Is a government decision on fortification of flour with folic acid finally going to be made?
In response to questions in the House of Lords, a government minister said that a decision upon whether to make fortification of flour with folic acid mandatory was likely to be made before Easter. This has been reported in several newspapers and on the BBC web-site and the assumption of the media seems to be that a decision in favour of fortification will be made.
What is behind this story?
Folic acid is the parent compound for a family of related substances known collectively as folate or vitamin B9. Folic acid itself is not found naturally in food but this is the form of the vitamin that is usually used in supplements and when fortifying food.
It was shown conclusively in the early 1990s that in clinical trial situations, supplements of folic acid taken just before and just after conception reduce the chances of babies developing a neural tube defect (NTD) by up to 75% depending upon factors like the dose used. NTD are a group of birth defects in which the brain, spinal cord, skull and spinal column do not develop properly. The most familiar condition is spina bifida where the spinal cord may protrude from the spine leading to lower body paralysis. In the other common form of NTD, anencephaly, the brain and spinal cord hardly develop and the baby is not viable.
In the early 1990s UK women were advised to take a folic acid supplement if they were planning a pregnancy but this was later widened and all women who might possibly become pregnant are advised to take these supplements routinely. In fact very few women take these supplements routinely and many young women have poor intakes and poor biochemical status for folate. If women wait until they know they are pregnant before taking them then they will have little or maybe no effect. When rates of NTD in several European countries were compared in the years immediately before and immediately after supplement advice was first given then the supplement advice was found to have had no measurable effect. Many pregnancies are not meticulously planned, taking folic acid several weeks into pregnancy is likely to be ineffective, few young women routinely take supplements and those that do are likely to be those with the highest natural folate intake from food.
Over the last 20 years, various expert groupings and professional organisations have recommended that flour in the UK should be fortified with folic acid. Over 50 countries around the world have now made fortification mandatory (since 1998 in the USA) and rates of NTD have dropped immediately in these countries. There are convincing indications that some other congenital defects of the heart and conditions like cleft lip have also declined. There is really no doubt that folic acid works in preventing NTD.
So why have we in the UK delayed so long?
Folic acid fortification would undoubtedly reduce the number of pregnancies affected by NTD and other birth defects. Exactly how many would be benefit would depend upon the dose selected but a figure of 300 less cases per year has been suggested and seems like a reasonable suggestion. This means that for every case prevented somewhere between 100, 000 and 200,000 people in the UK would be consuming extra folic acid.
Is it right to “treat” so many to help so few?
The answer to this question depends initially on how certain one is that no one will be harmed by the extra folic acid. The case for fortification would also be strengthened if there was convincing evidence that this extra folic might benefit other people in the population. In the 1990s, a number of concerns about possible hazards of folic acid fortification were raised as outlined below.
• Folic acid is not a natural dietary substance and it was argued that it might have different effects to the natural folate found in food.
• Lack of either folate of vitamin B12 leads to a form of anaemia but lack of B12 also causes neurological damage. Extra folic acid might mask the anaemia of B12, so delaying diagnosis and increase the risk of neurological damage.
• A number of drugs used to treat cancer and rheumatoid arthritis are designed to partially block the effects of folic acid and so extra in the diet might make these drugs less effective.
• It has been suggested that folic acid might accelerate the growth of bowel tumours or stimulate the conversion of benign bowel tumours into malignant ones. This is despite the observation that people who eat diets rich in natural folate seem to have a reduced risk of bowel cancer.
Each of these issues has been looked at quite extensively over the last 20 years and they have tended to fade away or have been shown to be unfound. There is now 15 years of experience of folic acid fortification in the USA and elsewhere and the pressure there seems to be to increase fortification levels rather than to stop it.
There has also been endless speculation about other benefits that might be gained from folic acid fortification. Large numbers of people in the UK, including many young women and many elderly people have poor folate status; supplements would obviously reduce this number. There have been many other suggestions that extra folic might reduce heart disease risk, cancer especially bowel cancer, strokes and even risk of dementia. These generally have not stood up to experimental testing and these could be summed as hopes rather than expectations.
My personal view
I think it is now time for a firm decision. There is clear evidence that fortification will improve folate status of the population and that it will reduce the occurrence of some birth defects especially NTD. After long experience of use in the USA and elsewhere there is still no evidence of any harm. There are some other speculative suggestions of benefit but the evidence to support these is also limited. It comes down to a clear decision about whether or not it is ethical to “treat” so many when only a relatively small number can be clearly shown to benefit. My personal views on this have changed over the years but I would now classify myself as a supporter of fortification having initially been quite wary in the 1990s.