The folate debate

I would like to know if there has been consideration of the general public vitamin supplement takers. In some branded products they contain 100% RDA of folate and other B vitamins, usually find the older generation taking them so the anaemia may be masked anyway. Also in text it reports if you are short of one B then you're more likely to be short of all vit. B's. Bread and other products are already fortified with riboflavin, Niacin, Pantothetic acid, thiamine- all vitamin B's. Is this not suggesting that the public are lacking in their B vitamins in general. Which also do not only have a role in neural tube defects but within DNA/RNA replication, Homocystine levels as well as other neurological assoc. ills. Why stop with folate - maybe our dietary guidelines need to be upped and follow in Canadas increased dietary guidelines
I'm doing my thesis presently on the student diet and folate.
All very interesting!!

Here is a report which I wrote for university on the consultation.

Please read it.

RE: Options to increase folate intakes of young women.
Start date: 12 December 2006 End date: 13 March 2007-04-10

Hello, I am writing in response to a consultation started on the 12th December 2006 with regards to increasing the intake of folate of young women and I am writing because this area interests me and will have a bearing on my future life.

The Food Standards Agency has proposed to increase the folate intake of young women to reduce the number of pregnancies affected by a neutral tube defect (NTD). At the moment the Agency is looking at 4 different possible options which would increase the amount of folate that young women take. The four options under consideration are:

Option 1 – Continue with the current policy of advice to women
Option 2 – Increase the effort to encourage young women to take folic acid supplements (folic acid a synthetic form of the vitamin folate, used in supplements and as a food fortificant) and changes to diet to increase the consumption of folate-rich foods
Option 3 – Encourage industry to fortify more foods with folic acid on a voluntary basis
Option 4 – Recommend the mandatory fortification of bread or flour with folic acid1

The four options put forward all have very different actions and outcomes. I welcome this consultation and strongly support the efforts to increase the folate intake of women of childbearing age, especially if planning pregnancy.

The discovery that mothers taking folic acid supplements are less likely to have babies affected by a neural tube defect is widely accepted.

It is terrible when an embryo develops an NTD. Normally, in human embryos, closure of the neural tube occurs around the 30th day after fertilisation. However, if something interferes and the tube fails to close properly, a neural tube defect will occur. Among the most common tube defects are anencephaly, encephalocele, and spina bifida2. Seen in the table below are the incidences for NTD’s in the years 1995-1998 for England and Wales as presented in a publication by the Office for National Statistics (2001).

In 2005 there were over 722,500 births in the UK3, of these births the scientific body advising the FSA has concluded that of the 2,000 pregnancies a year affected by such defects, 41% could be prevented by fortification of flour.

Current government advice is that in order to reduce the risk that their baby will develop a neural tube defect (NTD), like spina bifida, “all women who could become pregnant are advised to take 400 micrograms a day of folic acid, as a medicinal or food supplement, prior to conception and until the twelfth week of pregnancy4”.

Data from recent national surveys indicates that around 55% of women planning their pregnancy take supplements or change their diet in order to increase folate intake prior to pregnancy. Around half of pregnancies in the UK are unplanned, therefore this suggests that only about 25% of women take folic acid as recommended before becoming pregnant5. This would mean that 180,000 women take a supplement. Out of a population of 60 million people this is 0.3% of the population.

This should not be overlooked but I believe option 4 of the suggested considerations is an extreme approach. Pregnant women can still reach their required dose of folic acid through other mediums. Option 4 will also impact many different people as the ‘mass-medication’ of folic acid, through fortifying the nations flour industry, could have further reaching consequences.

