the big folic acid debate
by Jenny Bryan
Should folic acid be added to the nation's flour in order to reduce the risk of spina bifida in our children? By questioning the conclusions of a recent Department of Health advisory committee on folic acid and disease prevention in the pages of the British Medical Journal, two leading British specialists in child health have re-opened a debate which could yet rival that on water fluoridation which raged through the 1970s.
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'The very act of publishing their editorial has determined the outcome – which is, no universal mandatory fortification will now take place,' stormed London public health consultant, Dr Malcolm Perkin, in an e-mailed response to the article.
'This is because the press (correctly) report the scientific uncertainty and possible risk; then pressure groups are formed who oppose the exposure of the public to folic acid; and then the government is paralysed because there is no safe political way forward,' he reasoned.
Other correspondents fell into two camps – those who felt there is already enough evidence to support the addition of folic acid to flour and those who, like the original protagonists, felt that further research is needed.
what is folic acid?
Folic acid is a B group vitamin and is found in fresh green vegetables, fruit, liver and dried yeast. It is needed mainly for red blood cell production and, in adults, the most common result of folic acid deficiency is anaemia. This can arise in people who eat a very poor diet, such as alcohol or drug abusers, and in those with conditions which prevent them from absorbing food properly, including coeliac disease.
folic acid in pregnancy
The link between folic acid deficiency in pregnancy and spina bifida and other neural tube defects was first reported in 1968. But it was another 25 years before a Medical Research Council trial convinced doctors of the value of folic acid supplements taken from before conception through the first trimester of pregnancy. Women who had already had a pregnancy affected by spina bifida reduced their risk of recurrence by 72% if they took folic acid.
Since the mid 1990s, British women have been actively encouraged to take a daily 400 microgram supplement of folic acid as soon as they start trying for a baby and to continue for the first 12 weeks of pregnancy. Those at greater than average risk, who have a neural tube defect themselves or a family history, or who have had an affected pregnancy, are advised to take a 4-5mg dose of folic acid each day.
folic acid and flour
US health advisors were sufficiently impressed with the data on folic acid in pregnancy to instruct grain producers to add 140 micrograms of folic acid per 100 grams of grain products as long ago as 1993, and a 19% reduction in neural tube defects has followed.
In Britain, an expert committee was set up to review the issue and, in January 2000, concluded that the addition of 240 micrograms of folic acid into every 100 grams of flour could reduce the number of spina bifida pregnancies by just over 40%.
The Association for Spina Bifida and Hydrocephalus promptly supported the recommendation, pointing out that, since about half of pregnancies are unplanned, putting folic acid into flour will help to protect everyone who becomes pregnant, whether deliberately or not.
But those who want further research into the effects of mass exposure to folic acid supplementation continue to quote the possible risks.
when folic acid should be avoided
Folic acid should not be taken by people with vitamin B12 deficiency – a rare cause of severe anaemia, called megaloblastic anaemia. Folic acid can mask the nerve damage associated with vitamin B12 deficiency and allow it to progress to spinal cord degeneration.
Folic acid can also interfere with anti-folate and some anti-epilepsy drugs.
further research
In their BMJ article, Professor Brian Wharton from the Institute of Child Health, London, and Professor Ian Booth, from the Institute of Child Health, Birmingham, proposed that a field trial be carried out in two places – one where households used flour fortified with folic acid, the other where they didn't. They accepted that such a project would have immense logistical difficulties, given that people eat in so many different places, not just at their own dinner tables.
what's in it for the rest of us?
Two years after its advisors weighed up the scientific pros and cons of fortifying flour with folic acid to prevent spina bifida, the government has yet to rule. Growing evidence about the potential value of folic acid in heart disease may help them decide.
Folic acid has been shown to lower levels of homocysteine – a substance in the bloodstream which has been linked to arterial damage and blockage. Several trials are underway to find out whether lowering homocysteine can reduce an individual's risk of heart disease, and some early results appear promising.
If folic acid is shown to have wider effects on health, the fortification of flour could benefit far more than the 400 women whose pregnancies are affected by spina bifida each year. A similar number die from heart disease each day.
help and info
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organisations
Association for Spina Bifida and Hydrocephalus
42 Park Road
Peterborough PE1 2UQ
Tel: 01733 555988 (Mon-Fri 9am-5pm)
E-mail: info@asbah.org
Website: www.asbah.org
Provides advice and practical support to people with spina bifida and/or hydrocephalus, their families and carers. It also aims to improve services for people with these disabilities.
BDF Newlife - The Birth Defects Foundation
BDF Centre
Hemlock Way
Cannock WS11 7GF
Tel: 01543 468888
BDF Nurse Service: 08700 70 70 20 (Mon-Fri 9.30am-5pm)
E-mail: info@bdfnewlife.co.uk
Website: www.bdfcharity.co.uk
Offers comfort, support and information to anyone concerned about or affected by birth conditions. Their confidential 'Here to Help' service is managed by a team of BDF nurses who have experience of a wide range of genetic conditions and birth defects
British Heart Foundation
14 Fitzhardinge Street
London W1H 6DH
Heart Information Line: 08450 70 80 70 (Mon-Fri 9am-5pm)
Website: www.bhf.org.uk
Plays a leading role in the fight against heart disease and provides a range of information about the causes, prevention and treatment of the problem. Website contains a glossary, details of publications, plus practical advice on how to protect yourself from heart disease.
websites
BUPA
http://hcd2.bupa.co.uk/fact_sheets/html/Planning_pregnancy.html
Information on getting an adequate supply of folic acid as part of the action plan for a healthy pregnancy.
COMA Report
www.food.gov.uk/multimedia/pdfs/folicconsultoverview.pdf
Extract from the COMA report weighing up the benefits of fortifying flour with folic acid against the possible negative effects.
Department of Health
www.dh.gov.uk/PolicyAndGuidance/ ..
Information on policy decisions and the latest reports regarding folic acid.
Department of Health
www.dh.gov.uk/PublicationsAndStatistics/ ..
The Health Minister's decision on the fortification of flour with folic acid.
reading
'Folic Acid and the Prevention of Disease', Department of Health, London: Stationery Office, 2000, pages 1-101. A hard copy of the report can be ordered from: Department of Health publications.
'Fortification of Flour with Folic Acid' by B Wharton and I Booth in British Medical Journal, 24 November 2001 (vol 323), pages 1198-1199.
Can be read online at:
http://bmj.bmjjournals.com/ ..
'Is folic acid the ultimate functional food component for disease prevention?' by Mark Lucock in British Medical Journal, 24 January 2004 (vol 328), pages 211-214.
Can be read online at:
http://bmj.bmjjournals.com/ ..
(January 2002, resources updated March 2005)
