DEBATE: Should it be compulsory to add folic acid to flour?

We know the USA and Canada do it.. but should we tamper with such things?

Dr Geoff weighs up the debate:

First of all I’ll start with my own personal opinion. Initially I was very wary about mandatory folic acid fortification because the small number of beneficiaries did not seem to justify the risk. However I have gradually been persuaded to support fortification by increasing confidence in its safety and increasing evidence that it may have wider benefits than just for babies at risk of NTD (Neural Tube Defects, like spina bifida).

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Before reading the debate, why not read the my previous article and Did You Know? post giving some background to this issue.

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For:

As an alternative to flour fortification, all British women of childbearing are advised to take supplements of folic acid if there is any chance they may become pregnant. In those countries like the USA, Canada and Chile where fortification has been introduced, rates of NTD have dropped almost immediately by up to half whereas in the UK and Europe where supplements have been recommended for many years, rates have not changed by any measurable amount. This is because few young women routinely take folic acid supplements; many pregnancies are unplanned and to get the benefits folic acid need to be taken very early in pregnancy and preferably prior to conception i.e. it is too late to benefit from folic acid supplements by the time many women realise that they are pregnant. Also it is a general finding that those people who take supplements tend to be those who need them least i.e. those who already have the highest levels of vitamins and minerals in their diets.

So why is the government still delaying the introduction of legislation on folic acid fortification of flour? Firstly, only a relatively small number of babies would benefit from these supplements and yet everyone will be taking extra folic acid if flour is fortified. One must therefore be very sure that the supplements are safe. In recent years, evidence has been accumulating that extra folic acid may have wider benefits; for example it may reduce other birth defects like cleft lip and that it may be beneficial in preventing heart disease and perhaps even cancer although this latter evidence is fairly preliminary. Perhaps more significantly many people in Britain have blood levels of folic acid that indicate folic acid deficiency; around 30-40% of elderly people.

Against:

One persistent concern about folic acid fortification is that because it is involved with vitamin B12 in blood cell formation it might mask the anaemia caused by B12 deficiency. This would mean that diagnosis would be delayed and neurological damage due to other effects of B12 deficiency would occur before it was treated. The Food Standards Agency has concluded that folic acid supplements several times higher than the amounts that would be eaten in fortified flour are safe. A more recent concern has been raised because folic acid is an artificial form of the vitamin that is only used in supplements and food fortification. In food, folic acid is bound up in more complex molecules collectively termed folate and free folic acid does not occur. Some recent research has suggested that the body handles natural folate from food in a different way to the folic acid used in supplements and fortified foods. Free folic acid in the blood caused by taking large amounts of the synthetic form might interfere with some drug treatments and perhaps have other untoward effects. Despite this the Food Standards Agency insists that folic acid fortification, at the recommended levels, are safe and that they have taken this difference between folic acid and natural folate into account. The beneficial effects in pregnancy are accepted even by those who oppose food fortification.

One irony about this is that recent EU legislation (the 2005 Food Supplements Directive) makes folic acid the only form of folate that can be legally used in supplements. The complex forms found in food are not allowed to be used in supplements. This is one of several areas of this legislation that has been opposed by some consumer groups and supplement manufacturers.

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