Not only will this medicate the huge part of the nation that doesn’t need this extra folic acid but it will also incur extra costs for every flour miller by having to add folic acid to their product. “It is an extra cost, that may not yield the full public health befits predicted.” Quoted an organic miller6 who is looking at the possibility of having to add folic acid to his organic flour. “Who is going to pay for the extra costs involved?” NABIM’s (National Association of British and Irish Millers) position is “if the government decide that statutory fortification of flour is appropriate, it would accept the outcome providing that the basis was the same as that for the other nutrients added under the Bread and Flour Regulations.7”

The Soil Association (The Soil Association is the UK's leading campaigning and certification organisation for organic food and farming) released a statement in March 2007 expressing their views on the consultation. They are totally opposed to option 4 as they believe that this would remove consumer choice, is a disproportionate measure, and would bolster the health image of some otherwise nutritionally poor processed foods8.

We must also ask the question. Is too much folic acid bad for us?

Folate is part of the Vitamin B group; the vitamin B-complex is a collection of eight water soluble vitamins. The body cannot store most of the B-group vitamins (except B12 and folate, which are stored in the liver). Folate is generally considered non-toxic, although excessive intakes over a period of time can lead to malaise, irritability and intestinal dysfunction. The main risk with excessive folate intake is that it can mask a vitamin B12 deficiency so it is best to consume these two vitamins within the recommended amounts. Vitamin B12 deficiency is most common in the elderly, vegans (vitamin B12 is only found in foods of animal origin), breastfed babies of vegan mothers and is also a consequence of disease called pernicious anaemia caused be a deficiency of intrinsic factor secretion. Symptoms include: tiredness and fatigue, lack of appetite and weight loss, apathy and depression, anaemia, smooth tongue and degeneration of peripheral nerves progressing to paralysis9.

In 1998 in America the fortification of flour with folates came into law to try and increase the amount of folate intake for young women. In January 2007 the US Centers for Disease Control and Prevention reported among non-pregnant women of childbearing age concentrations of folate had decreased 16% since 199910.

Why is that and should the UK copy a failing system?

The likely explanations include 1) changes over time in the proportion of women taking supplements containing folic acid, 2) decreased consumption of foods rich in natural folates or foods fortified with folic acid (i.e., enriched cereal-grain products), 3) variations in the amounts of folic acid added to enriched grain products since fortification was mandated, and 4) increases in risk factors associated with lower folate concentrations such as obesity10. However, evidence to support these explanations is mixed and the rates of NTD’s have decreased.

Another concern with the fortification of flour in the UK is how would we be able to measure how much the individual is taking. At the moment 14% of 16–19 year old women and 41% of undergraduate women were aware of the need to increase folate intake before conception. Median folate intake was estimated to be 235 μg/d in 16–19 year olds and 248.5 μg/d in undergraduates11. This shows that although graduates don’t take the recommended 400 μg/d, almost half of them know that they should when planning pregnancy.

At the moment the group at largest risk are the young mothers from a lower social demographic.

“It is the poorest and most educationally underprivileged who are most at risk of a spina bifida pregnancy. Unfortunately, relying on women to plan pregnancy and take a folic acid supplement in advance is unrealistic in many cases,” said Andrew Russell, chief executive of the Association for Spina Bifida and Hydrocephalus12. This reinforces my feeling that the answer isn’t to medicate everyone but target the more vulnerable groups and educate them to the problems of having low folates in their diet.

Consumer choice is a great thing for any nation to have. By mass medicating the food that choice is being taken away. There is already the option to take folate supplements as well as eating some naturally enriched foods so why force the supplement upon people?

With these area’s discussed I would like to return to the questions asked in the consultation. What are our options to increase folate intake in young women?

Option 4 – For the reasons mentioned above I believe the mandatory fortification of all flour is a step to far and therefore I would like to discard option 4 from choice and I’m completely opposed to it.

Option 3 – To encourage the industry to fortify more foods is unlikely to succeed. As heard from NABIM, the Soil Association and a miller the extra costs involved and the morals dilemmas will inevitably be a high price to pay for the voluntary fortifying of more foods. Why should the food industry essentially mass medicate the population particularly when this is to make up for poor dietary choices. The effects of excessive food refining are causing inadequate intakes of a range of nutrients with serious public health consequences, not just folate.

