Could Folate Help Prevent A Broken Heart!

What can be more heart wrenching for the new parents of a baby born with a damaged heart than to find out that simple Folate supplements could perhaps have prevented this fatal condition from happening.

Congenital heart defects (CHD) are heart problems present at birth in the baby
This happens when the fetal heart does not develop the way it should during gestation.

In India, it is difficult to find detailed studies on folic acid status among Indians per se, but there are studies done on the prevalence of folate related anemia, which indicate that folic acid deficiency is rampant in the Indian population. In South India, up to 60% women, especially in the low socio economic group may be deficient in folate. The average daily intake of folate in the rural population of North and North East India may be as low as 75micrograms, which is less than 1/5th of the requirement of 400micrograms/day.

According to a Fortis Healthcare news bulletin, "The incidence of congenital heart disease (CHD) is 1 out of every 100 new born. Hardly 5% of cases of congenital heart diseases are treated in India and that makes it amongst the top five causes of child mortality in India". This of course is hospital-based data, which may not be reflective of the rural and small town (community) reality where many births occur at home. As mentioned, community based studies in India are scarce, but the few which have been done peg the prevalence of CHD at 2.5-5.2/1000 live births. At the All India Institute of Medical Sciences, Delhi, it is reported that neonatal CHD rates increased from 4% to 10% of all CHD cases seen in the out patient department from 1991 to 2004.

Fortification of grains with folic acid could be one way of increasing dietary intake of folate in Indians, especially among pregnant women.

RDA for folic acid (Recommended Dietary Allowance)    
Indian: Men and Women: 0.1 mg; Pregnancy: 0.3mg; Lactation: 0.15mg
US: Men and Women: 0.4mg; Pregnancy and lactation: 0.8 mg (<18yrs), 1mg (>18yrs)  

As seen here, the RDAs for Indian adults are way below those in the USA. Several experts in this field have been asking the RDAs for folic acid be revised upwards in order to prevent birth defects.

Fortification of grains and flours in India is still not mandatory. However, flour fortification is being done in India since 1998 on a voluntary basis at the State level in roller mills (but not in the small mills - the chakki shops from where a majority of Indians still buy there flour). Fortification is not easy on such a large scale unless it is done at the national level to really make a difference to the population at large.

Several studies are in progress to determine its impact on nutritional status and disease. It will be interesting to see the results.

What are the causes?
In 90% of the cases, the cause for CHD remains unknown. In the remaining cases, genetic disorders, maternal exposure to viruses (e.g. rubella) or medications, alcohol or cocaine during pregnancy, and uncontrolled gestational diabetes have been implicated in causing fetal heart defects.

Till date the role of nutritional deficiencies in causing CHD has remained uncertain. Folic acid deficiency has been reported to be higher among children with CHD (Rook et al, 1973), and may have a role to play in CHD.

The results of this Canadian epidemiological study, published this week in the British Journal of Nutrition, appear to support this hypothesis. In this study a positive association between fortification of flour and pasta products with folic acid and reduction in the occurrence of CHD at birth was observed.  

In Canada, fortification of flour and pasta products became mandatory in 1998.  This study was conducted in the Province of Quebec, Canada, to determine if fortification had any effect on incidence of CHD; analysis of data revealed that in the years preceding fortification the prevalence of severe heart defects was 1.64 cases per 1,000 births, but in the years following the change, rates fell to 1.47 per 1,000. The decrease in prevalence was calculated at about 6% every year after fortification.

While the role of folic acid in preventing neural tube defects at birth is well established, this study also indicates a role for folic acid in prevention of CHD.

Food Sources of Folic Acid
Folic acid is needed by the body to make healthy new cells. It is important that women get enough of it before and during pregnancy for a healthy outcome.
Fortified dry cereals, green, leafy vegetables, fruits, and dried beans are good sources of folate, the naturally occurring form of this vitamin. Folic acid is the synthetic form of the B vitamin and is found in supplements and in fortified products. Folic acid is more readily used by the body than folate. Egg yolk, though not very high in folate, has the maximum bioavailability of all foods that contain folate.

FOOD                                                        FOLATE CONTENT (microgram) (mcg)
Fortified dry cereal, 1 cup                          389-710 (varies)
Black Eyed peas (Lobia), boiled, 1cup      358
Lentils (Masoor dal), boiled, 1 cup             358
Chickpeas (Chhole), boiled, 1 cup             282
Kidney Beans, boiled, 1 cup                       230
Liver, chicken, 1 oz (30g)                           185
Turnip Greens, cooked, 1 cup                    170
Spinach, cooked, ½ cup                             131
Peas, green, frozen, cooked, ½ cup           47
Asparagus, cooked, ½ cup                         121
Fresh orange juice, 1 cup                            75
Broccoli, cooked, ½ cup                              52
Egg yolk, 1                                                  25
Banana, 1                                                    22

While there is work being done at the state and national level to combat the problem of vitamin deficiency, it is important that we as individuals take some responsibility as well for our health.

To all young women - eat a well balanced diet with plenty of fortified grains, fresh vegetables, fruits and dals; educate other women about the need for folic acid in the diet. If you are trying to get pregnant, talk to your doctor about taking a folic acid supplement. It is one of the cheapest ways of ensuring a healthy baby.

By, The Dietetic Team @ NutritionVista.com

if you are planning on getting pregnant soon or are currently pregnant, the NutritionVista team of dietitians can create customized menu plans that cover macro and micro nutrients in the recommended daily amounts.

References:
1. Ionescu-Ittu R, Marelli AJ, Mackie AS, Pilote L:  Prevalence of severe congenital heart disease after folic acid fortification of grain products: time trend analysis in Quebec, Canada. MJ 2009;338:b1673
2. Saxena, A: Congenital Heart Disease in India: A Status Report. Indian J Pediatr 2005; 72(7): 595
3. Fortis Health: http://www.fortishealthcare.com/visitor_patients/pedriatric_cardiac_care_india.html
4. Technical Consultation on Prevention of Folic Acid Deficiency
and Strategies to Alleviate the Consequences August 04, 2006: http://www.sph.emory.edu/wheatflour/COUNTRYDATA/MI_Proceedings-_India_Folate_meeting_08.04.06.pdf
5. G D Rook, R Lopez, N Shimizu, and J M Cooperman: Folic acid deficiency in infants and children with heart disease. Br Heart J. 1973 January; 35(1): 87-92