Proposed fortification of flour with folic acid

Dr Jonathan Sher of the Queen’s Nursing Institute Scotland has attacked the proposed UK policy for fortification of flour with folic acid (vitamin B9) as hopelessly inadequate.

Lack of folic acid before and during the early weeks of pregnancy is essential for the prevention of neural tube defects (NTDs) and their consequences - miscarriage, stillbirth, abortion, neonatal death, spina bifida and hydrocephalus. NTDs are not rare – but the cost in terms of suffering and demands on the NHS are considerable. 

The longstanding policy of encouraging voluntary folic acid supplementation by women of reproductive age is well-intentioned but benefits only those who take enough, early enough. Many women in underprivileged circumstances, or whose pregnancies are not planned, do not supplement with the result that voluntary Vitamin B9 supplementation has increased health inequalities.  

In 2019, the UK Government held a public consultation on folic acid fortification of flour which led to an announcement in 2021 that this public health measure would be implemented.  However, in September 2022, another UK-wide public consultation was launched. The lengthy consultation document is relevant principally to the food industry and has little to say about public health.  

Preventing up to 80% of NTDs is entirely possible by adding enough folic acid to multiple grains, such as wheat and rice. Unfortunately, the UK Government is proposing to add only a minimal level of folic acid to only one type of flour. This policy will prevent around 22% of NTDs as opposed to the 80% which could be achieved. 

Nearly 90 countries across the globe routinely fortify foods with folic acid. Experience has demonstrated it is both effective and safe and no country has ever discontinued its fortification policy. While the UK appears hesitant about folic acid fortification, it has nonetheless been adding four other vitamins and minerals to flour for more than 60 years - calcium, iron, Niacin (vitamin B3) and Thiamin (Vitamin B1). 

The lengthy consultation document focuses on technical details relevant to the food industry, but avoids the fundamental issues about the level and breadth of fortification. The sole opportunity to encourage fully effective fortification is in the ‘Other comments’ section. This denies everyone except the food industry the opportunity to voice support for a much more meaningful public health policy to prevent NTDs. 

The UK Government’s consultation ended on 23 November 2022.

This news item is based on Dr Jonathan Sher’s article available on the Queen’s Nursing Institute Scotland’s website: 

Background information about folic acid supplementation is available at:

Healthier Pregnancies, Better Lives (2022) Key Points about Folic Acid Fortification and Prevention of Neural Tube Defects (NTDs):  

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