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New Outlook on Folic Acid

St. Elizabeth Hospital

Nutrition & Fitness Talk

June 19, 1997

The American public was told to lower their fat intake, and hence this would lower their cholesterol, and it did. We are also told that this would reduce cardiovascular disease and it seemingly did that too, up to now. We were told to eat more complex carbohydrates for better health, and we did that also. Through the eating of complex carbohydrates, we were told, the overall health of the American public would increase because weight would come down and correspondingly, blood pressure, too.

However, something is not right; something's not working correctly; or, as we were led to believe. The American public is getting fatter on the low-fat, complex carbohydrate diet.

We are also seeing a corresponding increase in blood pressure from the weight gain. And I suspect, other problems are beginning or will surface in the not too distant future. Now just think about this: The consumer equates low fat or no fat with low calorie, and this just simply is not the case. Therefore, as the fat goes down in food products, what ingredient is most often increased--the sugar is increased, along with other things, oftentimes food starch, and you will find that you are getting fatter from this new diet.

We now see people with lower cholesterols to low cholesterol--anywhere below 200 to even 128 mg/dl. However, we are now seeing something else too, which I will address now. I will address the complex carbohydrate diet later if time permits.

Homocysteine

Let us consider a specific case in point. I had a client who ate a relatively balanced diet. His weight was within normal range for his height. He exercised regularly, had cholesterol below 200, and suffered no great stress in life. He was happily married, had a kid or two, and financial security. He also didn't smoke, but he did eat plenty of fish, or chicken.

Yet, one day he suffered from chest pains and found himself with bypass surgery to his heart. His doctor was perplexed. He was sent to a dietitian for diet analysis. The only thing his medical team could come up with was, It was just one of those things. The only finding was that he loved French pressed coffee and drank lots of it. This was not considered really bad in itself. He was told to cut down some.

However, all this did not please him, so he sought out a number of nutritionists as well as psychics. He was told a lot of stuff by the psychics.

He finally landed with me. I told him he'd best forget the psychic stuff. I didn't have much to work on except that I had a suspicion. I related it to him and he was tested for homocysteine in his blood. It was very high. I corrected his diet and made another suggestion or two relating to homocysteine and his homocysteine is now down to within normal levels.

What is homocysteine and how do you get it?

Homocysteine is an amino acid that naturally occurs in the body from the metabolism of methionine. That is, when methionine breaks down, homocysteine is formed. Even though you eat a low-fat, little to no red meat, moderate to high complex carbohydrate diet, you still form homocysteine. Methionine is found in protein foods such as beef, fish, chicken, and in other foods such as in beans and rice.

What homocysteine does.

Aside from certain biochemical things it by necessity does in the human organism, it also can pile up and damage blood vessels, causing atherosclerosis in the same way that high cholesterol may. When this occurs, then a cascade reaction occurs to heal the inside of the artery or capillary, and this can, and often does, narrow or occlude the artery from its patency or openness. When arteries narrow, you have the same end result that high cholesterol can doşcause a stroke, or a cardiovascular accident, such as a heart attack.

Folic Acid/Folacin/Folates.

The problems that are beginning to surface are that we eat by Choice, Ethnic Background, and Food Intolerance. Any of these things, and they often do, can alter our perception of the now current Pyramid Food Group.

A group of substances found in the foliage of certain plants have been given a generic name of Folacin or Folates, of which one of the number is Folic Acid. When we speak of Folacin, or Folates, we generally are referring to Folic Acid. This B-complex vitamin is found primarily in dark green leafy vegetables and heart. Next, it is found in green leafy vegetables and kidney; then, in lesser amounts in beef, chicken, grains and cereals, and some canned goods. The FDA mandates by January 1, 1998, that 400 mcg. be in all cereals and in a number of other food stuffs.

As you can readily see, however, many people don't eat heart and kidney. In fact, the new Pyramid Group places these items in the third and possibly "eat sparingly" levels. But it does say to eat 3-5 servings of the vegetable group, of which it is easy to eat more from the potatoes, lettuce and tomatoes there than the necessary servings of dark leafy green vegetables.

Also, the cereal group will command more bread, rice and pasta, which, as you have just seen, are not considered the highest means of getting Folic Acid.

This, therefore, is one of the reasons the government is mandating Folic Acid enrichment for these food stuffs. It was found that the American people will eat at least one serving or bowl of cereal every day compared to the other mandated foods too.

These are also, which you probably don't know, the reasons many physician researchers, nutritionists, and others are grumbling against the Pyramid Diet. In fact, there was similar grumbling before the diet came out and attempts to stop it in the form you now see. Actually, the present form went through some changes also, I understand, before its finality because of these and similar grumblings: " It is possible to eat from this group and still not get what you need."

Nevertheless, it is here and we are to make the best use of it. Hence, we will see changes and modifications and/or enrichment programs to our food stuffs as we discover more about the relationship between diet and disease, especially as food gets scarce in 1998.

