directed to the Australian study of Thompson et al. They
observed a protective effect of maternal folate supplementation against
acute lymphoblastic leukemia in childhood.Certainly this is further
support for prompt action in fortification of flour with folic acid.
Donald Pinkel,MD
Reference: ThompsonJR,Fitz GeraldP,et al.Maternal folate
supplementation in pregnancy and protection against acute lymphoblastic
leukemia in childhood:a case control study.The Lancet 2001;358:1935-40.
Competing interests: No competing interests
I am in full support of this gentleman's opinion. With the
many losses accomplished by the milling of such a prominent
social staple as flour it does seem virtually criminal not
to provide this support
Competing interests: No competing interests
The article about fortification contained this comment.
<< The other is that consumers should have the choice to buy
flour that is not fortified. Choice is easily preserved by not requiring
fortification of whole wheat flour. >>
Such a move would go against general dietary recommendations to
favour whole grain cereals over more processed (eg. white flour) versions.
This would be a major backward step in that it encourages choosing more
processed cereal products, when most benefits from eating grain foods -
comes from selecting whole grain versions.
Using wheat flour as the only means of fortification also ingores the
needs of those who require wheat-free diets.
Competing interests: No competing interests
USA fortification - effect
I was trying to get the same numbers of deaths from stroke and heart
attack from the original Martin et al. (1999) report, but I couldn't.
Could you please explain how you came up with these figures?
Thank you in advance
Competing interests:
None declared
Competing interests: No competing interests