select search filters
roundups & rapid reactions
before the headlines
Fiona fox's blog

expert reaction to the case for ‘fully effective folic acid fortification’ for the prevention of neural tube defects

This Roundup accompanied an SMC Briefing, in which a panel of experts made the case for a higher level of folic acid fortification in order to prevent a greater proportion of fetal neural tube defects.


Dr Gareth Nye, Ambassador, Society of Endocrinology, and Endocrinology theme lead, Physiological Society, said:

“For most women, a pregnancy is noticed after a missed period which can be some 4 weeks into the development of that growing baby and over half of pregnancies are unplanned.

“Those 4 weeks contain an enormous amount of growth and development, going from a single fertilised egg to the fundamental parts of the entire body.

“The importance of folic acid in parts of this early development has been known for some 30 years, enough time for a whole generation to now be having children of their own. That change in policy has undoubtedly changed the outcomes for millions of pregnancies since. 

“Despite this, around 1000 fetuses in the UK will still develop conditions relating to the neural tube (the early form of our brain and spine). This is one of the highest levels globally according to BPAS. It is reported that 80% of these babies will be subject to therapeutic abortion. 

“The suggestion here is to fortify foods with folic acids to reduce this risk. You can get folic acid from diet naturally through leafy vegetables but not at the level to be useful.

“The government’s plan is to fortify flour used in white bread but that in itself isn’t at a level thought to reduce the risk of neural tube defects. You also exclude a large proportion of women who do not eat white bread for dietary reasons.

“At the proposed level – the risk will only be reduced by 12%, certainly there is big room for improvement and the government should rethink the plan.

“The influence of our time in the womb during pregnancy is being further uncovered every day. We know how the maternal environment (diet, exposures, exercise, illnesses) can impact on babies and potentially lead to lifelong risks for cardiovascular disease and metabolic disorders. Neural tube defects however are a devastating issue with apparently a simple solution as long as it’s done right.”


Prof Andrew Prentice FMedSci, Head of Nutrition & Planetary Health Theme, MRC Unit The Gambia at London School of Hygiene & Tropical Medicine, said:

“This controversy has been bubbling for decades. The benefits of folic acid in preventing many NTDs are overwhelmingly proven but minority voices in prior committees have been concerned that collateral harm might be caused, for instance in increasing cancer rates or obscuring the diagnosis of other rare diseases. Now the accumulated evidence of benefit from many countries is surely sufficient to calm these fears. England is being left behind.”


Robin May, Chief Scientific Adviser of the FSA, said:

“Last year the UK government and devolved administrations announced that folic acid will be added to non-wholewheat flour across the UK. The development of folic acid fortification policy largely sits with the Department of Health and Social Care, Scottish Government, Welsh Government, and Department of Health in Northern Ireland. The Food Standards Agency has worked with health departments to ensure that the proposed fortification is safe and is in the best interests of consumers. 

“Both the Science Advisory Committee on Nutrition and the Committee on Toxicity have considered the issue in depth and published their guidance. There is a clear consensus from both committees that the proposed levels of fortification are appropriate and will offer substantial public health benefit.

“We remain fully supportive of the proposed implementation plans.”


Royal College of Obstetricians and Gynaecologists (RCOG) Statement:

“The Royal College of Obstetricians and Gynaecologists has long campaigned for the introduction of folic acid fortification. We welcomed the Government’s decision to introduce a policy of fortification of non-wholemeal flour, as a step towards reducing the numbers of neural tube defects in babies.

“Consumption of folic acid in the pre-conception period and up to the 12th week of pregnancy reduces the risk of neural tube defect affected pregnancies. One of the key arguments for fortification is that most women do not take folic acid supplements before and during early pregnancy, and around half of all UK pregnancies are unplanned. Fortification of foods therefore provides an effective solution to reducing neural tube defects without active supplementation.

“We are concerned about the proposed levels of fortification. As the open consultation to amend the Bread and Flour Regulations set out, modelling predicts that proposed levels of folic acid fortification will prevent around 20% of neural tube defects. We recommend that fortification of flour is set at a level sufficient to prevent about four out of five neural tube defects, namely 1mg of folic acid per 100g of flour.

“The consultation modelling adopted a Tolerable Upper Limit Intake Level originally set by the US Institute of Medicine in 1998 and adopted by the Scientific Advisory Committee on Nutrition (SACN). We are concerned that the evidence and analysis that led to this Tolerable Upper Limit Intake Level is flawed and must be reviewed.

“We encourage the Government to reconsider the proposed level of fortification of flour with folic acid, and SACN to review the evidence informing the Tolerable Upper Intake Level of folic acid.”


Department of Health and Social Care (DHSC) Statement:

“The current (just closed) consultation laid out the rationale for the proposed level of fortification with folic acid.  These are:”

  • The proposal is to introduce into the Bread and Flour Regulations the legal requirement to add 250 micrograms folic acid per 100g of non-wholemeal wheat flour.
  • This proposed level was determined following modelling by Food Standards Scotland (FSS) which explored the potential impact of fortification of non-wholemeal wheat flour with folic acid.
  • This estimated the effectiveness and safety of different options on levels of folic acid for the purpose of dietary intakes of folate (ensuring no decrease in current average folate intakes and no increase in numbers of people consuming too much folic acid) and reducing the number of NTD affected pregnancies in the UK.
  • Choosing a set level at which to fortify non-wholemeal wheat flour (the addition of 250 micrograms per 100g non-wholemeal flour), rather than a range of values, supports a standard approach to fortification across industry and allows enforcement authorities to assess compliance with legislation.
  • Choosing to fortify non-wholemeal wheat flour only, which is already subject to mandatory fortification allows an element of consumer choice as wholemeal flour and other milled grains and flours including those that are ‘gluten free’ are not currently subject to other fortification as per the current Bread and Flour Regulations.



Declared interests

Dr Gareth Nye: “I’ve recently submitted a UKRI fellowship grant to uncover the influence of preconception health on the fetus.”

Prof Andrew Prentice: “I have no CoI to declare.”

For all other experts, no reply to our request for DOIs was received.


in this section

filter RoundUps by year

search by tag