Volume 184 - Issue 4
Mandatory fortification of flour with folic acid: an overdue public health opportunity
Authors: Fiona J Stanley and Glen F Maberly
Med J Aust 2006; 184 (4): 199. || doi: 10.5694/j.1326-5377.2006.tb00195.x
Published online: 20 February 2006
Published online: 20 February 2006
Fiona J Stanley,* Glen F Maberly†
* Director, Telethon Institute for Child Health Research, PO Box 855, West Perth, WA 6872. † Professor of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA. fionaATichr.uwa.edu.au
In reply: Ekert suggests that in our article advocating for mandatory fortification with folate to reduce neural tube defects,1 we omitted to mention the “increased risk of multiple pregnancies”. He then misquotes the Lumley meta-analysis “(relative risk, 1.02; 95% CI, 0.97–1.07)” — the real relative risk was 1.40 (95% CI, 0.93–2.11). This Cochrane systematic review shows that folate supplementation does not carry a statistically significant risk for multiple births, but confirms the dramatic reduction in neural tube defects.2 Another study, which did suggest an increased risk, did not control for the known increased risk of multiple births following infertility treatments, which could explain the increase observed.3
Ekert suggests that we inform women about this unsubstantiated risk and “the as yet unknown risk” which mandatory fortification might add to “medically prescribed folic acid”. Folic acid is found in leafy green vegetables and in many fruits, nuts and other components of a healthy diet. Tablets are available over the counter. What advice would he give to women about these “risks”? Our evidence is that we are not reaching many women in our society by education and voluntary fortification, and that countries that have fortified their flour have achieved much better reductions in these major defects than we have in Australia. Hence our advocacy.
We acknowledge that the evidence for stroke and heart disease reduction is not as solid as that for neural tube defects. However, there is an increasing literature on the protective effects of folate on cardiovascular risk and possible mechanisms.4-8
Hence, with consideration of the proven benefits and the unsubstantiated risks, we will continue to advocate for the mandatory fortification of flour with folate.
References
- Maberly GF, Stanley FJ. Mandatory fortification of flour with folic acid: an overdue public health opportunity [editorial]. Med J Aust 2005; 183: 342-343. <eMJA full text>
- Lumley J, Watson L, Watson M, Bower C. Periconceptual supplementation with folate and/or multivitamins to prevent neural tube defects. Cochrane Database Syst Rev 2001; (3): CD001056. 0_CBBJJIDE
- Berry RJ, Kihlberg R. Folic acid supplementation is associated with an increase in dizygotic twinning. Early Human Dev 2005; 81: 465-467. 0_i1091551
- Schnyder G, Roffi M, Pin R. Decreased rate of coronary restenosis after lowering of plasma homocysteine levels. N Engl J Med 2001; 345: 1593-1600. 0_i1091553
- Baker F, Picton D, Blackwood S, et al. Blinded comparison of folic acid and placebo in patients with ischaemic heart disease: an outcome trial [abstract]. Circulation 2002; 106 Suppl II: S741.
- Lange H, Suryapranata H, De Luca G, et al. Folate therapy and in-stent restenosis after coronary stenting. N Engl J Med 2004; 350: 2673-2681. 0_i1091557
- Toole JF, Malinow MR, Chambless LE, et al. Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction and death. The Vitamin Intervention for Stroke Prevention Randomized Controlled Trial. JAMA 2004; 291: 565-575. 0_i1091559
- Cronin S, Furie KL, Kelly PJ. Dose-Related association of MTHFR 677T with risk of ischemic stroke. Evidence from a cumulative meta-analysis. Stroke 2005; 36: 1581-1587. 0_i1091561