Folic acid fortification

Folic acid fortification

On 25 October there will be a general debate in the Commons chamber on folic acid fortification.

Folic acid[1] helps the body to form healthy red blood cells and helps reduce the risk of fetal abnormalities called neural tube defects (such as spina bifida). [2]   Most people will get the required amount of folic acid through their diet, but it is recommended that all pregnant women, and those trying to conceive, take a daily folic acid supplement through early pregnancy to reduce the risk of neural tube defects. However, about a half of pregnancies in the UK are unplanned, so some women are missing out on this supplementation.[3] 

There has been support from health organisations for the introduction of folic acid fortification and on 23 October 2018, the Government announced a consultation on the introduction of mandatory fortification of flour with folic acid.

Neural tube defects

Neural tube defects are congenital conditions where the brain or spinal cord of an embryo does not develop properly.  They occur very early in pregnancy, often when the woman is not aware she is pregnant. 

Spina bifida is the most common neural tube defect where part of the neural tube doesn’t develop or close properly, leading to defects in the spinal cord and bones of the spine of the child. There are several different types of spina bifida which will vary greatly in severity.  Where needed, surgery can repair the opening in the spine, but some symptoms may remain.  These can include problems with walking, loss of skin sensation, impaired bladder and bowel function and learning difficulties.

Anencephaly is another neural tube defect where the skull does not develop properly, and this results in severe damage to the brain. Babies with anencephaly die before they are born or shortly after birth.[4]

The NHS fetal anomaly screening programme recommends that pregnant women are offered a mid-pregnancy scan at 18-20 weeks of pregnancy to screen for major fetal abnormalities.  Neural tube defects will be screened for at this scan.[5]

Approximately 700 to 900 pregnancies are affected by neural tube defects each year in the UK.[6]  Lower rates arise in countries where folic acid fortification has been introduced, such as the USA and Canada.[7]  A 2001 study found that the introduction of folic acid fortification in the USA was associated with a 19% reduction in birth prevalence of neural tube defects between 1990 and 1999.

Folic acid fortification

There has been longstanding support from health organisations for the introduction of folic acid fortification.

Following a 2017 review of the evidence in this area, the Scientific Advisory Committee on Nutrition (the body that advises the Government on nutrition and related health matters) published updated recommendations on folic acid fortification, which reiterated its previous recommendations for “mandatory folic acid fortification to improve the folate status of women most at risk of NTD-affected pregnancies.” ^[8]

In December 2017, the former Scottish Health Minister, Aileen Campbell and the Welsh Secretary for Health and Social Services, Vaughan Gething, wrote to the then Secretary of State for Health and Social Care, Jeremy Hunt, calling on him to introduce mandatory folic acid fortification across the UK.[9]

The Government has said that the evidence suggests that taking folic acid during pregnancy can significantly reduce the risk of fetal abnormalities. It also highlights that fortification is thought to be an effective way of ensuring that women with the lowest folate levels, such as those from the most deprived backgrounds get sufficient supplementation. However, it has also said that the consultation will consider wider implications and potential risks to other members of the general public.  One such concern is whether added folic acid might mask the diagnosis of pernicious anaemia (an autoimmune condition that affects the development of red blood cells).

The Chief Medical Officer, Professor Dame Sally Davies, set out the rationale for the consultation and encouraged the scientific community to respond:

• 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.
• I am pleased to see the government taking action on this issue and hope to see the wider scientific community feed in their views to this important consultation which could benefit and improve the lives of many women and babies in this country.[10]

The consultation will open in early 2019.  The Government’s announcement has been welcomed by the Royal College of Obstetricians and Gynaecologists, the British Dietetic Association and the Federation of Bakers.

[1]     Known as folate in its natural form

[2]     Known as folate in its natural form

[3]     Department of Health and Social Care, Fortifying flour with folic acid: government to consult, 23 October 2018

[4]     NHS screening programmes, Neural tube defects (NTDs): anencephaly, Information for parents, 2012

[5]     NHS, 20-week anomaly scan, March 2018

[6]     Department of Health and Social Care, Fortifying flour with folic acid: government to consult, 23 October 2018

[7]     Zaganjor I, Sekkarie A, Tsang BL, et al. Describing the Prevalence of Neural Tube Defects Worldwide: A Systematic Literature Review. PLoS One. 2016;11(4):e0151586. Published 2016 Apr 11. doi:10.1371/journal.pone.0151586

[8]     Scientific Advisory Committee on Nutrition, Folic acid: updated SACN recommendations, 2017

[9]     Scottish Government, Folic acid in flour, December 2017 

[10]    Department of Health and Social Care, Fortifying flour with folic acid: government to consult, 23 October 2018

Useful links 

Department of Health and Social Care press release, 23 October 2018 Fortifying flour with folic acid: government to consult

Royal College of Obstetricians and Gynaecologists and Faculty of Sexual and Reproductive Healthcare RCOG/FSRH joint statement on Government consultation on fortifying flour with folic acid to tackle birth defects, 23 October 2018

Shine Charity – Spina bifida, Hydrocephalus, Information, Networking, Equality

NHS UK – Spina bifida

Updated recommendations on folic acid issued by the Scientific Advisory Committee on Nutrition (SACN), 12 July 2017

BDA, the Association of UK Dietitians, Folic Acid Fortification