Folic acid, along with Vitamin B-12 and pyridoxine (B-6), mainly, Folic Acid, are used in an enzyme system to keep homocysteine from accumulating into toxic levels that cause damage to the endothelium or lining of the arteries or capillaries.

However, if your lifestyle includes less than 3-5 servings of dark green vegetables or less than 2-4 servings of fruit a day; or you can't tolerate these types of foods because of dislike or food intolerances; and you smoke cigarettes, then you have increased your risk of homocysteine buildup in the blood. Then your other option is to take Folic Acid supplements which are readily available and considered safe.

Many people's lifestyles include cigarettes and coffee. Well... the coffee that is not filtered, as in the French Press method, retains most of its oils in the brewed coffee that increase the cholesterol in the blood stream. But coffee, as generally found in the American percolation filter or filter method, has most of its oils filtered out such that this type of coffee adds little to the cholesterol fraction in the blood stream.

However, both types of coffee (filtered or the French Press method) add to homocysteine build up in the blood. Incidently, decaff coffee adds little or none to the blood build-up of homocysteine. There appears to be a mechanism centering around the caffeine in the coffee, but not in tea. There was no build up of homocysteine associated with tea. This data was discovered by Norwegian researchers at the University of Bergen through Ottar Nygård and his colleagues.

According to Boston University's School of Public Health in Brookline, Mass., epidemiologist, Julie R. Palmer, in a study she published two years ago, the heart attack risk climbed in 1,700 women, mostly postmenopausal, who downed 10 cups of coffee or more per day. They increased their risk to suffer heart attack by 2.5 compared to those averaging less than one cup.

Meir J. Stampfer, also an epidemiologist, at the Harvard School of Public Health in Boston, along with others, points to the fact that homocysteine is known to be a potent cardiovascular risk factor.

However, these new results should not condemn coffee in the U.S. The Norwegian results for coffee drinkers were not seen for their counterparts in America. The reason given by the Norwegian scientist, Nygård, is probably that American coffee drinkers eat enough folate and B vitamins in their diet to offset their coffee drinking, whereas Scandinavians do not.

The relationship is not clear yet. Because if this were so, then the FDA mandate to have Folic Acid supplementation in foods would not seem to be necessary. But, the solution may just be a vitamin pill away, Nygård suggests.

However, according to Dr. Claude Lenfant, Director of the National Heart, Lung, and Blood Institute, there is no question that high homocysteine levels are a risk factor for heart disease. But lowering homocysteine levels to protect against heart disease necessitates clinical trials.

Until such time, he does not advise Folic Acid supplements, but advises to eat lots of fruits and vegetables containing Folic Acid. He does suggest that the clinical trial will probably not be forthcoming because the trials would cost millions of dollars and take years to complete. And the Institute's budget would probably not allow this. However, private industry has not stepped forward as it did in the case of cholesterol-şlowering drugs.

The reason is M-O-N-E-Y. It's a Catch 22 situation.

Private industry is worried about heart disease, and is looking at blood pressure and lipids in regard to this. But we now know we have another risk factorşhomocysteine. And there's not much commercial interest in this. The reason is, something as simple as Folic Acid that can lower high homocysteine levels is so cheap, and it's not like medicines for treating high cholesterol and high blood pressure that bring in big dollars.

Consequently, industry is simply not interested in researching a vitamin, Folic Acid, and homocysteine, because it can't be patented, and they can't make money on it. But what YOU can do is take a Folic Acid supplement, or vitamins and minerals that have at least 400 micrograms a day of Folic Acid, in addition to eating plenty of fruits and vegetables.

However, as I've said earlier, we eat by Choice, Ethnic Background, and Food Intolerances. If any of these foods that supply Folic Acid in large amounts don't fall under these criteria, then we'll eat it.

I recommend no less than several milligrams a day, up to 45 to 65 milligrams a day if you have gouty arthritis. But there's a difficulty with this, and I'll explain this shortly.

Nonetheless, blood build-up of homocysteine will in the immediate future be added to obesity, cholesterol, and smoking as risk factors for heart attacks, say researchers from the University of Utah School of Medicine in Salt Lake City.

Allergy to Folate Supplementation:

Just a few minutes ago, I just said Folic Acid supplements are readily available and considered safe. However, some in this audience may be confused over the information in July of 1995, that Folic Acid supplementation may be a risk factor for an allergenic response. Let's clear this up now.

To insure that women of childbearing age receive enough folateşa B vitamin required to head off potentially debilitating fetal defectsşthe Food and Drug Administration has announced that it will require U.S. food manufacturers to fortify most grain-based products with a synthetic form of the vitamin. This decision came on the heels of a British study that dietary supplementation may be the only way to guarantee that women receive enough folate.

We know that every year, some 2,500 babies born in the United States begin their lives with the burden of spina bifida or anencephaly (being born without a brain). This taxes the health care system and taxpayers tremendously with millions of dollars of medical care over the lifetime of these infants, 90 percent of whom survive to adulthood.

