If your patients are not yet familiar with folate, they should be. Recent studies have tied this B vitamin - which appears as 'folic acid' when added to fortified foods and supplements - to a reduced risk of cardiovascular disease, including stroke. A study reported in a recent issue of the journal Stroke adds to what scientists know about this relationship.

The study

Tulane University researchers determined the usual folate intake of more than 9,000 adult participants of the first National Health and Nutrition Examination Survey (NHANES I), which was conducted from 1971 to 1975. They then tracked the participants for the next 19 years; outcomes of interest were the incidences of stroke and cardiovascular disease.

Data analyses showed an inverse relationship between serum folate status and risk of both stroke and cardiovascular disease. Participants who consumed more than 300 µg per day (75% of the current US intake recommendation) were 20% less likely than those who consumed less than 136 µg per day to suffer from stroke (RR=0.80, 95% CI 0.64, 0.99), and 13% less likely to suffer from cardiovascular disease (RR=0.87, 95% CI 0.79, 0.96).

What's the connection?

This study continues to develop our understanding of the relationship between serum folate levels and cardiovascular disease, a link that appears to be sequential. Low serum folate levels are associated with high levels of homocysteine, a by-product of protein metabolism. Elevated homocysteine, in turn, is associated with the increased risk of cardiovascular disease. How this might work is still unclear, but scientists speculate that homocysteine may facilitate the proliferation of endothelial cells and increase the effect of oxidative stress within vascular walls - both steps in the development of atherosclerosis. And, of course, atherosclerosis increases the risk of stroke.

Advice to patients

The authors of this study point out that a making a diet 'heart-healthy' takes more than just the addition of extra folate. The people in this study who consumed the most folate tended to have lower blood pressure and lower cholesterol levels. They were also less likely than others in the study to be overweight and more likely to get regular exercise - all factors that helped them stay healthy as they got older.

But while a folate-rich diet is only one part of the solution, it's a fairly easy one to implement. US-produced grain foods - bread, cereal, rice, and pasta - are now fortified with folic acid. Health officials estimate that this step has added an average of 95 µg of folic acid to the diets of middle-aged and older adults, which, according to the results of this study, may be enough to lower their risk of stroke by 12% over the next twenty years.

Where to get folate

Fortified breakfast cereals are a fast way to boost folic acid intake. Advise your patients to choose one that provides the recommended daily intake of 400 µg. Your patients can also plan meals to include some foods that are naturally good sources of folate, including green leafy vegetables, orange juice, beans, and wheat germ. If you believe that their diets still come up short, you may want to advise them to take a multivitamin to help close the gap.