What think ye of mandatory fortification of folic acid?

Bottle_of_Smoke

So folic acid supplements greatly reduce incidence of Spina Bifida and other horrific conditions like anencephaly. In Canada neuroblastoma incidence has gone down significantly since they started mandatory fortification.

On the other hand folic acid also masks the early symptoms of B12 deficiency as a person won't become anaemic. Although this sounds like a good idea it also means B12 deficiency goes undiagnosed which can cause irreversible neural damage. Some studies have also suggested folic acid may increase incidence of prostate cancer, though it was a fairly small sample in the study.

With an ageing population the b12 issue is very serious.

I was thinking an alternative might be to subsidise tampon companies to provide folic acid tablets free with tampons. This would mean only women who need the extra folic acid would be taking it.

Any thoughts?

Tree

Mandatory fortification is a bit nanny state. I wouldnt be entirely against it though, low level fortification of certain processed foods perhaps.

Not sure how it would mask b12 deficiency, as b12 is required for key folate reactions, both folate and b12 defiency have the same presentation.

Bottle_of_Smoke

I'm not sure exactly what causes it but it mentions it here

http://www.ssba.org.uk/folicacid.aspx

Kwekubo

Tree wrote: »

Not sure how it would mask b12 deficiency, as b12 is required for key folate reactions, both folate and b12 defiency have the same presentation.

That is precisely the point! B12 is required to recycle the inactive 5-methyl version of folate (in the middle of this pic), which accumulates over time, back into the active form (THF). As you can see in the pic, folate is needed for nucleotide biosynthesis and thus for synthesis and repair of DNA, so if you're folate-deficient then you will have impaired nucleotide biosynthesis. This affects fast-dividing cells (like the red blood cell precursors in the bone marrow) the earliest as they need to make lots of DNA, so megaloblastic anaemia is a key early diagnostic sign. But the same is also true for B12 deficiency, because the inactive 5-methyl version of folate can't be recycled back to THF, and you'll get an identical megaloblastic anaemia as seen in folate deficiency. If a B12 deficient person is given folate, then the anaemia will resolve as there is now a fresh supply of THF (although the backlog of inactive 5 methyl folate will keep increasing). However, B12 deficiency has other serious side effects like subacute combined degeneration, which is incurable without early treatment.

Long story short: megaloblastic anaemia is an red flag that leads to many patients being diagnosed with B12 deficiency at an early stage, and receiving treatment. If mass fortification with folate occurs, then you have the risk that B12 deficient patients receive enough folate to mask their anaemia while the other less obvious signs of B12 deficiency aren't noticed until it is too late to do anything about them.

The argument for fortification is that the critical period when folate is actually needed for neural tube development in the embryo is very early (days 7-21 after conception) - potentially before the mother is aware that she is pregnant.

angeldelight

Personally I'd prefer more health promotion and taking every opportunity to educate the public about the need for folic acid supplementation. I'm a Pharmacy graduate and so know about the benefits - I've been taking folic acid for a long time. I have no intention of becoming pregnant, in fact I take my folic acid along with my oral contraceptive which is an incongruous combination but better safe than sorry. I think an education campaign would be good. Obviously there would still be those who don't take it but there always will be. If tampon companies gave them there'd still be people who didn't use them/didn't bother taking them. They are very cheap and readily available as it is so I think it would be better to make more people understand why they should take them

jellytots!

I would be against fortification myself. just did a lit review of folic acid and cancer risk. In the studies i reviewed i found that natural folates seem to protect against cancer risk- by preventing hypomethylation (of proto oncgenes) and misincoporation of uracil into DNA instead of thymidine. However human intervention trials found folic acid increases cancer risk...exact mechanisms are not known...but it is quite obvious that folic acid would aid the growth of cancerous cells by provision of nucleotides. Also hyper methylation may occur... which also may cause hypermutability i.e mutations of very important tumour suppresor genes.

I know folic acid has obvious benefits against neural tude defects but it is not wise to mass dose the whole population especially when there are adverse side affects.

nesf

I'm conflicted on this. My cousin had severe spina bifida, not really the right term I know but paralysis below the chest + mental retardation + some brain malformities. He wasn't supposed to live past 3 or 4 but made it to 31 somehow. It's really horrible and that it's mostly avoidable through something as simple as folic acid fortification in food is amazing. It's really hard to argue against mass dosing after seeing what the cost of not doing it is (because let's face it, if it's voluntary many women won't be supplementing with it when they become pregnant due to a combination of "surprise" pregnancies and ignorance of when to take the drug etc).