We also know the chilling facts that mothers who take in an adequate amount of Folic Acid in the first days of their pregnancy, as many as half of these pregnancies each year can be spared neural tube deficits or complications. Yet, however, over half of all pregnancies are unplanned, and because these defects occur in the developing fetus within the first few days of pregnancy, before most women know they are pregnant, vitamin supplements would be too late to address the problem.

Think about that: over half the women in American who are pregnant right now did not plan it. We are talking about women in the entire range of their childbearing years. Most women 19 to 50 get only 0.2 mg of Folic Acid each day, according to Department Agriculture estimates. This is roughly half the amount the government currently recommends.

And since the government knows it would be unlikely that the entire target population would develop the habit of taking vitamin supplements throughout their childbearing years, then the need for fortification of food stuffs.

Also, because processing and cooking destroys Folic Acid, it is the most commonly deficient vitamin in U. S. diets, according to researcher Paul N. Hopkins of the University of Utah School of Medicine in Salt Lake City.

Before 1989, the Food and Nutrition Board of the National Academy of Sciences recommended that each adult get 400 mcgs. of Folic Acid per day. But, in 1989, the board cut that amount in half. Other researchers have found that homocysteine, our newşold friend spoken about earlier, increases when people drop below 400 mcg of Folic Acid per day, Hopkins said.

The foods required to be enriched by the January 1, 1998, mandate are enriched bread, rolls, and buns; all enriched flour, including bromated and self-rising flours; enriched corn grits and corn meals; enriched farina and rice; and all enriched macaroni and noodle products including vegetable macaroni, vegetable noodles, and non-fat milk and macaroni products. In addition, breakfast cereals can add Folic Acid up to the 400 mcgs. per serving.

These amounts are designed to keep daily intake of folic acid below 1 mg, because intakes above that amount may mask symptoms of pernicious anemia in persons who don't absorb vitamin B-12 efficiently. It may well mask megaloblastic anemia in pregnant women as well. Pernicious anemia can lead to severe permanent nerve damage.

The main reason cereals are targeted so strongly is that nearly 90 percent of the population eats a cereal grain product at least once a day, and according to the American Institute of Baking, cereal grains account for about 26 percent of the total calorie daily consumption. Neither of the other food products considered for Folic Acid fortification--dairy foods and juices--approaches this level of consumption.

Already, the food industry is having problems with fortifying the foods with Folic Acid. Pasta makers sought a delay in the implementation of Folic Acid fortification, saying that millions of dollars in inventory would be lost.

The FDA denied the request. There are also problems in the baking industry with fortification. Namely, the problems begin in the finished product, in assuring that the level of Folic Acid on the ingredient statement is what they say it is. The current tests are not adequate to the task of accurately measuring Folic Acid. The newer tri-enzyme test is, but it is also more expensive and will add to the cost of the finish product, it appears.

Now, with this background, let us see why some scientists are concerned about government mandates for foods we have just named.

Mark S. Dykewicz of the St. Louis (Mo.) University School of Medicine reported in March of 1996, at the New Orleans American Academy of Allergy, Asthma, and Immunology meeting that using synthetic folate, or Folic Acid to fortify foods and vitamin supplements can provoke an allergic response.

The FDA's mandate for the first of the coming year of 1998 is for excellent reasons, he says, but the change will make more people likely to develop a life-threatening allergic reaction. And until this change is exacted, the Public Health Service of the U.S. recommends that women obtain the vitamin through dietary supplements or foods naturally rich in folate, especially dark green, leafy vegetables, citrus fruits and juices, and lentils.

Women, however, may find it all but impossible to derive what they need from such natural sources, according to a 3-month-long study in 1996.

Geraldine J. Cuskelly at the University of Ulster in Northern Ireland and her co-workers randomly assigned women to take daily supplements containing:

0.4 mg of Folic Acid

To eat foods fortified with the same amount of the synthetic vitamin; or,

To eat foods naturally containing 0.4 mg more folate than the average diet.

Among the 41 women who completed the trial, concentrations of the vitamin in the blood rose only in those who consumed the Folic Acid supplements, Cuskelly's team reported in the March 9 issue of the 1996 Lancet Medical Journal. The most reasonable explanation, they said, is the fact that the supplements were better absorbed than that found occurring naturally in foods.

Now, here's the difficult part: The subtle chemical differences between food-derived folate and synthetic Folic Acid may also explain why a woman who could eat folate-rich foods without problems nearly died from an injection of Folic Acid. There are also anecdotal reports of such allergies surfacing now and then. They were discounted, until now, because the vitamin molecule is too small to elicit an immune system response.

For Folic Acid to trigger an immune response, the body must first pump up Folic Acid's size by binding to proteins in the body. This was tested, and researchers found that the body developed antibodies to the Folic Acid combo. This was the first proof of antibodies to a vitamin.

However, this was only one person who ever had a real life-threatening reaction to Folic Acid, and it was an injected, astronomical dose of Folic Acid as part of cancer therapy, and thus may represent an anomaly unsuited for gauging the risks of vitamin quantities in fortified foods, according to Timothy J. Sullivan of the Emory University School of Medicine in Atlanta.

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