Medicating the Masses
Katherine Rich gives her considered opinion in the Herald today on the subject of the supplementation of folate in bread. Ms. Rich at least addresses other issues than “Nanny state” concerns, citing the possible link between folate and prostate cancer and the unknowns involved in over-supplementing children.
Folate fortification has been going on for a decade in the US and Canada. They not only fortify bread, but pasta, cereals and rice as well. A recent study in the New England Journal of Medicine shows that supplementation in Canada has significantly reduced the incidence of devastating neural defects like spina bifida. Clearly supplementation works.
The Journal Of the American Medical association published a study in 2007 that indicated that folate did not reduce the number of pre-cancerous polyps formed in the colon. There was a significant increase in the incidence of prostate cancer noted in the study. But the study was not designed for prostate cancer and the increase has not bee demonstrated elsewhere. Certainly, the US and Canada has not reported an increase in Prostate cancers.
An epidemiological (raw data from the population and hospital statistics, rather than a clinical trial) study in Chile showed an increase in the incidence of colon cancer since the fortification of flour with folate, but this was a poor study and it would be unwise to take alarm at this. The US reports a decline in colon cancer over the past decade (actually over the past 40 years, with no change in the rate of decline since supplementation). The weight of evidence makes colon cancer a very unlikely consequence of folate supplements. Apparently, the Irish government is conducting a more definitive study, but these results will not be available until the end of the year.
Besides the colon cancer pseudo-scare, the New Zealand Food Safety Authority makes this peculiar observation:
“In rather alarming advice, the minister at the time was told by NZFSA: “There are unknown risks that may not become apparent for one or two generations. Children will be exposed to much higher levels of folic acid than in previous generations. It may not be until this generation of children have their own children that adverse effects become apparent.””
Now there is absolutely no evidence that this may be the case. There is no rational basis for supposing that even an overdosage of folate would cause such intergenerational harm. This is pure scaremongering. Folate supplementation has been used for decades in children with sickle cell anaemia with no significant problems and no strange intergenerational effects.
I consider both of these medical objections to be unconvincing, to say the least. I am left with the impression that the real reason for wanting to delay the fortification of flour is this:
“Practical problems have also arisen since New Zealand committed to the food standard two years ago. Bread companies have conducted clinical dosage trials and concluded that dosing the bread accurately every time within the tolerance levels will be impossible.”
The word impossible here means impossible without new, expensive equipment, of course. The US and Canada have been managing reasonably standardised levels for years. Clearly it is possible to achieve this, but the bread companies are reluctant to part with the capital investment. I have some sympathy for this problem, but let us debate the merits of folate fortification without the spurious resorting to medical scare tactics.
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Jun 10 09 9:39 am
So why do you insist that I be medicated for something I neither want nor need at my own expense. Pay for it yourself MD, and provide supplements to those most in need.
And what of those who gorge on breads and exceed the recommended maximum, surely you will now need a complex system to physically prevent people from eating thusly, perhaps a registration system for each slice. How can the studies separate the effects of supplementation from other changes ? And all this is predicted to prevent, what is it, 1 birth defect per year…
Jun 10 09 10:47 am
The answer, of course, is that women should plan their family and be educated enough to know to take Folic Acid before conception. I have no objection to folate in my bread per se, but once again it is the blunderbus approach of compelling the masses to do something for the benefit of the few who won’t accept responsibility for their own lives.
I don’t make the world, I just live in it. Although you are right, philosophically, the simple fact is that the vast majority of women (like the vast majority of men) are not that organised. Unfortunately, education programs are nowhere near as effective as fortification.
Jun 10 09 10:47 am
Ed:
I don’t know where they get the figure of 1-5 birth defects a year from. The Canadian and US literature puts it at a minimum 25% reduction and as high as 60% in areas of high defect rate. New Zealand has a rate of 25 neural tube defects a year, but that does not include the neural tube defects picked up on amniocentesis and terminated, which would at least double that figure. That means between 15 and 30 NTD prevented annually.
To get that level of prevention, women would have to be taking folate throughout the first trimester of pregnancy. Given that a woman won’t know she is pregnant until about six weeks, and often not until several months, the only way to ensure adequate folate supplementation in that first trimester is to supplement all women of child-bearing age. Hence fortification of flour.
The cost of this to you is about 5c a loaf. And folate supplementation has a number of additional positive benefits, including reduction in the rate of dementia and, possibly, reduction in heart disease. Apart from a few small children, exceeding the maximum recommended dosage (which is a guess anyway – there is no evidence folate is toxic beyond that dose) is extremely difficult. An adult would have to eat an entire loaf a day. I submit to you that someone who eats an entire loaf of bread a day probably has bigger issues in his/her life than a bit of extra folate.
Jun 10 09 11:06 am
So how many slices of bread a day is a therapeutic dose for a pregnant woman?
And what about all those women who have themselves on a low-carb diet? Would they need to supplement anyway?
For all sorts of reasons I say NO to mass medication.
Jun 11 09 3:04 pm
This would be a terribly blunt instrument, and highly ineffective.
During the first trimester many women have upset appetites and find it difficult to eat some foods – so in this situation not only may the pregnant woman’s intake of folate during the first trimester be actually LOWER than during the rest of her life (if her appetite is reduced), it may be virtually nil if she is living on complan and fruit (or whatever other wacky diet the pregnant mind thinks up).
We would be wasting tonnes of folate to try and treat a few women, who may not be being medicated by it at all. You may as well try and shoot a flea with a shotgun.
Stick with pills, subsidise them if you really want to get socialist about it, but don’t force us all to eat something we don’t need.
Here’s a more effective socialist scheme: Take the cost of ’5c a loaf’, multiply that by how many loaves we buy, and you’d probably have more than enough cash to give every woman 20 years supply of folate pills upon leaving high school. Problem solved far more simply and cheaply.
[rq=1260,0,blog][/rq]I am a right moderate social libertarian, apparantly
Jun 11 09 4:46 pm
Mr Dennis: This would be a terribly blunt instrument, and highly ineffective.
Actually, the Canadian and American experience is that it has been highly effective – much more so than a strong advertising drive to get all pregnant women to take their folate. Frankly, my first thoughts about this matter were like yours, but the facts are the facts…
Stick with pills, subsidise them if you really want to get socialist about it,
Too late – folate is already subsidised. The socialists beat you to it!
Jun 11 09 5:14 pm
“folate is already subsidised”
Can’t be publicised well enough then, I had no idea, as far as I knew it’s just on the supplement jar racks in the supermarket or pharmacy along with everything else, and similarly priced.
Folic acid is taken by women to make a very rare disease even rarer. Although it is important to try and combat this just as we should combat every disease, I still suspect that the enormous waste of resources involved in mass medication could probably be used to achieve greater results if targeted on another health problem.
I just cannot see how such a wasteful policy could be the right thing to do – quite apart from the moral issues with mass medication.
To quote Henry Hazlitt: “The art of economics consists … in tracing the consequences of that policy not merely for one group but for all groups”. It is easy to look at this and say it might prevent some birth defects, which may well be true, but that does not necessarily mean it is a good policy. How much cash are we talking about? And how many other health problems could be solved with that cash? That’s what no-one ever seems to consider.
[rq=1467,0,blog][/rq]Mrs Dennis is a right social moderate