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14 November 2013

Why we need folic acid in our flour

If we are serious about our children deserving better, it also makes sense to give our baked goods a little extra goodness.

By Michael Brooks

You could be forgiven for thinking that the recent report by the chief medical officer for England, Sally Davies, covered only one topic – improving child health. The press picked up on the argument that, given the upsurge in cases of rickets, the government should consider providing free vitamin supplements to all children, but there was much more in the report. Davies’s next point, that we should fortify our flour with folic acid, has been ignored for far too long.

This recommendation arguably has much greater potential impact. Boosting folic acid in foods eaten by pregnant women significantly decreases the occurrence of foetal “neural tube defects”, reducing cases of conditions such as spina bifida and anencephaly, in which large parts of a baby’s brain simply don’t form.

The neural tube, which eventually carries the spinal cord and the brain, starts as a groove that deepens and then closes off. A folic acid deficiency can prevent the closing process, leaving nerves exposed. Folic acid provides a “methyl group” – one carbon atom and three hydrogen atoms – that binds to foetal DNA and ensures the genetic instructions are carried out properly, fully closing the neural tube.

We’ve known about the importance of folic acid since a landmark paper was published in the Lancet in 1991. In an experiment involving 2,000 women known to be at higher risk of having babies with neural tube defects, supplements of folic acid prevented between 70 and 80 per cent of the defects. The benefits were so starkly obvious that the experiment was stopped early: it was deemed unethical to continue to withhold supplements from those in the control group.

The test results led more than 60 countries to mandate the fortification of flour with folic acid. The neural tube forms in the first four weeks of pregnancy, before many women know they are pregnant. For full protection, the foetus needs the folic acid right from conception, yet only 37 per cent of women in the UK are taking folic acid supplements when they fall pregnant.

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In the US, the fortification of cereal products with folic acid prevents roughly 1,300 neural tube defects a year and forestalls 360 infant deaths. Every year in the UK, 1,000 children are born with a neural tube defect, one and a half times the number of such births in the entire United States. That’s because the UK government advises only that women who might get pregnant should take folic acid supplements – it has consistently ignored scientific advice to put folic acid in the nation’s flour.

Until early this year, the government was able to hide behind claims that folic acid fortification might increase rates of bowel cancer. Those claims were disproved in a Lancet paper in January. The only remaining fig leaf for the government’s current position is a vague concern that one shouldn’t impose medicines on the country.

There is also an economic case for fortifying flour with folic acid. Each spina bifida patient costs the NHS about half a million pounds over their lifetime. In the US, the financial benefits have been shown to outweigh the cost of fortifying flour by 40 to 1. A 2011 costbenefit analysis of fortifying flour with folic acid suggested it would save the UK several million to hundreds of millions of pounds per year.

By all means, let’s get children out into the sun, and taking Vitamin D supplements if necessary: rickets has no place in 21st-century society. But if we are serious about our children deserving better, it also makes sense to give our baked goods a little extra goodness.