Article Text

Download PDFPDF
Urgent need for folic acid fortification of flour and grains: response to the 2019 UK Government’s public consultation
  1. Nicholas J Wald1,2,
  2. Joan K Morris2,
  3. Colin Blakemore3,4
  1. 1 Institute of Health Informatics, University College London, London, UK
  2. 2 Population Health Research Institute, St George’s, University of London, London, UK
  3. 3 Department of Biomedical Sciences, City University of Hong Kong, Kowloon, Hong Kong
  4. 4 School of Advanced Study, University of London, London, UK
  1. Correspondence to Professor Nicholas J Wald, Population Health Research Institute, St George's University of London, London SW17 0RE, UK; nwald{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


In June 2019, the UK Government took a step forward towards making a decision on the mandatory fortification of flour with folic acid (vitamin B9) in the prevention of neural tube defects (NTDs). It issued an open public consultation on the proposal in the form of a set of questions. The questions covered a range of issues including efficacy, safety, feasibility and cost. This review sets out the nine main questions and our answers. The aim is to present the rationale for mandatory fortification, what products should be fortified and the mean daily folic acid intake increase fortification should achieve across the population.

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

Answer: The evidence strongly supports agreeing with the proposal. In 1991, the report of the Medical Research Council (MRC) Vitamin Study,1 a randomised trial, showed that most cases of NTDs can be prevented by increasing folic acid intake immediately prior to pregnancy and in the early stages of pregnancy. Other studies have confirmed these results and over 80 countries have introduced mandatory fortification of flour and/or grains with folic acid. There has been no indication of any adverse effect in any of these countries, including the USA and Canada. The Centers for Disease Control and Prevention (CDC) have recently estimated that in the USA, fortification has saved 1300 children each year from death or a lifetime of handicap—a total of more than 27 000 since 1998 when fortification was introduced in the USA.2

In 2015, it was estimated that over 2000 children would have been saved each year from death or a lifetime handicap if folic acid fortification had been implemented in the UK at the same time as it was in the USA.3

Women have been advised to take folic acid supplements before pregnancy and in early pregnancy. This is the current …

View Full Text


  • Contributors All authors contributed equally.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

Linked Articles

  • Atoms
    Nick Brown