Bhutta ZA, Hurrell RF, Rosenberg IH (eds): Meeting Micronutrient Requirements for Health and Development. Nestlé Nutr Inst Workshop Ser, vol 70, pp 187–189, Nestec Ltd., Vevey/S. Karger AG., Basel, © 2012
Perhaps folic acid and vitamin B12 have been orphan micronutrients for too long. Even though they are the last of the vitamins to have been identified, I think we have had over 60 years to gather more information about the status of these vitamins and their importance, not only in nutritional health but in child development. This challenge was put forward both by Lindsay Allen and Aron Troen. Aron Troen has shown us a number of examples of the significant extent to which our understanding of the biologic importance of these nutrients have advanced. The advances that we heard from Aron Troen on our understanding of the biology of folic acid and folic acid and vitamin B12 interactions give us a very strong platform for application of knowledge about vitamin status to address some of the important current public health considerations. Lindsay Allen indicated there are more than 52 countries that are fortifying flour with folic acid. This is a remarkable demonstration of thinking globally but not thinking critically. As there is increasing information about those processes in human biology which are influenced by folic acid through methylation and epigenetics, we must be even more cognizant of local information that helps us make decisions about fortification and about interactions. Arguments put forward by Lindsay Allen suggesting that we have inadequate database about vitamin B12 in a number of countries should raise the question about whether this is a micronutrient that deserves to be increased in the public health priority as a way of promoting health and approaching prevention of deficiency, and whether in fact fortification with vitamin B12 does have as strong a scientific basis as the fortification with folic acid. The matter of the interaction of the two vitamins has become more fascinating and current. These two nutrients were intertwined in their early history, and now we realize that we have these national experiments of fortification with folic acid (driven by experiences in North America with control of neural tube defects) in countries which did not even have information about the folic acid status, vitamin B12 status, or even neural tube birth incidence. We have now the challenge of deciding to obtain information that will allow us to judge the
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Summary on Iodine Folate and Vitamin B12
188
Rosenberg
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relative importance and relative risk of fortifying with folic acid in order to prevent neural tube defects in countries with minimal reporting data. While neural tube defect control can be demonstrated to be an important goal of folic acid fortification, the question remains, what is the exposure with regard to safety and interaction of the vitamins? We are talking about synthetic folic acid, not about food folate. We are now able to measure the circulating levels of unmetabolized folic acid and analyze some of these observations in terms of whether we are looking at the effects of folic acid per se or total folate intake in relation to vitamin B12. The approaches that were presented in this session allow us to begin to look at these interactions in a way which is much more analytical in use of growing information about the fact that we actually can measure the status of these nutrients. This should help us put at a higher priority level the consideration of both decisions about folic acid and vitamin B12, and that can be done with an increasing foundation of a solid and growing biological database. Let me return again to the notion put forward by Pieter Jooste of ‘thinking globally but acting locally’. This is very much a challenge with many if not all the micronutrients that we have considered throughout these few days. Certainly it’s true of the micronutrients that we considered today with regard to iodine, folate and vitamin B12, and if we are to make our decisions about how to target our public health interventions, we are going to have to upgrade the level of information that we have in individual countries. We should not take as a global imperative or an initiative which is global, arguments for doing universal fortification. Sometimes that would be expedient when there may not be enough information from other sources. Lindsay Allen will remember and as will Richard Hurrell, the WHO consultation on Fortification [1] whose recommendations were clear that the decisions about fortification for any of these nutrients should be based to the extent possible on local information and public health priorities. Sometimes that local information is actually going to be regional. The points that Michael Zimmerman made in his discussion about iodine nutrition focus on ways in which we might improve the information on the infant or the neonatal child by using some new techniques of measurement such as steroid-stimulating hormones. There are ways forward with regard to being able to not only think locally on the basis of local information but to be able to actually define the target populations and whether the intervention that we have in mind is well suited to those target populations. Where a universal approach is not adequate to reach all the target populations, then we are clearly challenged to find ways to improve on the impact of whatever interventions we can do. Both of the sessions this morning should challenge us to be much more cognizant of the nutritional status, nutritional intake, not just of women in pregnancy, not just women who are breastfeeding and not even perhaps just in the preconceptional period and women of childbearing age, but also that we heard a great deal of support for the importance of targeting even the adolescent women who in many countries will soon become mothers. Their nutritional status will
have a great deal of influence not only on birth outcomes but even on outcomes that can be projected to even later times in the life cycle. Thus, by focusing on a number of these nutrients such as we did in this session and throughout this meeting, we can mount some very strong arguments for targeting our intervention to the populations which are the important targets. I would hope that we can use some of this kind of information and this discussion, to which all have contributed so well, to have this publication lead to a list of important targets and recommendations that could have an influence on how we go forward with health and development programs. Irwin H. Rosenberg Reference
Summary on Iodine Folate and Vitamin B12
189
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1 Allen L, de Benoist B, Dary O, Hurrell R: Guidelines on Food Fortification with Micronutrients. Geneva, World Health Organization and Food and Agricultural Organization of the United Nations, 2006.
