Adding Folic Acid To Flour Is A Public Health Policy With An Actual Evidence Base

This isn’t the nanny state gone mad - this is a sensible, evidence-based measure that impact on birth defects
undefined undefined via Getty Images

It appears the government is finally on the cusp of authorising the addition of folic acid to flour in the UK after more than a decade of campaigning by women’s health and disability charities.

This is really good news, and here’s why.

The UK has one of the highest rate of neural tube defects (NTDs) like spina bifida, which causes life-long disability and anencephaly, a fatal condition the baby’s skull and brain do not develop properly. Around 1000 pregnancies are affected every year, and the majority end with the decision to terminate what is often a very much wanted pregnancy.

It was British research that revealed the incidence of NTDs could be reduced by folic acid in a woman’s diet in the weeks surrounding conception. This paved the way to advice for women to start taking folic acid supplements for three months before conceiving.

But in order to know to take folic acid, women have to be planning a pregnancy – and herein lies the rub. About half of pregnancies are not formally planned. Contraception fails, sometimes we fail to use it properly, and by the time some women discover they are pregnant the neural tube, which develops extremely early, has already formed.

This is what has led dozens of countries to introduce a policy of fortifying flour with folic acid, so it enters the diet of women of childbearing age regardless of their pregnancy intentions.

It’s what the government’s own Scientific Advisory group advised it to do more than 12 years ago, but action was never taken. There were some concerns about what might be a safe upper limit, and suggestions that there may be a link with bowel cancer. However evidence from all the countries which had introduced this indicated it successfully reduced the rate of NTDs without any adverse impact on the population at large, including the US, Australia and Canada, and research published in the Lancet in 2013 ruled out any link between folic acid supplementation and cancer, finally drawing a line under this concern.

But that was five years ago. The intransigence on this has been curious, given that we live in a time when women are expected to make a multitude of behavioural changes to ensure the wellbeing of a pregnancy often on the basis of very little evidence at all. From the age at which they conceive, their BMI to how many glasses of wine they consume, women’s choices are often under intense scrutiny – even when improvements in pregnancy outcomes are marginal.

Yet here on a plate, quite literally, was an evidence-based public health measure, proven to reduce the risk of a serious abnormality, yet a real reluctance within government to act. Ask any minister if they would like to see a reduction in later abortions and they would doubtless nod vigorously, yet an effective means to reduce the numbers of women faced with this devastating diagnosis in their second trimester has been inexplicably ignored.

It is not as though fortification is a new concept – our flour is already enriched with other vitamins and minerals including calcium, thiamin, niacin and iron and has been for many decades. Breakfast cereals are routinely fortified with vitamins including folic acid.

But adding folic acid to white flour will mean it enters a variety of foods – bread of course but also pizzas, biscuits, cakes, sauces. It is likely to have a particular impact on the diet of younger women, who are more likely to have an affected pregnancy.

This isn’t the nanny state gone mad. This is a sensible, evidence-based measure that will have a far greater impact on birth defects than crude silhouettes of pregnant women behind a no-smoking sign on a wine bottle.

It protects the health of women and their pregnancies with no adverse impact on the rest of us. It is also a measure that recognises pregnancy cannot always be carefully planned and prepared for.

Unplanned pregnancy is a fact of life, but these particular birth defects don’t have to be. We urge the government to introduce folic acid fortification as a matter of urgency.