A more effective tool in the fight against birth defects? Supporting pre-natal nutrition with folic acid-enriched wheat flour

By:  Talking Nutrition Editors

  • Adequate consumption of folate – either naturally occurring or in the form of folic acid – in the early stages of pregnancy is vital for protecting babies from neural tube defects that can lead to debilitating conditions, such as spina bifida and anencephaly.1
  • As a result, many countries have implemented folic acid intake recommendations for prospective and expectant mothers that are primarily focused on increasing intake of folate from the diet and/or folic acid supplements.2
  • With low folate status of women of reproductive age being a concern, the UK decided to join 80 countries in adding folic acid to staple food products to help reduce neural tube defects.3 Read on to find out more about the factors behind this policy change and how fortification could protect thousands of babies from developing birth defects each year.

Undernutrition – and the impact it can have on health and growth and development – is a truly global issue. Efforts to combat the effects of folate deficiency among pregnant women, for example, may often be associated with low- and middle-income countries in the popular consciousness. In reality however, life-threatening birth defects related to poor folate status are a significant issue for even the world’s wealthiest nations – prompting the question, what more can be done to ensure babies are born healthy?  

Folate: An essential building block for growing babies

Folate, also known as vitamin B9, is a key micronutrient for people of all ages, responsible for regulating cell metabolism and the production of red blood cells.4 In healthy adults, a balanced diet rich in leafy green vegetables and pulses can usually satisfy the body’s folate requirements, but during pregnancy, demand for this nutrient skyrockets.5 The neural tube, a basic precursor to the central nervous system, is one of the first organs to form in the primary stages of gestation – so early, in fact, that many women will not yet know they are pregnant.6 This process requires a much higher than average folate status, meaning additional folic acid is almost always needed to reduce the risk of potentially life-threatening birth defects.

Affecting roughly one in 1,000 pregnancies in the UK each year,7 conditions like anencephaly (the absence of the brain and top part of the skull) or spina bifida (where spinal tissue herniates outside the body), are commonly life-shortening and can result in a baby being delivered stillborn or dying soon after birth.8,9,10,11 With the recent National Diet and Nutrition Survey (NDNS) finding that 90 percent of women of childbearing age have a folate status which puts babies at increased risk of developing neural tube defects,12 there is a clear need to support adequate folic acid intake in prospective and expectant mothers.

Sizing up supplements: Advantages and limitations

In the UK, women are advised to consumer 400 mg of folic acid per day for a month before conception and during the first 12 weeks of pregnancy to help support neural tube development.13 This was mainly offered in the form of supplement tablets prescribed following the first pregnancy check-up. With awareness of the importance of folate still relatively low however,14 concerns have been raised around whether a voluntary supplement is the most effective tool for guarding against folate deficiency.

Mandatory universal fortification of staple food products has several advantages. Most crucially, it avoids the issue of inadequate folate status in unplanned pregnancies, which make up roughly half of all pregnancies in the UK.15 Mandating folic acid fortification of staple foods, such as wheat-based flour, enables women to easily incorporate additional folic acid into their daily routines throughout pregnancy, without needing to remember to take a tablet each day. The addition of folic acid to food has helped to reduce neural tube defects in a number of countries worldwide; the US has seen neural tube defects fall by 28% since the policy came into effect in 1998.16 These results have been mirrored in countries such as South Africa and Chile, where similar schemes have been implemented.17 With the benefits clearly evident, the UK is now following suit and recently introduced the mandatory fortification of all non-wholemeal wheat flour with folic acid.

Leveling up nutrition

Wheat flour fortification is not new to the UK – millers are already required to reincorporate nutrients, such as iron, thiamine, and niacin, that are commonly lost during the milling process.18 Adding folic acid to this premixed blend of vitamins and minerals is an easy and extremely cost-effective way to protect babies against spinal conditions. Beyond the initial investment, the cost of incorporating folic acid and other minerals is very low.19 UK millers are endorsing the fortification initiative considering its tremendous public health impact.20 As witnessed in several other countries, the total healthcare savings from folic acid fortification are staggering, not taking into account the myriad social benefits of reduced childhood illness and mortality.21 For example, countries that have mandated folic acid fortification of wheat flour have reported very high benefit-to-cost ratios of 12-48:1.22

Expanding folic acid fortification

The evidence shows that expanding flour fortification to include folic acid is a cost-effective public health intervention to prevent birth defects, with a significant prevention of child mortality, disabilities in children and the associated costs of care savings. With other countries in Europe starting to reconsider their own fortification policies, demand for high-quality customized nutrient premixes to transform health outcomes is only set to rise.

