Consultation on Fortifying Flour With Folic Acid 

Siobhan Harris

October 23, 2018

The Government plans to consult on the mandatory fortification of flour with folic acid in a move to reduce birth defects.

The consultation will start early next year and will look at the evidence around folic acid fortification as well as its practicality and safety.

It follows a lengthy campaign by doctors, health charities, and scientists, who believe fortifying flour with folic acid would reduce the incidence of neural tube defect conditions such as spina bifida and anencephaly.

The proposal is supported by the UK Chief Medical Officers and the Scientific Advisory Committee on Nutrition.

Announcing the consultation, the Public Health Minister Steve Brine said: "We have been listening closely to experts, health charities and medical professionals and we have agreed that now is the right time to explore whether fortification in flour is the right approach for the UK. My priority is to make sure that if introduced, we are certain it is safe and beneficial for all."

Chief Medical Officer for England Professor Dame Sally Davies said: "The evidence shows that fortifying flour with folic acid is a practical way of reducing folate deficiencies in pregnant women and reducing birth defects.

"However, as with any intervention of this kind, we need to be certain it is also safe, and that means considering what the wider implications would be for the rest of the population who eat flour."

Current Guidelines

At the moment NHS guidelines recommend folic acid supplements should be taken by pregnant women and those trying to conceive.

Women are urged to take a daily supplement of 400 micrograms whilst trying to become pregnant, and to continue until the 12th week of pregnancy.

If a woman is at a higher risk of having a pregnancy affected by a neural tube defect she is advised to take 5 milligrams of folic acid daily whilst trying to become pregnant, and to continue until the 12th week of pregnancy. Women with sickle cell disease, thalassaemia, or thalassaemia trait, are advised to take 5mg folic acid throughout pregnancy.

More than 80 countries around the world already fortify wheat flour with folic acid to improve the 'folate status' of the population and to reduce the risk of neural tube birth defects.

There are some foods that contain folates naturally, like leafy green vegetables, but it's very difficult to eat enough of them to reach the necessary levels for protection. Some breakfast cereals and spreads may have folic acid added to them.

Many Women Don't Take the Supplement

In reality many women don't take the supplement, especially if they don't realise they are pregnant. The British Pregnancy Advisory Service (BPAS) estimated that almost half of pregnancies in this country aren’t planned so many women will start taking folic acid too late in pregnancy to protect their baby. 

BPAS Director of External Affairs Clare Murphy said: "The UK has one of the highest rates of neural tube defects in Europe. Most foetal anomalies sadly are not preventable, but those related to folic acid deficiency can be reduced."

She added: "Folic acid fortification is a straightforward public health intervention which would spare hundreds of women the heartbreak of receiving the news that their baby has a serious condition."
 

'The Evidence Is Clear'

The Royal College of Obstetricians and Gynaecologists (RCOG) has long supported calls to fortify flour with folic acid as a public health measure to prevent birth defects.

Dr Alison Wright, consultant obstetrician and gynaecologist and RCOG vice president said: "There are approximately 1000 diagnoses of birth defects in the UK, such as anencephaly and spina bifida per year, 85% of which currently result in an abortion. The evidence is clear that fortification will prevent around half of these defects.

"Fortifying flour with folic acid is a simple, safe and evidence-based measure that will reach women who don’t receive enough folic acid through their diet, as well as those who may not have planned their pregnancy. This is a real opportunity to improve outcomes for families and society as a whole."

The decision to consult on the idea has also been welcomed by the Faculty of Sexual and Reproductive Healthcare (FSRH). Its President Dr Asha Kasliwal said: "FSRH alongside other colleagues has long called on the Government to introduce this simple yet highly-effective measure to prevent neural tube defects in babies and improve the long-term health of the population.

"Currently, many women of childbearing age are not receiving enough folic acid from their diets, and we know that almost half of pregnancies are unplanned. Folic acid fortification will help to ensure that pregnant women will have higher chances of delivering a healthy baby."
 

Can You Have Too Much Folic Acid?

The consultation will also consider if there are any risks to other members of the general public.
 
These include whether additional folic acid in the diet will mask the diagnosis of conditions such as pernicious anaemia, which results in the production of poorly functioning red blood cells.

Professor Louis Levy, head of nutrition science at Public Health England said: "The vast majority of women between 16-49 have blood folate levels below global thresholds, highlighting a risk of neural tube defect-affected pregnancies.

"Comprehensive evidence shows that mandatory fortification of flour would go a long way towards reducing the number of complications some experience during pregnancy as well as improving the folate status of the general population. It's vital this positive statement of intent moves to action."

Research in January 2018, by scientists at the Wolfson Institute of Preventive Medicine, Queen Mary University of London, suggested there is no need for a folate upper limit.  

Professor Sir Nicholas Wald, professor of preventive medicine at the Wolfson Institute said: "There is no practical risk of toxicity from folate in the diet, folic acid fortification, or the use of folic acid supplements (capsules or tablets) or all three."

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