09 Sep 2019

This is a summary of some of the key questions from this consultation. For the full set of responses, please download the pdf. 

Do you agree or disagree with the proposal for mandatory fortification of non-wholemeal wheat flour in the UK with folic acid?

The BDA strongly supports the proposal to fortify flour in the UK with folic acid to reduce the risk of neural tube defects. We are not convinced that restricting this to just non-wholemeal wheat flour is the most effective policy.

This is a policy that has been a very long time coming. In 1991, the Medical Research Council[1] published a report recommending that white flour in the UK was fortified with folic acid as this had been shown in other countries to reduce the risk of neural tube defects (NTD) in foetuses. Mandatory fortification with limits on voluntary supplementation was backed by the Scientific Advisory Committee on Nutrition (SACN) in 2006[2] and again 2017[3]. The Welsh and Scottish Health Ministers wrote to the then Health Secretary, Jeremy Hunt in December 2017[4] to urge him to implement UK wide fortification of flour. 

We are pleased to have joined many other organisations, including SHINE, the Spina Bifida charity, the Royal College of Obstetricians and Gynaecologists and many others in welcoming this proposal and encouraging its adoption. This was most recently articulated in a joint consensus statement signed on 9th September 2019.

Many years of fortification with folic acid in many countries around the world has consistently proved effective in reducing NTDs while having no demonstrable negative impact on health. We also have direct experience of the benefits of fortification of other micronutrients, such as iron, in foods in the UK, with fortified breads and breakfast cereals now providing a significant proportion of many people’s iron intake.

NTDs are a serious health condition. Conditions such as spina bifida cause moderate to severe disability leading to significant suffering and higher health care costs. The prevalence of NTD pregnancies is 1.28 per 1000 total births (19% live births, 81% terminations and 0.5% stillbirths and foetal deaths ≥20 weeks’ gestation). A recent study[5] estimated that more than 2000 NTD pregnancies could have been prevented since 1998 had the UK adopted flour fortification when countries such as the US and Canada did the same. The failure to act on this straightforward policy recommendation made nearly 30 years ago has been a missed opportunity for those families affected. 

The most effective way to reduce the risk of NTD’s in individual women, is the intake of folic acid supplements (400ug daily) prior to conception. This is still an important health message that requires strong and consistent communication to women considering pregnancy. However, a significant proportion of pregnancies are unplanned, and taking supplements requires knowledge and organisation, and so this method cannot be fully effective on a population-wide basis, especially among younger women, and those with less access to health information. According to the NDNS[6], 91% of women of childbearing age (16 to 49 years) in the UK as a whole had a red blood cell folate concentration below the threshold (748nmol/L) indicating elevated risk of NTDs. This figure has been rising. Voluntary, self-supplementation has clearly not worked for many women.

What do you think mandatory fortification with folic acid should apply to?

All flour in the UK and other non-wheat products such as ‘gluten free’

The BDA believes that a wider range of flours, including gluten-free products, should be fortified for a number of reasons:

  • Although it has previously been recommended that only non-wholemeal wheat bread flour be included, evidence shows that people’s consumption habits have shifted considerably since the first recommendation was made to fortify in 1991[1]. Overall bread consumption has fallen significantly from 819g per person per week in 1993 to just 532g per person per week in 2016/17. White bread, consumption has fallen at an even faster rate so to limit to only white-bread flours would have much less impact.
  • Similarly, focusing on non-wholemeal flours directly contradicts advice for people to consume more whole-grain and wholemeal foods.
  • An increasingly diverse UK population consume a much wider variety of flours and flour-based products than in the past, and interest in “alternative” flours has grown. Data from NABIM highlights the growth in flour production for purposes other than bread, biscuits and cakes and the decline in flour for bread[2]. The US is currently considering widening its fortification programme to include corn-based flours in recognition of the higher consumption levels of these flour types amongst the Hispanic community.
  • It is argued that wholemeal can be excluded as it already had higher natural levels of folate. However, according to McCance and Widdowson the difference is 16 micrograms in white flour per 100g, and 27 micrograms per 100g in wholemeal[3]. Neither is sufficient at current levels to realistically improve the blood folate status of women. There may be value however in excluding specialist non-wheat flours with high folate content (e.g. soya flour)

[3] Finglas P.M et al (2015) McCance and Widdowson’s The Composition of Foods, Seventh summary edition. Cambridge: Royal Society of Chemistry p32

Are there any alternative ways of helping reduce the number of neural tube defects that you may prefer?

We strongly believe that fortification needs to be accompanied with a wider effort to encourage all sexually-active women of child-bearing age to take a regular folic acid supplement. It is clear that even with fortification, folate status will only be improved in those that consume flour, and even then, not in sufficient amounts in all cases to optimally reduce the risk of NTDs. Therefore, we are clear that this is not an alternative, but instead a further policy that is necessary alongside fortification.

This could include more clearly discussing the role of folic acid prior to pregnancy in school science and PHSE lessons, public health campaigns and more robust and regular marketing. Government may wish to consider wider provision of free folic acid supplements without prescription, as is currently possible for limited numbers of people through the Healthy Start Scheme[1]. It is worth noting that folic acid being provided as part of Healthy Start itself is actually likely to be of limited use as a woman needs to have been taking the supplement before they became aware that they were pregnant.

Advances in surgical treatments for those with a diagnosis of spina bifida are welcome, and can improve outcomes for an unborn baby, but they are not a cure for spina bifida. A baby diagnosed with spina bifida will always have spina bifida, even after surgical intervention. Health and social challenges for babies who undergo surgery may be lessened through surgery, but current evidence suggests they will still face a lifetime of on-going issues. Surgery is not an option for a diagnosis of anencephaly.


Consultation Document