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Folic acid fortification for Europe?

BMJ 2015; 351 doi: (Published 24 November 2015) Cite this as: BMJ 2015;351:h6198
  1. James L Mills, senior biomedical research service scientist,
  2. Aggeliki Dimopoulos, IRTA postdoctoral fellow
  1. 1Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD 20892, USA
  1. Correspondence to: J L Mills millsj{at}

Europe should consider mandatory fortification; the current strategies are not solving the problem

In 1991 the UK Medical Research Council published the exciting finding that women who took folic acid before conception could reduce their babies’ risk of a neural tube defect by as much as 72%.1 The US Public Health Service met and quickly issued a recommendation that all women of childbearing age capable of becoming pregnant should take 400 µg folic acid daily.2 Some of us who attended the meeting had doubts that women would take folic acid as instructed. Half of pregnancies are unplanned, and these women could be less motivated to take folic acid. In fact, many folate related neural tube defects were not prevented despite this recommendation and voluntary fortification in the United States. This led the United States to institute mandatory fortification of all enriched cereal grains (cereal, bread, rice, pasta) in 1998.3 Almost 80 countries have now instituted similar programs, and countries that fortify have experienced dramatic falls in rates of neural tube defects. Given that the recommendation that women take supplements had a modest effect in the …

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