As is right now, if you want to avoid it you can, it's labelled on products as far as I can tell. It's not really mandatory fortification, if you don't want folic acid have porridge for breakfast instead of Bran Flakes etc.

sam34

jellytots! wrote: »

I would be against fortification myself. just did a lit review of folic acid and cancer risk. In the studies i reviewed i found that natural folates seem to protect against cancer risk- by preventing hypomethylation (of proto oncgenes) and misincoporation of uracil into DNA instead of thymidine. However human intervention trials found folic acid increases cancer risk...exact mechanisms are not known...but it is quite obvious that folic acid would aid the growth of cancerous cells by provision of nucleotides. Also hyper methylation may occur... which also may cause hypermutability i.e mutations of very important tumour suppresor genes.

I know folic acid has obvious benefits against neural tude defects but it is not wise to mass dose the whole population especially when there are adverse side affects.

can you give us links to these studies please?

jellytots!

Well to be honest i feel it is mandatory 52 countries world wide have "mandatory" fortification of their flour. The american centre for disease control and prevention estimates one third of the worlds population has access to folic acid fortified flour. For example i had orange juice yesterday...it gave me 150% of my RDA for folic acid, i had a sandwich..folic acid....milk...folic acid....all of the above are not naturally rich in folic acid its added to them. I mean it isn't even advertised on the front of the orange that it contains added folic acid like many things with added vitamins are. You have to read the nutritional contents......and if you did that with everything shopping would take a very long time.

nesf i definitely see your point the consequences of NTD are horrific . However i feel that perhaps folate should be introduced into the contraceptive pill or by some other means not just introdced to a range of foods in an unregulated fashion.

Here is the link to 1 trials however you may not have access to the full article unless you are a member but you can read the abstract-> http://www.ncbi.nlm.nih.gov/pubmed/17551129?ordinalpos=&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.SmartSearch&log$=citationsensor

2.-->http://www.ncbi.nlm.nih.gov/pubmed/19276452?ordinalpos=&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.SmartSearch&log$=citationsensor

3.http://www.ncbi.nlm.nih.gov/pubmed/19920236?ordinalpos=&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.SmartSearch&log$=citationsensor

DrIndy

I remember reading a trial on the benefit of folate in cancer prevention - came out of sweden - I will need to search for it to provide here. But the jist of it was that there were too many other variable to prove it cast iron as a definite plus in cancer prevention.

The issue of fortification is a difficult one, folate deficiency causing neural tube defects is more common than severe b12 deficiency and so it is a balance of causing least harm. Prof John Scott who is the folate/b12 biochemist in TCD has spoken against barndoor fortification for the very same reason of masking irreversible neural damage from b12 deficiency.

Also there are other factors. There is a genetic tendency in celtic people to not process folate correctly resulting in normal folate intake but still having higher than average rates of spina bifida.

BUT how do you guarrantee all women of childbearing age have enough folate unless you fortify food?

Tree

DrIndy wrote: »

BUT how do you guarrantee all women of childbearing age have enough folate unless you fortify food?

Big brother stylee, tie them down and give them regular doses.

Realistically, i can't see any easier way to do it than fortification of foods. Giving it with the pill isnt a bad idea, but you miss the people who don't take it (those who can't or don't for whatever reason). Not everyone will take supplements, (i regularly forget to take whatever various pills im on, through genuine forgetting rather than any mistrust). And many girls just don't think they'll catch babies anytime soon.

Regularly taking supplements does require a bit of effort on the person's part, where eating fortified foods is no effort at all. Excessive fortification should be avoided, such that no single portion contains your entire RDA. I'm sure nutritiony types could survey large populations' diets to get an average day's food, and the fortification could be divided reasonably over each part.

Sapsorrow

Interesting idea for a thread.
I think your idea is a good one in theory about the tampons but wouldn't work in practice.
The whole point of mandatory fortification with folic acid is first of all the damage is done before most women would be aware they are pregnant and therefore it would be too late to start taking the supplements at that stage and second of all so many pregnancies are unplanned and happening to young girls.
So this means that if someone isn't planning on getting pregnant actually convincing them to take a precautionary supplement is very unlikely to happen (the classic it's never going to happen to me mentality), and even if it was possible very few people stick to taking a supplement for any length of time.
How can anyone expect teenage or young girls to rememeber or even be bothered taking a tablet everyday?
Public health campaigns highlighting the dangers of drinking, smoking eating crap foods don't make the majority of people change their habits so I don't see how advising women to take folic acid everyday just in case they get pregnant is going to work.