Folic Acid Supplements Still Advised
"Women should be cautioned that half of all pregnancies are unplanned and that folic acid must be taken before conception to be effective. Taking supplements is the safest and most effective way" to prevent the birth defects associated with folic acid deficiency," he concludes.
Mills tells WebMD he wrote the article because "there has been a lot of politicking to increase the amount [of folic acid]" in enriched flour. The dose for most women who could become pregnant is 400 mcg per day, and 4,000 mcg per day is recommended for women who have already had a child with a birth defect associated with low folic acid, Mills says.
The results of the current folic acid enrichment program are not expected to be available until sometime later this summer, says J. David Erickson, PhD, chief of the branch of birth defects and genetic diseases at the CDC.
"Our best guess at this was that you might see a 50% drop [in these birth defects]," Erickson says. "That would be our hope; that's what one would hope to achieve with fortification. The projections by the FDA at the time were that women would consume an extra 100 mcg a day [with fortification]. That is one-fourth the recommended amount."
Mills provoked an impassioned response from Godfrey Oakley, MD, who likened Mills' article to "yelling fire in a crowd." Until two years ago, Oakley was the director of the CDC's Division of Birth Defects and Developmental Disabilities.
"My view is that, from everything we know up this point, the amount of fortification is not enough," Oakley tells WebMD. "You would have to eat a loaf of bread" made with folic acid-fortified or enriched flour to reach the recommended level, says Oakley. He is currently a visiting professor of epidemiology at Emory University in Atlanta.
"What gets missed is [that] this is not about what is the dose at which you can start to see some protective effect," he says. "That is not what you are after. It is about what is the least dose that will give you the most protective effect. It takes 400 mcg to do the whole job. We should have no child with folic acid-preventable [birth] defects. I agree that until fortification is fixed, we need to be teaching as many women as we can ... to take a multivitamin." However, this is an ineffective solution, he notes, because "no more than 50% of women will take vitamin supplements."