The need to fortify flours with folic acid – to prevent and mitigate its deficiency in pregnant women, and the consequent incidence of neural tube defects such as spina bifida – has prompted the adoption of new obligations in the UK and recommendations in France, in line with the relevant World Health Organization resolution (WHO, 2023).
1) Malnutrition and micronutrient deficiencies
The United National Decade for Action on Nutrition report (2016-2025) aims to accelerate the implementation of the commitments made at the Second International Conference on Nutrition (ICN2). (1) The global targets on nutrition and diet-related Non-Communicable Diseases (NCDs), set by 2025, and the related Sustainable Development Goals (#SDG2, Zero Hunger; #SDG3, Ensure Health and Wellbeing) are increasingly distant. (2)
The shortcomings of vitamins and minerals – particularly folate, iron, vitamin A and zinc – affect 50% of all preschool children and 67% of all women of reproductive age globally. Micronutrient deficiencies can have serious consequences, including:
– premature births, low birth weight, spina bifida and other neural tube defects;
– increased risk of blindness, weakened immune system, weakness and reduced physical capacity;
– impaired brain development in children due to iodine deficiency, still prevalent in many countries. (3)
2) Food fortification, WHO resolution (2023)
Food fortification on large-scale by adding essential vitamins and minerals to staple foods (e.g. wheat and maize flours, rice, oils) can be used to correct a demonstrated micronutrient deficiency in the general population (large-scale fortification) or in specific population groups (targeted fortification) such as children, pregnant women and beneficiaries of social protection programmes.
Civil society – through more than 50 patient organizations, research institutes, foundations and charities – urged the adoption of a resolution by WHO to accelerate efforts to fortify foods with micronutrients. Stressing that micronutrient deficiency is a crisis that affects all communities globally, low- and high-income, and that there is still a large unfinished agenda on food fortification. (4)
On 30 March 2023 the World Health Assembly adopted a resolution on accelerating efforts to prevent micronutrient deficiencies through safe and effective food fortification. The resolution urges Member States to take initiatives on micronutrient fortification of foods and identify ways to strengthen financing and monitoring mechanisms. (5)
3) Neural tube defects, spina bifida and folic acid deficiency
Folic acid deficiency in pregnant women is a major cause of neural tube defects, including spina bifida, which can cause a number of serious and debilitating conditions in babies throughout their lives. These defects can also be caused by family history, certain drug treatments (e.g., anti-epileptic drugs), diabetes, and obesity.
ANSES (Agence nationale de sécurité sanitaire de l’alimentation, de l’environnement et du travail, France) therefore recommends that women planning a pregnancy take 600 micrograms of vitamin B9 per day, from at least 4 weeks before conception and up to 12 weeks of amenorrhea (suspension of the menstrual cycle).
The French agency also notes that this level of folate is rarely reached by the population.
According to several studies conducted in France and the National Perinatal Survey 2021, less than a third of women report having started vitamin B9 or folic acid supplementation before pregnancy.
4) UK, mandatory addition of folic acid to non-wholemeal flours
On 14 November 2024 the UK Government, after consulting the FSA (Food Standards Agency) and stakeholders, has adopted an amendment to ‘The Bread and Flour Regulation’ (1988) which requires operators to fortify non-wholemeal flour with 250 µg/100 g of folic acid from 13 December 2026. (6)
The new prescriptions, it is estimated, could reduce neural tube defects in the UK by 20% and improve the health of pregnant women. With a saving for the NHS (National Health System) of around 20 million pounds and a stimulus to the economic sectors involved estimated at over 90 million pounds, over 10 years.
5) France, the ANSES recommendations
Neural tube defects, as mentioned, are congenital malformations that can have very serious consequences on the development of the brain and spinal cord of the newborn. Studies also demonstrate a possible correlation between the incidence of these diseases and social inequalities: the younger the mothers and the lower their level of education, the less they report having started taking vitamin B9 before pregnancy.
To improve prevention of these anomalies, ANSES recommends enriching wheat flour with folic acid, the synthetic form of vitamin B9, in addition to vitamin B9 supplementation for women planning a pregnancy. This measure would make it possible to compensate for the insufficient intake of vitamin B9 in these women, which is one of the main risk factors for neural tube defects in the fetus. (7)
6) Which flours should be enriched with folic acid?
Prevention of neural tube defects, according to the recommendations of ANSES, requires the systematic enrichment of all wheat flours – including wholemeal flour, which is instead excluded from the new obligations established in the UK – with 200 µg/100 g of folic acid. Noting that in the numerous countries where this measure has already been implemented, an effective reduction in neural tube defects has been observed.
‘Wheat flour was chosen as a food to be enriched for two reasons: it is an ingredient used in many common consumer products (bread, biscuits, etc.) and these products are economically accessible to all target women‘, (Vincent Bitane, ANSES, scientific coordinator of the expertise).
Particular attention must therefore be dedicated to information – by general practitioners and gynaecologists, as well as by consumer and patient associations – on the risks of folate deficiency in women affected by Food allergies and celiac disease, who cannot benefit from this form of large-scale fortification due to their inability to access wheat flours (except for gluten-free ones, for celiacs only).
7) Pregnant women, dietary recommendations
It is necessary to inform women planning a pregnancy, ANSES emphasizes, on the importance of a diet rich in legumes (i.e. chickpeas, red beans) and dark green vegetables (spinach, broccoli, lettuce). In addition to resorting to a vitamin B9 or folic acid supplement from 4 weeks before conception until the first three months of pregnancy. Other useful indications in the previous articles cited in the note (8,9,10).
Dario Dongo
Footnote
(1) UN Decade of Action on Nutrition https://www.un.org/nutrition/
(2) Dario Dongo, Iudita Sampalean. World Food Day, 2024. FT (Food Times). October 16, 2024
(3) Stevens, Gretchen AAddo, O Yaw et al. (2022). Micronutrient deficiencies among preschool-aged children and women of reproductive age worldwide: a pooled analysis of individual-level data from population-representative surveys. The Lancet Global Health, Volume 10, Issue 11, e1590 – e1599
(4) UNICEF et al. Letter to WTO. 13.3.23 https://tinyurl.com/ycyyubu5
(5) WHO. Accelerating efforts for preventing micronutrient deficiencies and their consequences, including spina bifida and other neural tube defects,
through safe and effective food fortification. 30.5.23 https://tinyurl.com/8zweetz8
(6) Flour in the UK is already subject to mandatory fortification with calcium, niacin, thiamine and iron. See ‘The Bread and Flour (Amendment) (England) Regulations 2024’ https://tinyurl.com/ztcrh9wa
(7) Enrichir la flour en acid folique : une solution contre les malformations du neural tube chez les nouveau-nés. ANSES. 19.12.24 https://tinyurl.com/39v9ee8n
(8) Paola Dongo. Feeding in pregnancy. GIFT (Great Italian Food Trade).
(9) Marta Strinati. Dried fruits in pregnancy, babies with better learning ability. FT (Food Times). May 14, 2019
(10) Giulia Pietrollini. Mediterranean diet and reduction of adverse pregnancy diseases. FT (Food Times). January 24, 2023
Dario Dongo, lawyer and journalist, PhD in international food law, founder of WIISE (FARE - GIFT - Food Times) and Égalité.