Perhaps folic acid and vitamin B12 have been orphan micronutrients for too long. Even though they are the last of the vitamins to have been identified, I think we have had over 60 years to gather more information about the status of these vitamins and their importance, not only in nutritional health but in child development. This challenge was put forward both by Lindsay Allen and Aron Troen. Aron Troen has shown us a number of examples of the significant extent to which our understanding of the biologic importance of these nutrients have advanced. The advances that we heard from Aron Troen on our understanding of the biology of folic acid and folic acid and vitamin B12 interactions give us a very strong platform for application of knowledge about vitamin status to address some of the important current public health considerations. Lindsay Allen indicated there are more than 52 countries that are fortifying flour with folic acid. This is a remarkable demonstration of thinking globally but not thinking critically. As there is increasing information about those processes in human biology which are influenced by folic acid through methylation and epigenetics, we must be even more cognizant of local information that helps us make decisions about fortification and about interactions. Arguments put forward by Lindsay Allen suggesting that we have inadequate database about vitamin B12 in a number of countries should raise the question about whether this is a micronutrient that deserves to be increased in the public health priority as a way of promoting health and approaching prevention of deficiency, and whether in fact fortification with vitamin B12 does have as strong a scientific basis as the fortification with folic acid. The matter of the interaction of the two vitamins has become more fascinating and current. These two nutrients were intertwined in their early history, and now we realize that we have these national experiments of fortification with folic acid (driven by experiences in North America with control of neural tube defects) in countries which did not even have information about the folic acid status, vitamin B12 status, or even neural tube birth incidence. We have now the challenge of deciding to obtain information that will allow us to judge the
Downloaded by: La Trobe University 198.143.52.1 - 1/26/2016 10:15:10 PM
Summary on Iodine Folate and Vitamin B12
188
Rosenberg
Downloaded by: La Trobe University 198.143.52.1 - 1/26/2016 10:15:10 PM
relative importance and relative risk of fortifying with folic acid in order to prevent neural tube defects in countries with minimal reporting data. While neural tube defect control can be demonstrated to be an important goal of folic acid fortification, the question remains, what is the exposure with regard to safety and interaction of the vitamins? We are talking about synthetic folic acid, not about food folate. We are now able to measure the circulating levels of unmetabolized folic acid and analyze some of these observations in terms of whether we are looking at the effects of folic acid per se or total folate intake in relation to vitamin B12. The approaches that were presented in this session allow us to begin to look at these interactions in a way which is much more analytical in use of growing information about the fact that we actually can measure the status of these nutrients. This should help us put at a higher priority level the consideration of both decisions about folic acid and vitamin B12, and that can be done with an increasing foundation of a solid and growing biological database. Let me return again to the notion put forward by Pieter Jooste of ‘thinking globally but acting locally’. This is very much a challenge with many if not all the micronutrients that we have considered throughout these few days. Certainly it’s true of the micronutrients that we considered today with regard to iodine, folate and vitamin B12, and if we are to make our decisions about how to target our public health interventions, we are going to have to upgrade the level of information that we have in individual countries. We should not take as a global imperative or an initiative which is global, arguments for doing universal fortification. Sometimes that would be expedient when there may not be enough information from other sources. Lindsay Allen will remember and as will Richard Hurrell, the WHO consultation on Fortification [1] whose recommendations were clear that the decisions about fortification for any of these nutrients should be based to the extent possible on local information and public health priorities. Sometimes that local information is actually going to be regional. The points that Michael Zimmerman made in his discussion about iodine nutrition focus on ways in which we might improve the information on the infant or the neonatal child by using some new techniques of measurement such as steroid-stimulating hormones. There are ways forward with regard to being able to not only think locally on the basis of local information but to be able to actually define the target populations and whether the intervention that we have in mind is well suited to those target populations. Where a universal approach is not adequate to reach all the target populations, then we are clearly challenged to find ways to improve on the impact of whatever interventions we can do. Both of the sessions this morning should challenge us to be much more cognizant of the nutritional status, nutritional intake, not just of women in pregnancy, not just women who are breastfeeding and not even perhaps just in the preconceptional period and women of childbearing age, but also that we heard a great deal of support for the importance of targeting even the adolescent women who in many countries will soon become mothers. Their nutritional status will
have a great deal of influence not only on birth outcomes but even on outcomes that can be projected to even later times in the life cycle. Thus, by focusing on a number of these nutrients such as we did in this session and throughout this meeting, we can mount some very strong arguments for targeting our intervention to the populations which are the important targets. I would hope that we can use some of this kind of information and this discussion, to which all have contributed so well, to have this publication lead to a list of important targets and recommendations that could have an influence on how we go forward with health and development programs. Irwin H. Rosenberg Reference
Summary on Iodine Folate and Vitamin B12
189
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1 Allen L, de Benoist B, Dary O, Hurrell R: Guidelines on Food Fortification with Micronutrients. Geneva, World Health Organization and Food and Agricultural Organization of the United Nations, 2006.
