Supplements – certainly!

A previous editorial emphasized that a balanced and broad fortification of food with micronutrients is superior to a chaotic commercial supplementation in healthy populations (1). However, fortification is insufficient for women aged 15-45 and for elderly people. Such individuals need supplementation with cobalamin (vitamin B12) and folate (vitamin B9). Doses and strategies are subject to an intense scientific debate (2-8). Other supplements lack at present modern documentation (cf 9).

During the last decade, folate has been launched as potent depressor of plasma homocysteine and healer of hurt neurons (2, 3). There have also been warnings that overdoses of folate, corresponding to folic acid 5 mg a day or more, might trigger isolated cases of arousal, overactivity, sleeplessness, hypomania (2). Such reports are difficult to evaluate. As an old clinician, I am inclined to suspect that mood changes during folate therapy are akin to the euphoria seen in B12-deficient patients treated with cobalamin.

In the methionine cycle, folate and cobalamin are joined by a series connection as substrate and coenzyme (10). Thus, it is reasonable to preserve the medical tradition always to give cobalamin during folate therapy. Conversely, time now is ripe for always giving folate during cobalamin therapy; an incipient folate deficiency may block the effect of cobalamin on patients with deficiency of vitamin B12 (11). Folate addition is cheap, about 0.02 US dollars a day in Sweden.

The role of folate in the function of the nervous system may have been under-estimated previously (2). The corresponding role of cobalamin is generally acknowledged (2-8, 10). The majority of general practitioners in Sweden know that it is an error of the art to prescribe folate without sumultanous cobalamin therapy. However, it is an ill omen that this insight decreased significantly from 1996 to 1998 (12). It is essential to keep sound practice going.

Fertile women and elderly persons need supplementation with cobalamin and folate (2-8). Other micronutrient supplements are at best harmless, provided that doses are reasonable low (1, 9, 10, 13). Except for cobalamin and folate, fortifications appear promising. The scouring of the supplement market by UN and EU (Codex Alimentarius) is encouraging.

Bo Norberg

1. Norberg B. Fortification, supplementation, and medication [editorial]! Rondel 2002; 11. URL: http://www.rondellen.net publisher11_eng.htm
2. Reynolds EH. Benefits and risks of folic acid to the nervous system. J Neurol Neurosurg Psychiatry 2002; 72:567-71
3. Reynolds EH. Folic acid, ageing, depression, and dementia. BMJ 2002; 324:1512-5
4. Rajan S, Wallace JI, Beresford SAA, Brodkin KI, Allen RA, Stabler SP. Screening for cobalamin deficiency in geriatric outpatients: Prevalence and influence of synthetic cobalamin intake. J Am Ger Soc 2002; 50:624-30
5. Duthie SJ, Whalley LJ, Collins AR, Leaper S,Berger K, Eeary JJ. Homocysteine, B vitamin status, and cognitive function in the elderly. Am J Clin Nutr 2002; 75:908-13
6. Smith AD. Homocysteine, B vitamins, and cognitive deficit in the elderly. Am J Clin Nutr 2002; 75:785-6
7. McCaddon A, Regland B, Hudson P, Davies G. Functional vitamin B12 deficiency and Alzheimer disease. Neurol 2002; 58:1395-9
8. Auer J, Berent R, Eber B, Homocysteine and dementia. N Engl J Med 2002; 346:2007-8
9. Heart Protection Study Collaborative Group. MRC/BHF heart protection study of antioxidant vitamin supplementation in 20536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360:23-33
10. Hultdin J. Down syndrome – should we increase homocysteine [debate]? Rondel 2001; 9. URL: http://www.rondellen.net debate09_eng.htm
11. Kuzminski AM, Del Giacco EJ, Allen RH, Stabler SP, Lindenbaum J. Effective treatment of cobalamin deficiency with oral cobalamin. Blood 1998; 92:1191-8
12. Nilsson M. Error of the art [debate]. Rondel 2002; 11. URL: http://www.rondellen.net debate11_eng.htm
13. Hägglöf M. Superstition in supplementation [culture]! Rondel 2002; 11. URL: http://www.rondellen.net culture_eng.htm

Published October 6, 2002