Fortification of the food supply with folic acid to prevent neural tube defects is not yet warranted

The relationship between adequate folate intake by pregnant women and reduced risk of delivering infants with neural tube defects (NTDs) has raised the public health issue of increasing folate intake among women of reproductive age. The U.S. Food and Drug Administration has proposed fortifying cereal and grain products with folate, although at a level less than half that recommended by its sister agency, the Centers for Disease Control and Prevention. We question the wisdom of fortifying foods with folate at this time, given a variety of uncertainties, which include the following: 1) the fact that neural tube defects seem to be a multifactorial group of disorders that are polygenic as well, so folate will not help in all or perhaps even in most cases; 2) the incidence of NTDs, which varies geographically, has been decreasing in the United States for years; 3) fortifying more food with folate may pose safety concerns for some not at risk for NTDs; 4) no dose-response relationship has been established between folate and NTDs; and 5) fortification in this case would represent a conceptually new intervention strategy for addressing what may be a metabolic abnormality where pharmacological doses of a nutrient may be required. Launching a major nutritional intervention before better understanding the relationship between nutrients and NTDs and without reasonable assurance that it will not shift health risks from one group (developing embryos) to another (primarily adults with pernicious anemia) might prove ineffective and/or harmful.