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Importance of getting the right UK folic acid fortification policy
  1. Joan K Morris1,
  2. Nicholas J Wald1,2
  1. 1 St George’s University of London, London, UK
  2. 2 UCL Institute of Health Informatics, University College London, London, UK
  1. Correspondence to Professor Joan K Morris, Population Health Research Institute, London SW17 0RE, United Kingdom; jmorris{at}

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Neural tube defects (NTDs) are a global problem that result in many distressing adverse outcomes including miscarriage, stillbirth, neonatal death and termination of pregnancy following screening. Children born with spina bifida typically have multiple surgical operations and many are paraplegic and incontinent for all their life. In 1991, a Medical Research Council (MRC) funded randomised double-blind study provided robust evidence that the risk of an NTD could be reduced by an estimated 83% among women who took a daily 4 mg supplement of folic acid.1 However, relying on supplement use to reduce NTDs has not been effective because only a small percentage of women take folic acid supplements before becoming pregnant.2 3 In contast, there is substantial evidence in support of the efficacy and safety of increasing folic acid intake through fortification. About 80 countries in the world have introduced folic acid fortification. Although the UK government has decided to fortify flour, this has not yet been implemented and there remains an important issue over the level and scope of fortification that would achieve a meaningful reduction in the risk of NTDs.

The UK decision to fortify

In June 2019, the UK government issued an open public consultation on the proposal to introduce mandatory fortification of UK flour with folic acid (vitamin B9) to help prevent NTDs in fetuses. The consultation received responses from 1438 participants. In September 2021, the UK government and the devolved administrations provided a summary of these responses and announced their decision to proceed with the mandatory fortification of non-wholemeal wheat flour such that …

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  • Correction notice This article has been corrected since it was first published. The article includes a correction relating to the Government’s estimate of the neural tube defect risk reduction for a 200μg per 100g flour fortification.

  • 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.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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