Folic acid fortification to reduce brain and spinal conditions in babies – expert opinion

Prof Andrew Prentice, MRC Unit The Gambia at LSHTM, responds to the case for higher folic acid fortification in the UK
loaves of packaged bread on British supermarket shelves

Experts from around the UK, including the Food Standards Agency,  Physiological Society, and Department of Health and Social Care, recently responded to calls for higher levels of mandatory folic acid fortification in non-wholemeal flour to reduce brain and spinal conditions in foetuses.

The Department for Environment, Food, and Rural Affairs (DEFRA) held a public consultation in 2019 around mandatory fortification as a means to reduce neural tube defects (NTDs). 53% of respondents agreed with the fortification, of which 64% further thought all flour and other non-wheat products should also be fortified.

In September 2021, the UK government and devolved administrations decided to proceed with mandatory fortification of 0.25mg of folic acid per 100g of non-wholemeal flour. However, scientists raised concerns that these levels were too low to be fully effective. DEFRA had noted this level would prevent 15-22% of NTDs overall, whereas scientists argued that levels of 1mg per 100g could come closer to 80% prevention.

Previous studies in the late 90’s erroneously concluded that high doses of folic acid could exacerbate vitamin B12 deficiency and thereby potentially neurological damage, but recent research shows no evidence of this.

Prof Andrew Prentice, Head of Nutrition & Planetary Health Theme at the MRCG at LSHTM, stated:

“This controversy has been bubbling for decades. The benefits of folic acid in preventing many NTDs are overwhelmingly proven but minority voices in prior committees have been concerned that collateral harm might be caused, for instance in increasing cancer rates or obscuring the diagnosis of other rare diseases.”

He added, “Now the accumulated evidence of benefit from many countries is surely sufficient to calm these fears. England is being left behind.”

Another public consultation around the 0.25mg levels was held in late 2022, the outcomes of which remain to be seen.

In the meantime, scientists are calling for the further full fortification across other flours and grains, pointing to widening health inequalities for pregnant women who may not be taking or have access to supplements.

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