From staple food fortification to multiple micronutrient supplements, DSM is your end-to-end partner in the fight against nutrient deficiencies. This mission is reflected in our measurable and transparent food systems commitments, designed to deliver Health for People, Health for Planet and Healthy Livelihoods. What’s more, we are always innovating affordable, aspirational and accessible nutritional solutions to empower our customers to ensure every baby gets the positive start in life they deserve.

Ready to discover how DSM’s fortification offering can help you shape brighter futures for children worldwide? Download our dedicated wheat flour fortification brochure here:

Published on

03 November 2021

Tags

  • Essentials for early life
  • Quali-B
  • Preconception
  • Pregnancy
  • Industry News
  • Article
  • R&D
  • Procurement
  • Senior Management

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References

  1. R. J. Berry, L.B. (2010). Fortification of flour with folic acid. Food and Nutrition Bulletin, vol 31, no. 1 (supplement), p.s22, https://journals.sagepub.com/doi/pdf/10.1177/15648265100311S103.
  2. Ibid., Fortification of flour with folic acid.
  3. UK Government, Department for Health and Social Care, Folic acid added to flour to prevent spinal conditions in babies, 20 September 2021, https://www.gov.uk/government/news/folic-acid-added-to-flour-to-prevent-spinal-conditions-in-babies.
  4. University of Maryland Medical Centre. “Vitamin B9 (Folic acid)” 5 August 2015.
  5. Ibid., Folic acid added to flour to prevent spinal conditions in babies.
  6. Ibid., Folic acid added to flour to prevent spinal conditions in babies.
  7. Morris JK. Et al. Prevention of neural tube defects in the UK: a missed opportunity. Archives of Disease in Childhood. 2016; 101 (7): 604-607. http://adc.bmj.com/content/101/7/604.
  8. Centers for Disease Control & Prevention (CDC), 4.2 Congenital Malformations of the Nervous System: Neural tube defects, last reviewed 28 December 2020, https://www.cdc.gov/ncbddd/birthdefects/surveillancemanual/chapters/chapter-4/chapter4-2.html.
  9. Centers for Disease Control & Prevention (CDC), 4.2a Anencephaly (Q00.0), last reviewed 25 November 2020, https://www.cdc.gov/ncbddd/birthdefects/surveillancemanual/chapters/chapter-4/chapter4-2a.html.
  10. Centers for Disease Control & Prevention (CDC), 4.2e Spina Bifida (Q05.0-Q05.9), last reviewed 25 November 2020, https://www.cdc.gov/ncbddd/birthdefects/surveillancemanual/chapters/chapter-4/chapter4-2e.html.
  11. Centers for Disease Control & Prevention (CDC), 4.2d Encephalocele (Q01.0-Q01.83, Q01.9), last reviewed October 19, 2020, https://www.cdc.gov/ncbddd/birthdefects/surveillancemanual/chapters/chapter-4/chapter4-2d.html.
  12. NDNS Supplementary Folate Report – a summary of findings – British Nutrition Foundation, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/699241/NDNS_results_years_7_and_8.pdf.
  13. UK National Health Service. Vitamins, supplements and nutrition in pregnancy. Last reviewed 14 February 2020, https://www.nhs.uk/pregnancy/keeping-well/vitamins-supplements-and-nutrition/.
  14. Johannes Bitzer et al. Women’s awareness and periconceptional use of folic acid: data from a large European survey. Int J Womens Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3643291/.
  15. Public Health England. Health Matters: Reproductive health and pregnancy planning. 2018. https://www.gov.uk/government/publications/health-matters-reproductive-health-and-pregnancy-planning/health-matters-reproductive-health-and-pregnancy-planning.
  16. Ibid., Fortification of flour with folic acid.
  17. Ibid., Fortification of flour with folic acid.
  18. Ibid., Folic acid added to flour to prevent spinal conditions in babies.
  19. Ibid., Folic acid added to flour to prevent spinal conditions in babies.
  20. G. Hyslop. UK’s move to fortify flour with folic acid to help prevent birth defects hailed. Bakery and Snacks, 2021. https://www.bakeryandsnacks.com/Article/2021/09/21/UK-s-move-to-fortify-flour-with-folic-acid-to-help-prevent-birth-defects-hailed.
  21. Food Fortification Initiative (FFI). Cost-effectiveness of Grain Fortification. 2017 http://ffinetwork.org/why_fortify/documents/Cost-effectiveness_2017.pdf.
  22. H. Pachón et al. Folic acid fortification of wheat flour: A cost-effective public health intervention to prevent birth defects in Europe. 2015 https://doi.org/10.1111/nbu.12023.

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