JOURNAL OF WOMEN'S HEALTHVolume 6, Number 2, 1997Mary Ann Liebert, Inc.

Letter to the Editor

Fortifying Food with Folie Acid

To the Editor:In their Point of View commentary, "Folie

Acid Food Supplementation: An Idea WhoseTime Has Not Come"1 Drs. Rosner andGrünwald create some confusion by the use ofthe term "supplementation" in reference to thefortification of food products with folie acid.The fortification of grain products (cereals, rice,etc.) in the amount of 140 ¿ug/100 g of producthas been approved by the Food and DrugAdministration (FDA), to begin no later thanJanuary 1, 1998.2 That differs from supplemen-tation with folie acid, for which the U.S. PublicHealth Service, since 1992, has recommendedthat all women of reproductive age take a mul-tivitamin containing 400 ¿ig of folie acid dailyto help prevent neural tube defects.3 The pur-pose of food fortification is to increase folie acidintake of women of reproductive age, twothirds of whom fail to ingest the recommendedamounts daily.The authors raise the argument that food for-

tification for the benefit of one population(women of reproductive age) could put othersat some risk. The authors stress that some in-dividuals, particularly the elderly with perni-cious anemia, might be harmed because folatecould correct the anemia but allow the neuro-

logic manifestations to progress. This concern

relates primarily to studies from the 1940s and1950s (reference 8 in their article) in which mil-ligram, not microgram doses of folie acid were

used. We can find no convincing evidence thatquantities of folate in the American diet, levelsof folie acid approved for fortification by theFDA, or even the larger dose of 400 fig used insupplementation, have been shown tomask thediagnosis of pernicious anemia. In addition,folie acid may reduce the risk of cardiovascu-lar disease and stroke.4,5

We applaud the authors' suggestions con-

cerning folie acid supplementation for womencontemplating pregnancy. However, becauseat least 50% of all pregnancies are unintended,for many pregnant women, care begins long af-ter the optimal time interval (the first 4 weeksafter conception) when folie acid must be con-sumed to prevent neural tube defects. It wouldindeed be helpful if supplements could be pro-vided free of charge. Therefore, we continue toadvocate that both fortification of food andsupplementation with multivitamins contain-ing the required amount of folie acid are es-sential components of the national initiative toprevent neural tube defects. In a journal de-voted to women's health, the message shouldbe especially clear that the potential benefits ofdaily folie acid for all women of childbearingage are enormous and the risks are exceedinglysmall.

Richard B. Johnston, Jr., M.D.March of Dimes Birth Defects Foundation

White Plains, NYand Yale University School of Medicine

New Haven, CTRichard H. Schwarz, M.D.

New York Methodist HospitalBrooklyn, NY

Karla Damns, Ph.D.Albert Einstein College of Medicine

Bronx, NY

Authors' Reply:In reply to Drs. Johnston, Schwarz, and

Damus, we apologize for using the term "sup-plementation" of food in our article1 instead ofthe term "fortification" of food, which has beenthe term chosen by nutritionists and the FDAfor this purpose. However, our basic premise

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