UK proposal to fortify flour with folic acid a “long overdue” move, say experts

22 Oct 2018 --- The UK’s proposal to fortify flour with folic acid is long overdue, but nonetheless, a welcome move, UK nutritionists have stated. The policy, which will reportedly be introduced within weeks, came after ministers backed a plan that medical experts say will reduce the number of babies born in the UK with serious birth neural tube defects (NTD) – a serious consequence of folic acid deficiency around the time of conception – UK media outlet the Guardian has reported.

Despite countries such as the US, Canada and Australia having mandatory folic acid fortification policies, the UK has not followed suit: “The first recommendations for fortification were made in 1991 and have been repeated by multiple bodies, including the government’s own Scientific Advisory Committee on Nutrition (SACN) since then. Over 80 countries worldwide have mandatory fortification of flour with folic acid, some since the mid-1990s,” a spokesperson from the British Dietetic Association tells NutritionInsight. 

The UK instead took a voluntary approach, including marketing campaigns attempting to highlight the necessity of folic acid supplementation in reproductive ready women. However, recent figures show that the approach did not bear the desired results.

“It is currently estimated that only 31 percent of pregnant women take a folic acid supplement before conception and, since more than 40 percent of pregnancies are unplanned, that's a huge number of women and their babies missing out on the protective benefits of folic acid when it is most needed,” Catherine Macdonald, a Nutritionist, food industry expert and health writer, tells NutritionInsight.

Indeed, the latest National Diet and Nutrition Survey noted that 91 percent of women of childbearing age have a red blood cell folate level below the level (748nmol/L) estimated to lower risk of Neural Tube Defects.

“Given that so many pregnancies are unplanned, a voluntary approach will never catch all pregnancies, as supplementation needs to be taking place in the very first weeks of a pregnancy, if not before conception,” the BDA spokesperson adds.

Regarding the implementation of the policy, there remain a number of decisions that must be made, regarding the level of folic acid, as well as the products or types of flour that should be fortified, the spokesperson adds.

“Industry will also need time to put in place the processes necessary to fortify flour. The BDA will be engaging fully with any consultation process to ensure we put in place the safest and most effective policy possible,” they add.

Blanket nutrition policies: The way to go?
Since Canada introduced mandatory fortification with folic acid in 1997, it has seen the rate of NTDs fall from 7.6 births per 10,000 in 1996 and 1997 to 4 per 10,000 in the period 2004-2007. By comparison, NTD rates in the UK have remained relatively stable at around 12.8 per 10,000 births between 1991 and 2012, according to the BDA.

A recent study estimated that more than 2,000 NTD pregnancies could have been prevented since 1998 had the UK adopted flour fortification at levels similar to the US.

In an article to be featured in the October/November edition of The World of Food Ingredients, Macdonald poses the question whether mandatory food fortification is a public health safety net or using a sledgehammer to crack a nut?

“Despite the shelves being full of popular fortified foods, public opposition to mandatory mass fortification is often both powerful and persuasive. Therefore, before a staple food undergoes fortification, a number of factors need to be considered. For example, the ‘vehicle’ food needs to be capable of carrying the deficient nutrient, be available to the target population and be eaten in large enough. Perhaps most importantly, and controversially, the fortifying nutrient should have a benign effect on the non-deficient population.” says Macdonald.

However, one issue with fortifying flour with folic acid is that it may not have a benign effect on the whole population. 

“Concerns over folic acid masking the early signs of vitamin B12 deficiency anemia in older people (potentially delaying the early diagnosis of neurological conditions which can arise from B12 deficiency) and possible links to cancer, are cited as reasons for the somewhat tardy approach,” she says.

The UK government’s move to implement a fortification strategy is arguably a strong step toward ensuring the health of a new generation of babies. Although supplementation with folic acid would be ideal for this, it relies too heavily on motivation and the prevalence of unplanned pregnancies further complicates the situation. Where folic acid fortification is mandatory, the instances of NTD are far lower. 

“At last, we have a single nutrient which we know protects people from harm. Let's increase the focus on folate and hope that at last, fortification happens,” concludes Macdonald.

By Laxmi Haigh