The Department for the Environment, Food and Rural Affairs (DEFRA) are still considering fortifying flour with Folic Acid. There has been some developments in this area.  Niacin, Thiamin, Iron and Calcium are all added to bread.  This practice began in 1940 when millers were required to extract 80% of flour from grain.  This was reduced to 70% in 1954 but it was considered wise to keep adding the nutrients to compensate for any dietary deficiency.  Calcium was added to flour to compensate for the lack of dairy products in the diet of the population due to strict rationing of dairy products.  All milled flour (with the exception of wholemeal) is required to have Niacin, Thiamin, Iron and Calcium added to it.

The Scientific Advisory Committee on Nutrition (SACN) were asked to look at whether this practice should be continued and they concluded:

“In order of public health nutrition importance, the case for maintaining the mandatory addition of calcium to wheat flour (other than wholemeal flour) is strongest, followed by iron. Evidence to continue the mandatory addition of niacin and thiamin to wheat flour (other than wholemeal flour) is much weaker”.

So it could be that the mandatory fortification of flour with Niacin and Thiamin may be discontinued though Iron and Calcium will remain.  Thiamin is also known as Vitamin B1; Niacin is also known as Vitamin B3.

And that brings me back to the issue of fortifying flour with Folic Acid.  No decision has yet been taken – here’s what the SACN have to say:

In 2006 SACN concluded that mandatory fortification of flour with folic acid would reduce the risk of inadequate folate status in women most at risk of neural tube defect-affected pregnancies. The decision whether to introduce mandatory fortification of flour with folic acid is with government Ministers.

So they have simply stated that adding folic acid to flour would “reduce the risk of inadequate folate status” in pregnant women – thereby reducing, quite significantly, the risk of the foetus developing neural tube defects (such as spina bifida).  So why the delay?  There have been significant reductions in the number of babies being born with neural tube defects where folic acid is added to flour (both Canada and the USA have been fortifying their flour for years with an accompanying decrease in the number of neural tube defect births) and so really it should be a no-brainier.

Well there is a drawback – high levels of Folic Acid can mask one of the indicators of B12 Deficiency – enlarged red blood cells.  When a Full Blood Count is conducted B12 is not analysed; instead doctors will look for enlarged red blood cells (macrocytosis) as an indicator of either alcohol abuse or low B12.  So does that mean we shouldn’t be fortifying flour?  Well, if all patients with low B12 status had macrocytosis then there would be a case for not fortifying flour.  The fact is that only around 60% of patients with low B12 levels will display any macrocytosis.  So should the Pernicious Anaemia Society be against of for folic acid fortification?  This has been a question that we haven’t really answered for many years.  I think I now know the answer.

The evidence that folic acid fortification causes a decrease in the number of babies born with Neural Tube Defects is compelling.  Over fifty countries in the world now have mandatory fortification of flour.  And according to the Flour Fortification Initiative those countries that have introduced folic acid fortification have seen Neural Tube Defects fall by between 30% and 60% and this fall not only leads to healthier babies but also reduces the cost of healthcare in dealing with the consequences of Neural Tube Defects.

So what should we be doing?  I believe, and this is my own personal opinion and not that of the PA Society, I believe we should support folic acid fortification with one proviso.  The serum B12 test – although the current test is flawed and not really fit for purpose – should be made part of the Full Blood Count.  Something will have to be done about the current test and a replacement introduced which should, hopefully provide doctors with a more accurate picture of the patient’s B12 status.

Fortify flour with folic acid but introduce a better test for serum B12 and make that test part of the Full Blood Count – a win win situation.