Review calls for ‘extensive’ folic acid fortification in Germany

The review, published in Deutsches Ärzteblatt International​, argues for an extensive programme of folic acid fortification across Germany.

“The high incidence of neural tube defects in Germany could be lowered by 30 per cent to 50 per cent by means of mandatory folic acid fortification; furthermore, substantial cost savings could be made,”​ said the reviewers Wolfgang Herrmann and Rima Obeid of Saarland University, Germany.

Need for folate​

Folic acid intake before and during early pregnancy ensures that the fetus does not develop the neural tube defect – commonly known as spina bifida.

Women of child-bearing age need sufficient body stores of folate before conception to prevent folate-sensitive neural tube defects (NTDs), which make up 20 to 60 per cent of all NTDs.

The researchers said that every year, 800 pregnancies in Germany are diagnosed with a neural tube defect, most of which are terminated. Acording to data from EUROCAT the German incidence rate of NTDs equates 12.36 cases per 10,000 births, which is much higher than the European average of 7.88 cases per 10 000 births.

However, Herrmann and Obeid explained that merely recommending folic acid supplementation before conception has been found to be an unsuitable strategy – mainly due to the fact that many pregnancies are unplanned, and the average time until the first antenatal visit is 9 weeks, “which is too late to prevent neural tube defects.”​

Herrmann and Obeid noted that the ingestion of folate-fortified food “markedly increases folate intake, generally by about 50 per cent of the recommended daily total intake.”​

Such mandatory fortification of staple foods with folic acid began in the USA in 1998; since then over 50 countries around the world have followed suit in adopting a fortification strategy.

Low cost​

The authors noted that the costs of folic acid fortification are low, adding that in the US they amount to 1.5 to 3 dollars per ton of wheat flour.

They added that in Chile, the annual costs of fortification are said to be covered by the saved expenses of as few as two prevented cases of neural tube defects.

German fortification​

“In Germany at present, debate surrounds the issue whether folate intake should be raised by mandatory folate supplementation, which will affect the entire population,”​ said Herrmann and Obeid.

Folate deficiency is associated also associated cancer and other diseases; however there is some concern that very high folic acid intake may promote the growth of pre-neoplastic lesions (tissue ambormalities that may develop into tumors).

However the reviewers noted that there is no consistent evidence to support such ideas, adding that the idea “is derived from research in animals whose folate metabolism differs from that in humans.”​

“Mandatory folic acid fortification should be adopted, as it is a highly effective and inexpensive way to prevent NTDs,” ​concluded Herrmann and Obeid.

However, the review made ten recommendations for preventing neural tube defects by means of such a strategy. The authors said that all the items recommended should be assessed to gain a better understanding of the benefits for the population, before the implementation of folic acid fortification is made mandatory in Germany.

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Source: Deutsches Ärzteblatt International|​
Volume 108, Issue 15, Pages 249 to 254, doi: 10.3238/arztebl.2011.0249
“The mandatory fortification of staple foods with folic acid: A current controversy in Germany”​
Authors: W. Herrmann, R. Obeid

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