Abstract
Folic acid is an essential water soluble B vitamin which has been used for decades in the prevention of folate deficiency anemia of pregnancy. In 1991, folic acid taken prior to the start of pregnancy was shown unequivocally to prevent spina bifida and anencephaly—two of the most serious and common birth (neural tube) defects. Soon governments recommended that women of reproductive age consume folic acid daily to prevent these birth defects. Because compliance was low and since more than half of pregnancies are unplanned, the United States Food and Drug Administration mandated in 1998 that all enriched flour be fortified with folic acid at a concentration estimated to give the average woman an intake of 100 micrograms of folic acid a day. Canada and Chile followed with similar requirements for folic acid fortification of wheat flour. Now there is mandatory fortification in more than 50 countries globally. Where fortification has been implemented and studied, it has led to dramatic increases in serum folate concentrations, reduction in neural tube defects, folate deficiency anemia, as well as the reduction in homocysteine concentrations and stroke mortality with no known risk. Australia implemented mandatory folic acid fortification in 2009. To date, no country in Europe has implemented mandatory folic acid fortification of flour, although it has been recommended by the UK Food Safety Authority. This review discusses the vital importance of mandatory flour fortification with folic acid and vitamin B12, for public health food security and as a challenge to the New Public Health in Europe and globally.
Highlights
Dr Lucy Wills reported in 1931 that yeast extract/marmite could provide a remarkable cure for the “pernicious anemia of pregnancy” and “tropical anemia” among her patients at the Haffkine Institute, Parel, India, where she worked at the Maternal Mortality Inquiry, Indian Research Fund Association.[1]
Folic acid was synthesized in the 1940s and has been used by millions of pregnant women to prevent folate deficiency anemia associated with pregnancy
The FDA decided based on a risk hypothesis stating that the fortification concentration should be set so that an 18-year-old male consuming a multivitamin with 400 micrograms of folic acid, and eating food made with fortified flour, would not consume more than 1000 micrograms of total folate daily—the sum of synthetic folic acid and the natural folate in food
Summary
Dr Lucy Wills reported in 1931 that yeast extract/marmite could provide a remarkable cure for the “pernicious anemia of pregnancy” and “tropical anemia” among her patients at the Haffkine Institute, Parel, India, where she worked at the Maternal Mortality Inquiry, Indian Research Fund Association.[1]. Sixty years after the Wills paper, Sir Nicholas Wald and colleagues at the United Kingdom’s Medical Research Council demonstrated that spina bifida and anencephaly are folate deficiency diseases by reporting a randomized controlled trial proving that folic acid would prevent these important birth defects. The FDA decided based on a risk hypothesis stating that the fortification concentration should be set so that an 18-year-old male consuming a multivitamin with 400 micrograms of folic acid, and eating food made with fortified flour, would not consume more than 1000 micrograms of total folate daily—the sum of synthetic folic acid and the natural folate in food They were concerned that folic acid could mask the anemia of B12 deficiency, and thereby potentially prevent diagnosis and treatment of this condition. This form of vitamin B12 deficiency would likely disappear if there was mandatory fortification of flour in Europe
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