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Should folic acid fortification be mandatory? Yes

BMJ 2007; 334 doi: (Published 14 June 2007) Cite this as: BMJ 2007;334:1252

This article has a correction. Please see:

  1. Nicholas J Wald, director1,
  2. Godfrey P Oakley, professor2
  1. 1Wolfson Institute of Preventive Medicine, Barts and The London, Queen Mary's School of Medicine and Dentistry, University of London, London EC1M 6BQ
  2. 2Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
  1. Correspondence to: N J Wald n.j.wald{at}
  • Accepted 30 May 2007

The UK's Food Standards Agency recently recommended mandatory folic acid fortification of some foods. Nicholas Wald and Godfrey Oakley argue that it's a safe effective way of preventing spina bifida and anencephaly—but Richard Hubner and colleagues say that more research into the harms is needed

Delay in fortifying flour with folic acid is unjustified. In many countries this public health measure has increased blood folate levels and reduced neural tube defects. When the effect of folic acid on neural tube defects was shown in 1991, prevention was attempted through diet and supplements.1 But supplements must be taken before pregnancy is confirmed, and most pregnancies remain unprotected.

Voluntary fortification has proved inadequate. Expert advisory committees considering mandatory fortification with folic acid have concluded that it is necessary, effective, and safe; about 40 countries, including the United States, have adopted this policy.

It is important to reach people who are less well off—they have most to gain from fortification. In Chile, where fortification has achieved a relatively high folic acid intake, neural tube defects were reduced by 43%; in the United States, with a lower fortification level, the reduction was about 20%.2 With fortification on a global basis, …

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