March 07, 2007

Foolish Folate

tomato.jpgThis week on CNE I mouth off a bit about trans-fat bans.

While planning to write, I was tempted to report on folic acid, since a recent paper yet again demonstrated that supplementation reduces the risk of facial cleft (and worse) malformations and the design of a folate-enriched tomato (see the original paper for details). This research is extra interesting since a very new report from the Swedish Council on Technology Assessment in Health Care adviced against folate fortification of flour, continuing the anti-fortification line the Swedish food administration has held about folate.

Their reasoning is based on applying the precautionary principle in the worst possible way. The consistent and reproducible studies showing beneficial effects are outweighed by the possible risks that are not scientifically proven. Some risks, like masking B12 deficiency, they admit have never been observed. Increased number of twins might or might not happen, but only seems relevant at higher levels of intake than is relevant for fortification. Theoretically there could be a cancer effect in that folate increases the replication of malign cells, but several studies seem to suggest it is protective instead. Finally, they name unknown effects of synthetic folic acid and inadvertent genetic selection for embryon with certain variants of the MTHFR gene. It seems that the cancer risk is the clincher, but if it is so worrying, why not at least look at the cancer rates in societies with folate fortification in the report? The group also decided not to look at other possible positive effects, despite quite a few hopeful findings.

It seems that this kind of reasoning would mean we ought to stop fluoridating the drinking water. Who knows what it does to our purity of essence?

One can do a principled argument against folate fortification on ethical grounds: the public shouldn't be medicated without their own consent. While folate (a "vitamin") might be pretty acceptable compared to a "drug" both conceptually and safetywise, it still represents health paternalism. The report actually suggests voluntary enrichment of flour, which nicely gets around this problem and might help give consumers more choice. But if high folate intake is problematic - and from the typical european publich health perspective any high intake of anything is automatically suspect and ought to be limited or regulated (cmp. the Food Supplements Directive) - the same arguments used against fortifying flour will soon be used against 'excessive' folate intake. Don't eat that flour or spinach, it will genetically modify your kids, hide your anemia and give you cancer! (maybe)

The big problem isn't an overly cautious approach to fortification. Just like in the case of the trans-fats I'm convinced the consumers actually will tend to reward producers of healthier food if they can demonstrate its benefits. It is the acceptance that very uncertain risks that do not even appear to be large (nothing seems to have been observed in the US and Canada since fortification was instituted in 1998) are valid grounds for blocking something. At the same time this acceptance is uneven: any medical decision is regarded as potentially very risky while political decisions are assumed to be risk-free - even when they affect medical decisions.

Posted by Anders3 at March 7, 2007 05:42 PM