Pernicious anemia

Both the United Kingdom and the United States have planned programs of folic acid fortification of staple foods in an effort to ensure that women of childbearing age receive enough of this vitamin to minimize the occurrence of neural tube defects. Concerns have been expressed, however, about the possibility that individuals with vitamin [B.sub.12] deficiency might consume enough of the fortified foods to mask the anemia associated with this deficiency, leading to delayed diagnosis and the possibility of permanent neurologic damage.

In a commentary published in The Lancet, Nicholas J Wald and Carol Bower of the Wolfson Institute of Preventive Medicine at St Bartholomew's Hospital, London, contend that this concern is misplaced. They state, "We believe that it is a mistake to regard this effect--the correction of the blood abnormality in pernicious anaemia by folic acid--as a masking of the disease or as a toxic effect of the vitamin. Currently about 12% of patients with pernicious anaemia present with neuropathy alone. An increase in dietary folic acid might increase this percentage while reducing the proportion of patients presenting with anaemia....It is not necessary to 'preserve' the anaemia to achieve an earlier diagnosis. Moreover, it is unreasonable to encourage extra haematological morbidity to help make the diagnosis, which in any case should be based on assessment of [B.sub.12] status."

Concerns about the possibility of masking the anemia of vitamin [B.sub.12] deficiency have prompted authorities to recommend relatively low levels of folic acid fortification--levels which may not be adequate to provide all women of childbearing potential with sufficient folic acid. The authors criticize this decision, stating, "Concern over the presence or absence of an accompanying macrocytosis or anaemia [in patients with neurologic symptoms attributable to vitamin [B.sub.12] deficiency] is misplaced; and, to the extent that this might limit public health measures designed to prevent neural tube defects, it represents an error of judgment. The haematological effect of folic acid in pernicious anaemia should not be used as a reason for failure to implement adequate folic acid fortification for prevention of neural tube defects." Nicholas J Wald and Carol Bower, Folic Acid, Pernicious Anaemia, and Prevention of Neural Tube Defects [Commentary], Lancet 343(8893):307 (5 Feb 1994)

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