Fortified Flour: Why the Government is Adding Folic Acid to Flour
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Fortified Flour: Why the Government is Adding Folic Acid to Flour

Fortified Flour: Why the Government is Adding Folic Acid to Flour

January 12, 2022

Dr. Joel McCay, Haematologist, breaks down why the Government is adding folic acid to the nation's flour.

A recent paper was published in the prestigious medical journal The Lancet around the news that the UK is set to introduce the fortification of flours with folic acid¹.

The Government’s goal is to reduce the rates of neural tube defects (NTDs) in newborns. Folic acid is recommended to all mothers during pregnancy at a dose of 400mcg before conception and up until 12 weeks pregnant². Countries like New Zealand have already adopted this approach in an attempt to reduce NTD, which is one of the leading causes of preventable disability³.

We’ve looked at the benefits of folic acid in pregnancy, neural tube disorders and the science behind the new project, and projected savings to the health service.

What does Folic Acid do?

Folic acid, or Folate, is a B vitamin (B9) which is required for maintaining healthy red blood cells, as well as other important bodily functions such as nerve development and function⁴.

Folate is an essential vitamin for DNA synthesis and stability which allows our cells to effectively replicate throughout our body⁵ . Conditions associated with folate deficiency, besides NTDs, include anaemia, heart disease, dementia and even certain cancers⁶.

Where do we get Folate from?

Folate is not produced by the body so you have to get it from your diet. Foods high in folate include broad beans, peanuts, liver, eggs and whole grains6.

Those at risk of folate deficiency are those who either don’t have the ability to absorb folate from the gut lining, such as in coeliacs disease or other bowel conditions, or in those with certain diets low in folate. Folate deficiency can lead to symptoms of lethargy, shortness of breath, a painful tongue, pins and needles in the fingers and toes (neuropathy) and in severe cases, seizures⁶,⁷.

Folate During Pregnancy

In pregnancy, the first 12 weeks, known as the first trimester, are vitally important to the physical development of the fetus and is often where many structural abnormalities occur.

One particular problem, known as neural tube defects, was found to be linked to women with low folate levels in their blood in a large study in the 1990s⁸. Neural tube defect is an umbrella term for disorders which affect a part of the developing fetus responsible for creating the spinal cord and brain³. The two most common defects are spina bifida, where the spinal cord does not develop properly which can lead to disability, and anencephaly, where the brain does not develop correctly and leads to severe disability and often death. Rates of NTDs vary from country to country with about 1 in every 1000 pregnancies affected in the UK¹⁰.

Prevention of NTDs involves ensuring that women have adequate B12 and folate in their diet, reviewing and avoiding any potentially harmful medications, and avoiding smoking and excessive consumption of alcohol⁹.

A significant amount of distress can be caused to families with such a diagnosis. Furthermore, NTDs are a significant preventable cost to the NHS with increased need for inpatient care, managing other associated health problems, caregiver costs and supportive treatments¹¹.

Though recommended through the NHS, it is not always a given that everyone will receive adequate folic acid supplementation during pregnancy. Factors to consider which may impact folic acid supplementation or absorption include those with gastrointestinal issues, autoimmune disorders, pre-existing folic acid deficiency or other vitamin deficiencies and those with certain types of anaemia.

What does the paper show

The Medical Research Council, or MRC, vitamin study which took place 30 years ago was a landmark study looking at the rates of NTDs in women, The study took part across 33 centres in 7 countries and looked at 1,800 women thought to be high risk pregnancies due to previous history of NTDs affecting other pregnancies. The women were analysed and found that folic acid supplementation reduced the rate of NTDs with a protective effect when started prior to pregnancy¹².

What is actually happening to the flour?

Countries such as New Zealand and Canada have already introduced flour fortification with folic acid though it is too early to see the benefits it may have. The fortification process itself involves adding additional folic acid to non-wholemeal flour which has been milled. During the milling process, flour can lose large amounts of folic acid and other B vitamins. As flour is responsible for 94% of the production of the world's cereals it seems the most likely place to target these nutritional deficiencies rather than separate supplementation on a person-by-person basis¹³.

This isn’t a solution for all people though. Some groups who should still consider supplementation are those with Coeliacs disease or wheat intolerance. If you suffer from this, it’s likely you would still be at an increased risk of folic deficiency even after the fortification of flour with folic acid.

Cost Savings to Health Services

As well as the anticipated benefits to health there is an argument to be had that this process could save substantial amounts of money to health sectors all over the world.

In the NHS, a “QALY” is a term used to estimate the cost of a particular ailment or disease to the NHS over a period of time and can be used to estimate the cost effectiveness of treatments. It stands for Quality Adjusted Life Years. For example someone living with diabetes for 60 years would have a different cost of treatment to the health service overtime versus a 30 year old who needs an operation following a broken bone.

QALYs also take into account the effect of the illness on the individual's ability to work, quality of life and other associated health problems¹⁴. As mentioned earlier those with NTDs may often have substantial disability and care needs throughout their entire life. Not only is this physically and emotionally tough for those affected and their families but is also a huge economic cost to the NHS. One large study from America showed that though the initial cost to start fortification of flour was high the projected savings per year were estimated at $88-154 million per year¹⁵.

Get tested

If you're planning to get pregnant and want to discover whether you're getting enough folic acid, our Nutrition and General Health Check Plus will tell your folic acid/folate levels. Find out more by clicking below.

References

1 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02134-6/fulltext

2 https://www.nhs.uk/pregnancy/keeping-well/vitamins-supplements-and-nutrition/#:~:text=Folic%20acid%20before%20and%20during,tube%20defects%2C%20including%20spina%20bifida.

3 https://www.cdc.gov/ncbddd/birthdefectscount/features/kf-neutral-tube-defects-burden.html

4 https://www.nhs.uk/medicines/folic-acid/

5 https://academic.oup.com/jn/article/132/8/2444S/4687602

6 https://www.hsph.harvard.edu/nutritionsource/folic-acid/

7 https://www.nhs.uk/conditions/vitamin-b12-or-folate-deficiency-anaemia/symptoms/

8 https://pubmed.ncbi.nlm.nih.gov/1677062/

9 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250719

10 https://action.org.uk/research/preventing-neural-tube-defects#:~:text=Neural%20tube%20defects%20(NTDs)%20are,in%20the%20UK%20every%20year.&text=Taking%20folic%20acid%20can%20help,it%20is%20not%20always%20effective.

11 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3197907/

12 https://pubmed.ncbi.nlm.nih.gov/1677062/

13 https://www.who.int/elena/titles/wheat-flour-fortification/en/

14 https://www.celforpharma.com/insight/do-you-know-what-qaly-and-how-calculate-it

15 ncbi.nlm.nih.gov/pmc/articles/PMC1449459/

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