Folate fortification: enough already?

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Abstract
The Food and Drug Administration mandated the folate fortification of grain products in the United States by January 1998. The primary driving force behind this policy was the recognition that periconceptional folate supplementation in addition to normal dietary folate intake significantly reduced the incidence of neural tube defects (NTDs), one of the most common birth defects (1, 2). Food fortification rather than supplementation in planning pregnancies was deemed necessary because of a perceived failure of public health efforts to influence those persons most at risk and because the neural tube closes during the fourth week of gestation, a time when many women are unaware of their pregnancy. Because of concerns that folate fortification may mask symptoms of vitamin B-12 deficiency, primarily in the elderly population, the level of fortification chosen was estimated to provide on average 100 μg additional folic acid daily with only a very small proportion of the population receiving >1 mg. The upper limit of 1 mg was a round number chosen by the Institute of Medicine (IOM) (3) as unlikely to produce masking, although the folate intake that produces masking is controversial, with some arguing that intakes <1 mg may cause this effect.