Global Folate Deficiencies Require New Approach To Supplementation – Study

New and "creative" approaches are needed to improve the folate status of the global population and prevent birth defects such as spina bifida and anencephaly, a review article published in The Lancet April 22 states.

"Despite worldwide public health campaigns recommending periconceptional daily supplementation of synthetic folic acid to reduce the risk of neural tube defects, many women are not following these recommendations," according to Monika Eicholzer, Institute of Social & Preventive Medicine, University of Zurich, Switzerland, et al.

"In the absence of mandatory fortification on a sufficient level, national campaigns to increase knowledge and use of folic acid among women should be intensified and adequately funded," the authors add.

The article is a non-systematic overview of publications in English, German or French during the last decade that were identified through a search of the MEDLINE database.

New educational approaches are needed because many countries elect not to require folic acid fortification of food, either because the health benefits have not yet been scientifically proven or because of the freedom of choice, Eicholzer et al. state.

Health concerns, such as the belief that folic acid fortification could mask vitamin B12 deficiency, are cited by some countries where fortification is not mandatory, the authors add.

Meanwhile, they note, there has been "no decline" in neural tube defects in most European countries in recent years.

"Despite public health campaigns, knowledge about the proper periconceptional time to use folic acid supplements for the prevention of neural tube defects is not widespread in women and only a maximum of half of them are following the recommendations."

For example, despite "high awareness" in Ireland, a study found that only 23% of pregnant women there were taking folic acid prior to conception, the authors state.

Although "most" women in Western countries of childbearing age have heard of folic acid, "fewer women know that folic acid can prevent spina bifida and neural tube defects and an even lower percentage of women is aware of the fact that folic acid should be taken before pregnancy," the authors maintain.

Common neural tube defects can occur within 24 days after conception and before a woman realizes she is pregnant. Thus, supplementation should begin prior to pregnancy, Eicholzer et al. state.

Infants with anencephaly are stillborn or die shortly after birth, while those with spina bifida often suffer from paralysis or bowel and bladder incontinence.

The U.S. Institute of Medicine recommends an intake of 0.4 mg daily of dietary folate, while the EU and Australia suggest 0.2 mg and 0.5 mg, respectively.

"Translation of these recommendations into practice, however, has proved difficult," the authors note. "An important issue is how effective are recommendations alone, or in combination with campaigns to increase knowledge and use of folic acid supplements periconceptionally among women."

In addition to education campaigns, the authors support providing access to inexpensive folic acid supplements, and state that physicians should inform and motivate female patients to take folic acid supplements during childbearing years.

"An alternative could be adding the folic acid supplementation recommendations to contraceptive packages and recommending women to start folic acid supplementation after stopping their contraception," Eicholzer et al. state.

The UK's Food Standards Agency is considering requiring folate fortification of certain foods in the country, as is required in the U.S. A recent study in Circulation suggested that a more rapid decline in stroke mortality in the U.S. than in other countries could be linked to mandatory fortification (¹ (Also see "Folate Fortification Linked To Lower Stroke Mortality In U.S., Canada – Study" - Pink Sheet, 20 Mar, 2006.), p. 9).

However, Eicholzer et al. maintain that "the evidence for a protective effect is much stronger for folic acid supplements than for food folate, and an effect of natural folate on neural tube defects has yet to be shown."

- Bridget Behling