While it is important that women take folic acid daily, I have a number of concerns about fortifying oral contraceptive pills (OCPs) with folic acid. What happens when the woman stops taking OCPs? A behavior change will need to occur. Since folic acid is a water-soluble vitamin and daily consumption is necessary to achieve adequate levels, women who formerly obtained their folic acid in OCPs would need to obtain sufficient levels of folic acid consumption from other sources. Since we know diet alone is not adequate to achieve this (Centers for Disease Control and Prevention [CDC], 2004), women would need to immediately establish a new behavior of taking a multivitamin supplement containing 0.4 mg of folic acid each day. The timing of folic acid intake is crucial since the fetal brain and spine develop during the first few weeks of pregnancy. If a woman waits until she knows she is pregnant to begin taking folic acid, the window of opportunity to prevent neural tube defects (NTDs) such as spina bifida and anencephaly has closed. Will women who are getting their folic acid from their OCPs understand that as soon as they stop the OCPs they need to take a multivitamin daily?
Additionally, fortification of OCPs would not benefit a significant number of women who elect to use other forms of birth control. Some women may choose to abstain from sexual activity prior to marriage, seek to start a family shortly thereafter, and never have a need for birth control methods of any type. Other women may view hormonal birth control methods as being in direct conflict with their religious and moral views. Additional strategies would be needed to encourage these groups of women to consume daily folic acid.
The health benefits of daily synthetic folic acid consumption reach far beyond the prevention of NTDs. Recent efforts around folic acid education have begun to include the benefits this vitamin has in terms of cardiovascular health and cancer prevention. By linking folic acid supplementation to OCPs, the message that folic acid is good for general health could be diluted, and the focus would continue to be limited to pregnancy outcomes. By broadening the scope of the message we can broaden the appeal and hopefully increase the number of women who take folic acid to improve their health, regardless of pregnancy intention.
Over the last decade there has been a substantial increase in folic acid awareness and in the understanding of the role this B vitamin plays in the prevention of NTDs and other health-related conditions among the general public. In surveys conducted by the March of Dimes and other groups, more women indicate an awareness of folic acid and its benefits, but the number of women actually taking steps to consume sufficient folic acid remains low (CDC, 2004). Fortification of foods with folic acid has been one strategy used to help women increase their folic acid consumption. However, even with fortification, many women do not consume adequate amounts of the vitamin. Fortification is passive in nature and requires little effort or change in behavior.
Instead of focusing on fortification of OCPs with folic acid, our time and money might be better spent working to increase fortification levels in foods. At the current fortification levels women are still not consuming enough folic acid through dietary sources. Many inroads have been made in terms of fortification of breads, pastas, and cereals, but a wide range of levels exists. In looking at popular breakfast cereals, several are reaching the 100% daily value of folic acid in a single serving. Others are still only achieving the 25% mark. One wonders what the impact on daily folic acid consumption would be if all cereals and cereal products, such as bars and cereal-based snack foods, were brought in line to the 100% daily value of folic acid per serving.
If the fortification net was cast more broadly than just adding folic acid to OCPs, the benefits of folic acid consumption would reach more individuals. This is important, because all segments of the population would benefit from greater folic acid consumption through passive methods. Folic acid fortification of OCPs is but one avenue, and may not be the best one. Other approaches deserve consideration.