End the mandatory fortification of white flour with folic acid immediately

We call on the Government to stop the fortification of flour with synthetic folic acid. Folic acid is a medicine not a food. We believe it is unethical to mass medicate the entire population without their knowledge or consent in the hope that a minority group of people might see a benefit.

The NHS website lists sections of the population (including people with cancer, a stent or low vitamin B12 levels) who should avoid folic acid exposure because of possible detrimental health impacts. Even if these people are aware of the issue, it is becoming harder to avoid as wholemeal and gluten free products are voluntarily adding folic acid.

The UK Government is mandating fortification of non-wholemeal wheat flour with folic acid with the primary objective to increase folic acid intake among women of childbearing age, thereby improving blood folate levels and reducing the risk of neural tube defects (NTDs) during pregnancy. The policy is projected to prevent around 200 NTD-affected pregnancies annually—approximately 20 per cent of UK cases. The population-level policy will have the wider benefit of increasing the intake of folic acid and improving folate status across the whole population. Folate, including folic acid, plays an important role in forming healthy red blood cells and maintaining brain health.

Previous efforts through public health campaigns to promote supplementation, as well as voluntary fortification by manufacturers, have had limited success. Despite longstanding UK public health advice recommending a daily supplement of 400 micrograms of folic acid before conception and during early pregnancy, uptake remains suboptimal, particularly among younger women and those from lower socio-economic backgrounds. Since almost half of pregnancies in the UK are unplanned, many women may not take supplements during the critical early weeks of gestation.

The policy has been carefully designed to be proportionate, targeting non-wholemeal wheat flour because it is widely consumed across the population and is the most effective vehicle for delivering the intended public health benefits. This approach is consistent with long-standing UK fortification requirements for wheat flour, including the mandatory addition of calcium, iron, niacin and thiamine, which also apply to non-wholemeal wheat flour produced to organic standards. Not fortifying wider than the type of flour that is presently fortified, means that individuals can avoid fortified flour if they choose to or need to. This includes wholemeal flour, gluten-free products and other flour types such as soya or spelt flour.

To ensure people can easily identify products that are suitable for them, added vitamins and minerals, including folic acid, must be labelled in the product’s ingredients list. This must also be declared when fortified flour is used as an ingredient.

The decision to fortify non-wholemeal wheat flour with folic acid has a long history and has been considered both by the Scientific Advisory Committee on Nutrition (SACN), which advises the four UK governments on nutrition-related matters, and its predecessor, the Committee on Medical Aspects of Food and Nutrition Policy. Folic acid fortification was recommended by the SACN in 2006, after an extensive review of the evidence on folate and health, which is available at the following link: https://www.gov.uk/government/publications/sacn-folate-and-disease-prevention-report. Since then, there have been several further evidence reviews and modelling work (for example: https://www.foodstandards.gov.scot/science-and-evidence/stochastic-modelling-to-estimate-the-potential-impact-of-fortification-of-flour-with-folic-acid-in-the-uk) to establish the level of folic acid to be added to flour, as well as to address concerns about potential adverse effects.

The policy has been subject to public consultations, including the 2019 Department of Health and Social Care and devolved governments consultation (available at the following link: https://www.gov.uk/government/consultations/adding-folic-acid-to-flour/outcome/proposal-to-add-folic-acid-to-flour-consultation-response) on the proposal to fortify flour with folic acid (including a question on the effect on small businesses), and the 2022 Department for Environment, Food and Rural Affairs (Defra)-led consultation on the Bread and Flour Regulations. These consultations allowed members of the public, industry and health professionals to provide feedback and were a key part of policy development. Feedback to the Defra consultation highlighted consumer choice as a key concern. Limiting mandatory fortification to non-wholemeal wheat flour helps preserve choice by maintaining the availability of unfortified wholemeal and non-wheat flours. In addition, the policy does not apply to flour produced by small mills (definition based on their limited production capacity).

The NHS provides guidance for individuals who may need to avoid folic acid, for example, due to specific medical conditions or interactions with medication. People in this situation are advised to seek advice from a healthcare professional. Foods in the UK have been voluntarily fortified with folic acid for many years, including products such as breakfast cereals and spreads, without evidence of adverse health effects.

The UK Government and devolved governments are exploring how we will evaluate the impact of the policy.

Department of Health & Social Care