Fortifying flour with folic acid can help prevent neural tube malformations in newborns
Neural tube defects (NTDs) are congenital malformations that can have very serious consequences for the development of a newborn’s brain and spinal cord. To improve the prevention of these defects, ANSES recommends fortifying wheat flour with folic acid, the synthetic form of vitamin B9, in addition to vitamin B9 supplementation for women planning a pregnancy. This measure would compensate for the inadequate vitamin B9 intake of these women, which is one of the main risk factors for NTDs in unborn children. The Agency’s expert appraisal on the prevention of NTDs included an initial socio-economic analysis of various options for action and recommended a stakeholder consultation, with a public health objective of scaling up prevention.
Women of childbearing age in France have inadequate vitamin B9 intakes
NTDs affect more than one in a thousand pregnancies in France. Several risk factors can be at the root of these malformations: a family history of NTDs, certain treatments – in particular anti-epileptic drugs – diabetes, obesity and inadequate folate status in the mother. It should be noted that a daily intake of 600 micrograms of vitamin B9 is necessary at least four weeks before conception and up to 12 weeks of amenorrhoea. And yet this intake is seldom reached in practice.
According to several French studies and the 2021 National Perinatal Survey, less than a third of women say they started vitamin B9 supplementation before they became pregnant, even though this is recommended. This proportion decreases with social inequality: studies show that the younger and less educated mothers are, the less likely they are to report having started taking vitamin B9 before their pregnancy.
Systematic folic acid fortification of wheat flour is useful for preventing NTDs
In its expert appraisal, ANSES concludes that systematic folic acid fortification at a level of 200 µg/100 g of wheat flour (white and wholegrain) would help reduce the risk of NTDs in France. Indeed, a decrease in this risk has been observed in the many countries where this measure has already been implemented.
“Wheat flour was chosen as the food to be fortified for two reasons: it is an ingredient used in many staple products (breads, biscuits, etc.), and these products are affordable for all the women targeted”, explains Vincent Bitane, scientific coordinator of the expert appraisal.
This systematic folic acid fortification also helps increase the intake of the rest of the population, without exposing it to health risks. A World Health Organization (WHO) resolution issued in 2023 encourages countries to implement such fortification.
In France, fortification would complement the recommendation for vitamin B9 supplementation during pregnancy. ANSES therefore recommends that healthcare professionals be made more aware of the need to prevent NTDs in women of childbearing age. These women should be informed of the importance of a diet rich in pulses (chickpeas, kidney beans) and dark green vegetables (spinach, broccoli, lettuce) and of taking folic acid supplements before they become pregnant and then during the first three months of pregnancy.
Public health prevention measures need to be taken after consulting with stakeholders
Systematically fortifying wheat flour with folic acid and improving supplementation practices can raise socio-economic questions. Based on an initial socio-economic analysis, the expert appraisal highlights the main challenges associated with the various prevention options that could be considered, including the systematic fortification of staple ingredients or foods. To document the implications of various options, ANSES recommends planning a consultation with the stakeholders involved, as has been done in other countries such as the United Kingdom.
Going further
Vitamin B9
Vitamin B9 is essential for certain functions of the body, particularly cell renewal. In which foods is it found? Which population groups are most likely to be consuming inadequate amounts? What are the health risks of this inadequate intake? All the answers to these questions are in this article.