Nonsensical policy? UK folic acid fortification not enough to prevent neural tube defects, scientist warns

23 Aug 2022 --- The UK government’s proposal to fortify flour with folic acid in a bid to prevent neural tube defects (NTDs) is “simply inadequate,” according to a paper by University College London (UCL) Professor Sir Nicholas Wald. The dosage is so low that it will fail to prevent hundreds of cases of severe birth defects, he says in a paper slamming the current policy.

His stance is that the government should aim for a folic acid intake of 4mg a day – the same level as that given to women who took part in a landmark MRC Vitamin Study – meaning that the level of fortification should be increased from about 0.2 mg of folic acid per 100 g of flour to about 1mg of folic acid per 100 g.

“Mandatory fortification of flour with folic acid has the potential to greatly reduce the number of disabilities and early deaths caused by NTDs. However, what is currently proposed is only a token level of fortification,” highlights Wald.

“It does not make sense to implement a policy preventing only 10% of neural tube defects when 80% could be safely prevented simply by increasing the level of fortification and extending it to wholemeal flour and grains. Once the decision to fortify has been taken, there is no practical or moral justification for rejecting a more effective version of fortification in favor of a less effective version.”

The paper estimates that effective fortification of flour with folic acid could have prevented 6.7 million cases of neural tube defects globally between 1992 and 2020.

Primary prevention spares families the distress of a positive screening result and the difficult decision of a pregnancy termination.Defying logic and reason?
Last September, the UK government announced plans to fortify non-wholemeal flour with folic acid to better prevent neural tube defects, joining about 80 countries around the world who already do this. The proposal was hailed as “long overdue” by nutritionists in the country.

“No European country has introduced folic acid fortification for reasons that defy logic and reason.” Deficiencies in folate – or vitamin B9 – can cause defects in the neural tube. Folic acid is the synthetic and stable form of folate. While women are advised to take folic acid supplements prior to and during the early part of pregnancy, many mothers do not take the supplement early enough.

“Flour and grains, such as rice, are sensible ‘vehicles’ for fortification because they are part of people’s daily diet without wide variation in intake. The supply and milling of grains is, in many countries, industrialized among relatively few companies, making fortification highly efficient,” says Wald.

Perverse choices and racial disparities
According to the paper titled Folic acid and neural tube defects: Discovery, debate and the need for policy change published in the Journal of Medical Screening, one of the problems surrounding fortification is that in many countries, it has been limited to white bread flour. 

“This perversely means that people choosing healthier whole grain bread are denied the health benefit of folic acid fortification. In many countries, fortification is limited to wheat flour which means that people with gluten intolerance are denied the benefit even though this affects about 6% of the population.”

“Families that tend to eat rice instead of bread will also be denied the benefit in countries that do not fortify rice. This overly selective application of what to fortify creates inequity in the delivery of a public health measure. The restrictions are confusing and unfair. They tend to favor certain ethnic and racial groups over others.”

Revising supplement figuresFortifying one type of flour is inadequate, the expert warns.
Currently in the UK, women who could become pregnant or are planning a pregnancy are advised to take a folic acid supplement before pregnancy and to continue taking it until their 12th week of pregnancy. 

However, in a survey of half a million women in England, only one in three said they followed this advice, with a smaller proportion of “less well-off women” doing so, the study notes. Adequate fortification would avoid this health inequality by making it unnecessary to take supplements.

“Fully effective fortification of all flour and grains would have a considerable global impact. It would at one stroke have a significant effect in preventing serious birth defects and associated stillbirths, neonatal deaths, miscarriages, elective terminations of pregnancies and the physical disability from spina bifida,” highlights Wald.

In the absence of fully effective fortification, taking folic acid supplements is still needed, but the paper states that current advice needs to be revised. Most women are advised to take a daily tablet containing 0.4 mg of folic acid, while women who have previously had a neural tube defect pregnancy are advised to take a higher dose of 4 mg or 5 mg, only available in the UK and some other countries with a doctor’s prescription. 

The paper calls for the advice to be revised so that all women were recommended to take the higher dose, available without a prescription.

By Andria Kades