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CMAJ • October 15, 2002; 167 (8)
© 2002 Canadian Medical Association or its licensors

Letters
Correspondance

Folic acid fortification: time for a concentrated effort

Godfrey P. Oakley, Jr

Visiting Professor of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Ga.

Vidia Persad and colleagues1 nicely show that folic acid fortification of cereal grains is rapidly followed by a remarkable reduction in the incidence of spina bifida and anencephaly. Their data indicate that countries that do not fortify grain are allowing thousands of babies to be born each year with these preventable defects.2,3

As wonderful as this prevention is, data suggest that increased concentration of folic acid in flour would further reduce these birth defects. Although the rate of spina bifida that is not preventable with folic acid is unknown, data from a community trial in China showed that taking 400 mg/d of folic acid reduced the prevalence to about 6 per 10 000 in high- and low-risk areas.4 The Chinese data suggest that increasing the concentration of folic acid in grains in Canada would reduce the incidence of spina bifida and anencephaly in Canada by least an additional 50%.

Before fortification, it was estimated that fortification at 140 mg/100 g of flour (the concentration required in the US and Canada) would increase the average women's daily consumption of folic acid by 100 mg. Some subsequent estimates suggest that the average woman consumes 200 mg/d of folic acid. The US Public Health Service and Institute of Medicine recommend that all women of reproductive age consume 400 mg/d of synthetic folic acid.

The US Centers for Disease Control and Prevention and the March of Dimes suggest that fortification concentration should be at least 350 mg/100 g of grain. In 2000 the UK Committee on Medical Aspects of Food and Nutrition Policy (COMA) recommended a concentration of 240 mg/100 g of grain.5 Chile has implemented a concentration of 220 mg/100 g; however, women in Chile consume about twice as much flour as women in Canada and the United States.

Canadian nutrition regulators discouraged the US Food and Drug Administration from requiring fortification, saying that Canadians did not need folic acid fortification. Persad and colleagues have shown this not to be the case. Fortunately for Canadian children and their families, commercial interests forced Canadian regulators to adopt the US standard. Perhaps Canadian regulators will now show leadership in North America by increasing folic acid fortification concentration to at least 240 mg/100 g, as recommended by COMA.

Godfrey P. Oakley, Jr. Visiting Professor of Epidemiology Rollins School of Public Health Emory University Atlanta, Ga.

References

  1. Persad VL, Van den Hof MC, Dube JM, Zimmer P. Incidence of open neural tube defects in Nova Scotia after folic acid fortification. CMAJ 2002; 167(3):241-5.[Abstract/Free Full Text]
  2. Oakley GP. Delaying folic acid fortification of flour. BMJ 2002;324:1348-9. [Free Full Text]
  3. Oakley GP. Inertia on folic acid fortification: public health malpractice. Teratology 2002;66:44-54. [Medline]
  4. Berry RJ, Li Z, Erickson JD, Li S, Moore CA, Wang H, et al. Prevention of neural-tube defects with folic acid in China. China–U.S. Collaborative Project for Neural Tube Defect Prevention [published erratum appears in N Engl J Med 1999;341(24):1864]. N Engl J Med 1999;341(20): 1485-90.[Free Full Text]
  5. Folic acid and the prevention of disease. Report of the Committee on Medical Aspects of Food and Nutrition Policy. Rep Health Soc Subj (Lond) 2000; 50:i-xv, 1-101.




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