Inertia on folic acid has caused thousands of unnecessary deaths

May 17, 2003

As many as 350,000 deaths could have been prevented over the last decade if the UK government had acted on the compelling evidence for the benefits of folic acid, a conference was told last week. Had flour been fortified with folic acid when the evidence regarding neural tube defects was published, thousands of people would not have died from coronary heart disease.

Godfrey Oakley, visiting professor at the department of epidemiology at the Rollin School of Public Health of Emory University, Atlanta, said: “The failure to require mandatory fortification of flour with folic acid is public health malpractice.” He was speaking at a conference in London organised by Dr Jean-Pierre Lin, consultant paediatric neurologist responsible for the spina bifida services at Guy’s and St Thomas’s hospitals on behalf of the charity the Little Foundation and MacKeith meetings (a product of publishers MacKeith Press).

Recent evidence shows not only the benefits of folic acid in preventing neural tube defects but that it is protective against heart disease, strokes, deep vein thrombosis, and pulmonary embolism. Folic acid lowers concentrations of homocysteine, an amino acid that for about 15 years has been believed to be associated with heart attacks and strokes.

Dr David Wald, a cardiologist at Southampton General Hospital, said: “Until public health agencies fortify our diet with sufficient folic acid, people should consider taking an 800 µg supplement each day, especially if they have coronary heart disease.”

The Medical Research Council vitamin study was published in 1991 and gave compelling evidence that taking folic acid prevents up to three quarters of neural tube defects, such as spina bifida (Lancet 1991;338:132-7). Despite the publicity that the report generated, the incidence of neural tube defects has not declined in the United Kingdom over the last decade, despite quite a steep decline between 1970 and 1992.

The government recommends that women who are trying to conceive take 400 µg of folic acid a day. But experts point out that about half of pregnancies are unplanned, meaning that many women start taking the vitamin only once they find out they are pregnant or not at all. Specialists say that the optimal time for women to take the vitamin is from stopping contraception to 12 weeks after conception.

Public health doctors and charities such as the Association of Spina Bifida and Hydrocephalus have called on the UK government many times to fortify flour with folic acid. They point out that 39 countries around the world, including the United States and Canada, now either fortify flour or have agreed to do so, and that the rate of neural tube defects has fallen in these countries. In Nova Scotia, where fortification was implemented in 1998, the incidence fell from 2.58 per thousand people in 1991-7 to 1.17 per thousand people in 1998-2000 (Canadian Medical Association Journal 2002;167:241-5).

No country in the European Union, however, has yet decided to fortify flour. The folic acid working group of the European Surveillance of Congenital Anomalies is soon to publish a report, concluding that most women in Europe do not take folic acid around the time of conception, despite education programmes in some countries encouraging them to do so.

The group collated data from 17 countries showing that the overall incidence of neural tube defects in Europe has not declined over the 1990s. Even women who do take folic acid often do not start until after conception. The report will recommend that EU countries adopt a policy of fortifying flour with folic acid.

If flour were fortified at the recommended level on a worldwide scale 100 000 pregnancies resulting in neural tube defect would be prevented each year, according to Professor Nick Wald, of the St Bartholomew’s and the Royal London School of Medicine and Dentistry.

He said, “There is no evidence or reason to regard fortification at any of the doses proposed as a risk to health, and there is compelling evidence that failure to fortify causes considerable harm.”

The meeting was held the day before the UK’s Food Standards Agency issued a report warning people against taking too many vitamin supplements. The Birth Defects Foundation issued a press release urging women to keep taking folic acid, after receiving a flood of calls to its telephone.

By: Anna Ellis,

BMJ. 2003;326(7398):1054.