REPORT OF COUNCIL ON SCIENTIFIC AFFAIRS
CSA Report 5-A-07
Subject: Folic Acid
Presented by: Laurie Sutor, MD, Chair
Referred to: Reference Committee on Science and Education
TMA Policy 330.007, Folic Acid, was scheduled for policy sunset review by the Council on Scientific Affairs (CSA) in 2006. The Committee on Maternal and Perinatal Health also had an interest in the review and made several recommendations for amendments. The committee had a general consensus that a wider range of grain products should be fortified with folic acid, i.e., corn products that are favored by Hispanic populations, but debate ensued as to whether that, coupled with the amount of folic acid fortification (per 100 grams of grain) currently in the TMA policy, would result in consumption of too much folic acid by some people, leading to additional clinical concerns, including risk for vitamin B12 deficiency, for those individuals. The committee then asked their sponsoring council, the Council on Public Health (CPH), to review the policy and the committee's concerns. After review, CPH referred the issue about the actual fortification level to CSA.
At the same time, the American Medical Association (AMA) Council on Science and Public Health (CSAPH) submitted a report entitled "Folic Acid Fortification of Grain Products" at the AMA Annual Meeting in June 2006. CSA has reviewed the CSAPH report and found it to have a strong basis in scientific evidence. The report covers the protective effect of folic acid in preventing neural tube defects, the need for fortification of all grains, fortification levels, and the benefits and risks of folic acid intake. Some of areas covered are vitamin B12 deficiency, vascular disease, cancer, natural killer cell cytotoxicity, and selection for folic acid dependency. CSA felt strongly that TMA and the health of all Texans will be well served to include the AMA recommendations in the TMA policy on folic acid.
Amendments to the TMA policy are as follows:
330.007 Folic Acid . The Texas Medical Association encourages broad-based public education about the need for women with childbearing potential to consume an adequate level of folic acid (400 micrograms per day) through intake of a well-balanced diet and supplemental vitamins to reduce the risk of a child with a neural tube defect. Women with a prior history of pregnancy affected by a neural tube defect should consult closely with their physician on appropriate prevention steps before considering another pregnancy.
TMA encourages the Food and Drug Administration (FDA) to continue its rulemaking process expeditiously to require comprehensive fortification of all cereal grain s marketed for human consumption, including grains not carrying the "enriched" label, products with folic acid at an appropriate level to reduce the risk of neural tube defects. Based on available data, TMA believes an appropriate fortification level for cereal grain products is 350 micrograms per 100 grams of cereal grain needed to achieve a reduction of neural tube defects. FDA is also encouraged to require food, food supplement, and vitamin labeling to specify milligram content, as well as RDA levels, for critical nutrients, which vary by age, gender, and hormonal status (including anticipated pregnancy) .
TMA encourages the Centers for Disease Control and Prevention and the Texas Department of State Health Services to give priority to establishing monitoring programs to assess implementation and effect of the neural tube defect prevention programs.
TMA encourages the National Institutes of Health and Centers for Disease Control and Prevention to fund basic research, epidemiologic studies, and clinical trials to assess expeditiously the causal and metabolic relationships among homocysteine, vitamins B12 and B6, and folic acid, so as to reduce the risks for and incidence of associated diseases and deficiency states, potential for reducing the risk of vascular disease associated with elevated homocystine levels such as low birth weight babies associated with reduced levels of folate in red blood cells through consumption of folic acid and that the metabolic interrelationships of folate, vitamin B6, and vitamin B12 continue to be assessed TMA also encourages research efforts to identify and monitor those populations potentially at risk for masking vitamin B12 deficiency through routine folic acid supplementation of enriched food products (Council on Scientific Affairs, p 160, A-96).
Recommendation: Approve as amended.
TMA House of Delegates: TexMed 2007