Folic acid: Old women and children first!

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Folic acid: Old women and children first!
Look at the globe and you’d be hard pressed to find two countries further apart than Ireland and New Zealand. But they stand side-by-side on the folic acid fortification issue – it is not needed.

While babies are still being born in these two countries with birth defects (neural tube defect or NTDs), I applaud European measures not to impose mandatory fortification.

In the US, mandatory fortification of all grain products with folic acid was introduced in 1998, and has led to big drops in the incidence of NTDs.

Surely the evidence is clear? Well, no.

With manufacturers increasingly taking it upon themselves to fortify their products without any governmental prodding, and women, and consumers in general, increasingly aware of their nutritional needs, data suggests adequate levels are already being consumed.

Adding in a little extra for good measure may even be counter-productive, possibly putting the mental well-being of our elders at risk, as well as the health of our bowels.

It’s a complex and emotional debate, and one that industry and academia need to be more vocal about. Recent findings from the Netherlands and Ireland found that manufacturers are voluntarily fortifying more products. And this is having beneficial effects: On the Emerald Isle the incidence of NTDs has dropped to 0.93 per 1000 births from 1-1.5 in three years.

Public health success story

Many people are aware that folate, and folic acid (its synthetic form), is essential for reducing the incidence of NTDs in babies. Such defects occur within the first 22 to 28 days of pregnancy, when the mother-to-be is not aware she is even pregnant.

And with a sizable portion of pregnancies being unplanned (45 per cent in the US, about 30 per cent in Western Europe), there are clear benefits to ensuring women of child-bearing age are folate-replete.

My thoughts on mandatory fortification do not ignore this public health miracle. Nor am I saying that American measures are wrong and should be repealed – they were probably the right decision based on the local factors at that time. But the folic acid story is not all good news.


Evidence shows that folic acid and folate may mask vitamin B12 deficiency in the elderly, which can have severe neurological consequences.

And then there are concerns over colorectal cancer. Epidemiological evidence suggests a slight increase in colorectal cancer rates following the introduction of fortification. Such associations have been noted in the US, Canada, and Chile.

This is an incredibly complicated, and emotive, subject. On the one hand we are reducing the number of birth defects. On the other hand, we are blunting our ability to spot B12 deficiency in our elders, as well as possibly increasing the risk of colorectal cancer in certain segments of the population.

How do you choose between ensuring the healthy development of Junior and helping grandma keep her marbles? There should be no choice – we can do both.

Follow iodine’s lead

If we follow my train of thought and close the door on mandatory fortification, what next? How do we ensure adequate intakes? A recent paper by the Health Council of the Netherlands touted an idea that demands serious consideration: Controlled voluntary fortification.

Dr Rianne Weggemans from the Health Council of the Netherlands told me that this hinges on the premise that the government reaches agreements with manufacturers on the kind of food products folic acid can be added to, with the obvious choice being staple food products, like bread and bread substitutes.

The Netherlands already has a working model of this, with agreements currently in place for iodized baker's salt, which are fortified with higher iodine levels than iodized salt used for other purposes.

And shouldn’t manufacturers also agree to simultaneous fortification with vitamin B12? Results from a Dutch double-blind, placebo-controlled trial indicated that fortifying bread with folic acid and low dose vitamin B12 is effective in improving vitamin B blood status in the elderly.

Better the devil you know, than the devil you don’t

Concern over colorectal cancer risk is a different issue. The problem here, according to Joel Mason from USDA Human Nutrition Research Center on Aging at Tufts University, is that high folate levels in certain people who harbour pre-cancerous or cancerous tumours may actually promote cancer.

The complex links between folate and cancer have created a “global dilemma”​, he said. Indeed, a new study published in the Proceedings on the National Academy of Sciences​ (PNAS) shows that our ability to convert folic acid to folate may be relatively slow, leading to extended exposure to unconverted folic acid.

It is not a dilemma we should shy away from. With manufacturers increasingly fortifying products voluntarily, and consumers increasing label savvy, there is no need for mandatory fortification at this point.

New Zealand and Europe may be oceans apart, but their approach to a very real issue displays a maturity and understanding of the science that shows they stand together.

Stephen Daniells is the science editor for FoodNavigator and NutraIngredients. He has been writing on nutritional and food science issues for four years. He has a PhD in chemistry from Queen’s University, Belfast. He has also worked in research in Netherlands and France.

If you would like to comment on this article, please email: stephen.daniells’at’


Reader comments

You did a service by improving awareness of the situation regarding folic acid. In future please do not fall into the all-too-common implication that "the elderly" are the only people who can and do become deficient in B12 and incur horrible damage.

Because of this common myth, many young and even more middle-aged people are damaged terribly. Severe malabsorption occurs in a surprising number of people in these groups, and too few doctors know to look. Even fewer know that people can be damaged severely and even near death without megaloblastic anemia.

Thank you,

Rose Fuhrman
Patient Advocate

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