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On October 16th, Mathew Limb reported that the UK is poised to start fortifying flour with folic acid to help prevent birth defects such as spina bifida and anencephaly, affecting around 1000 pregnancies per year. Food fortification is one of the most powerful public health tools available to improve health and even save lives. Canada mandated white flour fortification with folic acid exactly twenty years ago (November 1998). It has been a huge success at a very low cost, estimated to be US$0.50 per metric ton of flour (1). Of 337,000 women from Ontario who underwent antenatal maternal serum screening for open NTD between January 1994 and August 2000, the rate of open NTD before fortification was 1.13 per 1000 pregnancies, declining to 0.58 per 1000 pregnancies after fortification thereafter (crude rate ratio [RR] = 0.52; 95% confidence interval [CI], 0.40 to 0.67) (1). Similar rates of decline were observed across Canada (2).
At an estimated decline of 50% in NTDs after folic acid fortification of flour, had the UK mandated flour fortification in 1998, as was the case in Canada, about 10,000 tragic cases would have been averted.
1. Ray JG, Meier C, Vermeulen MJ, Boss S, Wyatt PR, Cole DE. Association of neural tube defects and folic acid food fortification in Canada. Lancet 2002;360:2047–8.
2. De Wals P, Tairou F, Van Allen MI, et al. Reduction in neural-tube defects after folic acid fortification in Canada N Engl J Med 2007;357:135-42.
No competing interests
22 October 2018
Chief, Global Child Health
Hospital for Sick Children, University of Toronto
525 University Avenue, Toronto, Ontario, Canada M5G2L3