Option 2 – This is my most favoured option out of the four as well as the favourite option for the Soil Association8 and the Institute of Biology13. With this option we can address a number of real concerns, not just folate deficiencies. Young women can be educated at to the dangers of folate deficiency and the complications that could arise through deficiency. The option addresses two areas, a change in diet and increased supplementation of synthetic vitamins. Personally I would prefer the change of diet rather than an increase of vitamin pills. Firstly because I believe that it is a much more natural approach and secondly because the Cochrane Review of 21 studies on folic acid concluded “There is not enough evidence to evaluate whether folic acid supplementation has any effect, beneficial of harmful, on clinical outcomes for mother and baby.”

Option 1 – To continue with the current policy. I feel that it would be wrong to do this. NTD and the other associated diseases and illnesses that come with folate deficiency need to be acted upon. Also if this option was to be chosen the current advice to young women should be improved.

I hope that this answers the first two questions on the consultation, as to the third question on monitoring I would have to direct my attention to the study in America by the US Centers for Disease Control and Prevention mentioned above. In that study they use the NHANES (National Health and Nutrition Examination Survey) for their data collection. Within the UK the body NICE (National Institute for Clinical Excellence) or The Food Standards Agency should be collecting similar data. This data could be analysed to see the trends resulting from their decisions. Other factors must be taken into consideration though, such as food consumption trends and dieting. There is a downward trend at the moment on bread consumption so would folate fortification actually have the benefits predicted.

I do hope that something is done to reduce the amount of NTD’s and as I have discussed above I believe that option 2 is the best option for this nation and young women.

I hope that this letter has been insightful and helps with your decisions.

Yours Sincerely

Jethro Marriage

References

1) Options to increase folate intakes of young women: The Food Standards Agency 12th December 2006
2) http://www.surgical-tutor.org.uk/default-home.htm?system/hnep/neural_tube.htm~right
• Table 1) National Statistics (2001), Health Statistics Quarterly: Trends in Neural Tube Defects. Available online at http://www.statistics.gov.uk/downloads/theme_health/HSQ10_v3.pdf
3) National Statistics Online: www.statistics.gov.uk
4) Food Standards Agency http://www.food.gov.uk/multimedia/pdfs/folateconsultation.pdf: Page 27
5) Blake M, Herrick K & Kelly Y (2003) Health Survey for England 2002:Maternal and Infant Health. The Stationery Office, London.
6) Michael Marriage: Director and miller of Doves Farm Foods www.dovesfarm.co.uk
7) Letter from NABIM to Doves Farm Foods
8) Reply for the Soil Association to the FSA Consultation on ‘Options to increase folate intakes of young women’
9) Better Health Channel - regularly rated the number one consumer health information site in Australia http://www.betterhealth.vic.gov.au/BHCV2/bhcarticles.nsf/pages/Vitamin_B?OpenDocument
10) US Center for Disease Control and Prevention: Folate Status in Women of Childbearing Age, by Race/Ethnicity. Vol 55, No MM51;1377
11) Jennifer Wild, Christopher J. Schorah, Karen Maude and Malcolm I. Levene, (1997). Title: Folate intake in young women and their knowledge of pre-conceptional folate supplementation to prevent neural tube defects: www.sciencedirect.com
12) Andrew Russell, chief executive of the Association for Spina Bifida and Hydrocephalus quoted in The Times 10th December 2006
13) Reply from the Institute of Biology to the FSA Consultation on ‘Options to increase folate intakes of young women’

Other Reading

Natural Products: April 2007

Oxford Handbook of Clinical Medicine: Sixth Edition: Oxford

I am no expert just a granny who needs b12 injections.

I have heard that it is better to take the whole vitamin B complex rather than just a single component. Is it not possible to add the whole B complex to food, if you have to add anything at all?

During the 2nd world war vitamins were added to to bread and, white bread was better for it as the processing of the flour robbed it of these. Nutrition is better now even without the additions and folk more informed. Many young women are on diets restricting their carbohydrate intake, is this aspect also being considered?