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Probable Benefits of Increasing Folic Acid Intakes

Carol J. Boushey, PhD, MPH, RD; Shirley A. A. Beresford, PhD; Gilbert S. Omenn, MD, PhD; Arno G. Motulsky, MD

JAMA. 1995;274(13):1049-1057.

Abstract
Objective.
—To determine the risk of elevated total homocysteine (tHcy) levels for arteriosclerotic vascular disease, estimate the reduction of tHcy by folic acid, and calculate the potential reduction of coronary artery disease (CAD) mortality by increasing folic acid intake.

Data Sources.
—MEDLINE search for meta-analysis of 27 studies relating homocysteine to arteriosclerotic vascular disease and 11 studies of folic acid effects on tHcy levels.

Study Selection and Data Extraction.
—Studies dealing with CAD, cerebrovascular disease, and peripheral arterial vascular disease were selected. Three prospective and six population-based case-control studies were considered of high quality. Five cross-sectional and 13 other case-control studies were also included. Causality of tHcy's role in the pathogenesis of vascular disease was inferred because of consistency across studies by different investigators using different methods in different populations.

Data Synthesis.
—Elevations in tHcy were considered an independent graded risk factor for arteriosclerotic vascular diseases. The odds ratio (OR) for CAD of a 5-µmol/L tHcy increment is 1.6(95% confidence interval [Cl], 1.4 to 1.7) for men and 1.8 (95% Cl, 1.3 to 1.9) for women. A total of 10% of the population's CAD risk appears attributable to tHcy. The OR for cerebrovascular disease (5-µmol/L tHcy increment) is 1.5 (95% Cl, 1.3 to 1.9). Peripheral arterial disease also showed a strong association. Increased folic acid intake (approximately 200 µg/d) reduces tHcy levels by approximately 4 µmol/L. Assuming that lower tHcy levels decrease CAD mortality, we calculated the effect of (1) increased dietary folate, (2) supplementation by tablets, and (3) grain fortification. Under different assumptions, 13 500 to 50 000 CAD deaths annually could be avoided; fortification of food had the largest impact.

Conclusions.
—A 5-µmol/L tHcy increment elevates CAD risk by as much as cholesterol increases of 0.5 mmol/L (20 mg/dL). Higher folic acid intake by reducing tHcy levels promises to prevent arteriosclerotic vascular disease. Clinical trials are urgently needed. Concerns about masking cobalamin deficiency by folic acid could be lessened by adding 1 mg of cobalamin to folic acid supplements.

(JAMA. 1995;274:1049-1057)

Author Affiliations
From the Northwest Prevention Effectiveness Center (Drs Boushey, Beresford, Omenn, and Motulsky), the Nutritional Sciences Program (Drs Boushey and Beresford), and the Departments of Epidemiology (Drs Boushey and Beresford), Environmental Health (Dr Omenn), Medicine (Drs Omenn and Motulsky), and Genetics (Dr Motulsky), University of Washington, Seattle.

Footnotes
Reprint requests to Department of Epidemiology, University of Washington, Box 357236, Seattle, WA 98195-7236 (Dr Beresford).

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