It sounds simple. Taking supplements of folic acid before conception and in early pregnancy can of a fetus developing a neural tube defect (NTD) – when the spinal cord or brain doesn’t develop properly – that can result in spina bifida or anencephaly.
And yet, advising women who might become pregnant to do this hasn’t been effective at reducing NTDs in the UK and Europe; supplements probably need to be taken before conception to be effective and not all pregnancies are planned. Fortunately, there is another approach that works.
Most flour, and hence bread, in the US and Canada has been fortified with folic acid, also known as vitamin B9, since 1998. This was followed by an immediate fall in NTD cases; for example, in Canada rates halved between 1996 and 2000, from 1.69 to 0.86 cases per 1000 live births. Over 80 countries, but none in Europe, now fortify in this way. Some, such as Australia, have opted for even higher levels of fortification than the US.
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This backdrop is why groups like the UK’s Food Standards Agency, Scientific Advisory Committee on Nutrition and the British Medical Association have been recommending mandatory flour fortification in the country for two decades. The devolved governments of Scotland, Wales and Northern Ireland have also recently urged the UK government to take that advice.
If the UK had brought in fortified flour at the same time and level as the US, this would have , which resulted in stillbirths, miscarriages, terminations, or the births of babies with disablities.
Mass medication?
Why would anyone resist fortification? Folic acid isn’t a natural form of vitamin B9, also known as folate, and some people have objected to the mandatory addition of a synthetic chemical to food. Natural folate and synthetic folic acid are both converted in the body to 5-methyl-tetrahydofolate, so use of this natural form might address such objections, although most efficacy and safety studies have only looked at folic acid.
Some critics argue that mandatory flour fortification is mass medication without consent. But mandatory fortification of UK flour and margarine with some vitamins and minerals has been in force since 1943, so it isn’t without precedent. Unfortified flour could still be permitted, provided it carries a warning that it doesn’t meet government fortification recommendations.
Those opposed to folic acid fortification also point to evidence that very high doses can mask the anaemia caused by deficiency in vitamin B12 and so potentially delay its diagnosis and increase the handful of cases of neurological damage caused by prolonged deficiency. However, this is a theoretical rather than a practical risk at the fortification levels proposed.
What’s more, while high natural folate intake is associated with reduced bowel cancer risk, there are claims that folic acid could increase this risk. This doesn’t fit the evidence. Rates of bowel cancer in the US have declined steadily since 1970 and this trend wasn’t affected by the introduction of fortified breakfast cereals in 1973 or flour fortification in 1998. A study of 100,000 people in the US associated with total folate intake from natural sources, fortified food and supplements.
This week came the latest study that backs the flour fortification case. UK scientists released and that the current upper safe limit of 1000 micrograms a day could be raised substantially.
Folate deficiency is a real problem, one that is . Flour fortification would eliminate this. Yes, several hundred thousand people are exposed to fortified food for every case of NTD prevented, so governments have a responsibility to be cautious. But when does admirable caution become dithering?
