What are the wider implications of the new reports? The im-
mediate concern relates predominantly to older persons. Morris
et al found that 4% of the elderly persons they studied had a
combination of low vitamin B-12 status and high folate status. If
the same proportion of all elderly persons in the United States is
affected, then 1.8 million elderly might be at increased risk of
cognitive impairment and anemia because of an imbalance be-
tween folate and vitamin B-12. Thus, this large number of elderly
at increased risk of cognitive impairment and anemia has to be
balanced against the number of infants in whom NTDs are being
prevented. Simply put, is it ethical to save one infant from de-
veloping an NTD and hopefully provide that child a high-quality
life but increase the risk of poorer health in 1000 elderly per-
sons? Questions that surely need to be discussed include the
following:
1) Should those calling for the addition of extra folic acid to
food in the United States to further to reduce the number of
infants with NTDs be required to show beyond reasonable
doubt that such a step will not cause harm to others?
2) Should the issue of fortifying food with vitamin B-12 be
reopened in those countries that have already fortified certain
foods with folic acid? An expert group has already recom-
mended vitamin B-12 fortification in the Americas (21).
3) Should countries considering folic acid fortification defer
a decision until more is known about the interaction be-
tween folate and vitamin B-12 status? This question is
particularly pertinent for the many countries that have a
high prevalence of poor vitamin B-12 status (22, 23).
4) Are sectors of the population, eg, vegetarians (24), preg-
nant and lactating women, infants, and ethnic groups with
a poor vitamin B-12 status, being harmed by the existing
level of folic acid fortification and supplement use?
5) Is it of concern that, after folic acid fortification, children
aged 5 y have the highest mean serum folate concentra-
tions in the US population? Many (43%) of these children
have concentrations 45 nmol/L (25).
6) Should countries in South Asia, which have a high preva-
lence of NTDs (26), reconsider the need for folic acid
fortification (27), especially in view of their high prev-
alence of vitamin B-12 deficiency (28), which itself
might be one of the causes of NTDs (29)?
7) Should supplements containing folic acid be combined
with high doses of vitamin