Pros
1. Few women take folic acid supplements before pregnancy.Researchers reviewed 52 studies about folic acid supplementation conducted in about 20 countries between 1992 and 2001. They found that in many countries, fewer than 50% of women take folic acid supplements before pregnancy (1).
In Norway, researchers evaluated reports of folic acid supplement use by mothers-to-be from 1998 to 2003. They found that in spite of education about its importance, few Norwegian women started folic acid supplementation before they were sure they were pregnant (4).
2. Fortifying food works.
Data from Chile, which began fortifying flour with folic acid at double the rate of the United States beginning in January 2000, indicates that the incidence of the neural tube defects spina bifida and anencephaly (a brain malformation) have significantly decreased since that time (2).
Fortifying foods with folic acid is a safe and cost-effective way to prevent neural tube defects. It may be the only possible way to provide folic acid to women with unplanned pregnancies.
Con: Don't add folic acid
1. Fortifying foods affects the whole population.Sufficient evidence that increased folic acid intake may have benefits for all individuals in a given country has not yet been put forth. Claims that folic acid may prevent cancer or cardiovascular disease are still under study (3).
There is no indication that putting folic acid in the food supply is beneficial for anyone other than mothers-to-be. No data exists on the safety of the increased levels of folic acid intake which fortified foods provide. In fact, there is concern that a long-term intake of folic acid may promote the progression of existing cancers (6).
2. Health education could increase folic acid use.
A survey of 818 new mothers in Turkey revealed that only 13% knew of the link between folic acid supplementation and prevention of neural tube defects. Educated women were more likely to have heard about folic acid than less-educated women. The researchers note, "It is the responsibility of national authorities to increase health education concerning folic acid and the prevention of neural tube defects in their countries" (4).
Strategies could be developed to educate the most vulnerable groups of women about folic acid, including the less educated, the young, and women with unplanned pregnancies (5).
Where it Stands
Countries such as Australia and New Zealand are debating whether to implement folic acid fortification of food. There are strong arguments both for and against fortification. If the effects of long-term folic acid intake could be clarified, this would help countries determine if the benefits outweigh the risks.References
1. Ray, J.G., Singh, G., & Burrows, R.F. (2004). Evidence for suboptimal use of periconceptional folic acid supplements globally. BJOG: and International Journal of Obstetrics and Gynaecology, vol. 111, p. 399.
2. Lopez-Camelo, J.S., et al. (2005). Reduction of birth prevalence rates of neural tube defects after folic acid fortification in Chile. American Journal of Medical Genetics Part A, published online 4/21/05.
3. Staff, A.C., et al. (2005). Does folic acid have effects on other health problems than neural tube defects? Tidsskr Nor Laegeforen, vol. 125, pp. 438-441.
4. Unusan, N. (2004). Assessment of Turkish women's knowledge concerning folic acid and prevention of birth defects. Public Health Nutrition, vol. 7, pp. 851-855.
5. Knudsen, V.K., Mikkelsen, T.B., Michaelsen, K.F., & Olsen, S.F. (2004). Low compliance with recommendations on folic acid use in relation to pregnancy: Is there a need for fortification? Public Health Nutrition, vol. 7, pp. 843-850.
6. Kim Y.I. (2004). Will mandatory folic acid fortification prevent or promote cancer? American Journal of Clinical Nutrition, vol. 80, pp. 1123-1128.
