UK Health Secretary Jeremy Hunt announced plans Halve the number of infant deaths, stillbirths and brain injuries by 2025. Yet successive UK governments have resisted expert advice to fortify flour with folic acid – including food Standards Agency. This simple measure would prevent many serious birth defects, known as neural tube defects.
Neural tube defects are abnormalities of the central nervous system that occur within the first month of an embryo’s life. They include conditions such as spina bifidawhere the spine does not close properly, and anencephaly, a condition where large parts of a baby’s brain and skull are missing. The incidence of neural tube defect pregnancies in the UK is approximately 13 per 10,000 births.
In 1991, folic acid supplements given before conception and in early pregnancy were shown to reduce the rate of neural tube defects. This finding has since been backed up by numerous other studies. A meta-analysis of these studiesconducted in 2010 found that if a woman takes 400 micrograms of folic acid a day before conception, she can reduce her baby’s risk of having a neural tube defect by about 70%.
Since 1992, women in Britain and Europe have been advised to take folic acid supplements if they are trying to conceive. However, a study conducted by the United States Centers for Disease Control and Prevention found that in 1998 it made no difference to neural tube defect rates in Europe, as over-the-counter supplements tend to be taken by those who need it least – because they get enough folic acid in their diet. And the people who need them are the least likely to take them.
The United States and Canada have taken a different path. Instead of advising supplementation with folic acid pills, they made it mandatory for flour to fortify with folic acid. Since then, more than 70 countries have followed suit and neural tube defects have dropped by 25-50%.
Canada implemented flour fortification in 1997. By 2000, rates of neural tube defects had dropped to half the rate in 1996 (see graph below).
In 2014, a group of British scientists reported in Archives of childhood illnesses that UK rates of neural tube defects had not changed much since 1998 (the year the US introduced mandatory enrichment). The graph below shows how this played out.
If the British government had introduced flour fortification at the same time and at the same level as the United States, then nearly 3,000 cases of neural tube defects would have been prevented. Without abortions, this would equate to approximately 1,500 dead or aborted babies and 1,500 severely disabled babies.
To be most effective, folic acid should be taken before or just after conception. However, in the UK, 40% of pregnancies are unplanned, meaning the window of opportunity to take the supplement is lost. A study conducted by Queen Mary University of London revealed that only 25% of British women take folic acid supplements at the right time. And, as stated earlier, people who take supplements tend to have the best diets and are the less likely to need it.
Objections don’t stand up to scrutiny
For every case of neural tube defect averted, several thousand people eat the fortified food. It could be considered ‘medicine’ without choice or consent, although since World War II flour has been enriched with several vitamins and minerals. Several other objections to fortifying foods with folic acid have been suggested by opponents of fortification:
- It could mask the symptoms of vitamin B12 deficiency in the elderly and thus delay diagnosis and treatment.
- It could promote the growth and malignancy of existing benign intestinal tumors.
- It could interfere with drugs like methotrexate, which is used to treat rheumatoid arthritis, which have folic acid antagonist action.
The United States has been fortifying flour for 20 years with no indication that these represent real dangers. The doses of folic acid concerned are unlikely to seriously affect diagnosis of vitamin B12 deficiency.
Bowel cancer rates in the United States decline since 1970and this fall was not slowed by the introduction of fortified breakfast cereals in 1973 nor by the mandatory fortification of flour in 1998. Most epidemiological evidence suggests that folic acid could be protector against bowel cancer and one meta-analysis folic acid supplement trials published in The Lancet found no increase in bowel cancer after five years of use.
Folic acid alleviates the side effects of methotrexate and therefore some methotrexate regimens for rheumatoid arthritis use folic acid for this purpose.
According to International Spina Bifida and Hydrocephalus Federation, the British government decided not to introduce enrichment. More recently, the health ministers of Scotland and Wales wrote a joint letter to Jeremy Hunt, asking him to reconsider his position on the fortification. According to Food Standards Scotland, 80% of women of childbearing age in Scotland and Wales are lacking in folic acid.
I recently advocated flour fortification with 50% more folic acid than the US level. This could result in 300 fewer affected pregnancies each year. Unenriched flour could be permitted, but with a warning that it does not comply with government fortification advice.
