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Folic Acid and Vitamin B12 Fortification of Flour: A Global Basic Food Security Requirement

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Folic acid is an essential water soluble B vitamin which has been used for decades in the prevention of folate deficiency anemia of pregnancy. In 1991, folic acid taken prior to the start of pregnancy was shown unequivocally to prevent spina bifida and anencephaly—two of the most serious and common birth (neural tube) defects. Soon governments recommended that women of reproductive age consume folic acid daily to prevent these birth defects. Because compliance was low and since more than half of pregnancies are unplanned, the United States Food and Drug Administration mandated in 1998 that all enriched flour be fortified with folic acid at a concentration estimated to give the average woman an intake of 100 micrograms of folic acid a day. Canada and Chile followed with similar requirements for folic acid fortification of wheat flour. Now there is mandatory fortification in more than 50 countries globally.

Where fortification has been implemented and studied, it has led to dramatic increases in serum folate concentrations, reduction in neural tube defects, folate deficiency anemia, as well as the reduction in homocysteine concentrations and stroke mortality with no known risk. Australia implemented mandatory folic acid fortification in 2009. To date, no country in Europe has implemented mandatory folic acid fortification of flour, although it has been recommended by the UK Food Safety Authority. This review discusses the vital importance of mandatory flour fortification with folic acid and vitamin B12, for public health food security and as a challenge to the New Public Health in Europe and globally.


  1. 1.

    Wills L. Treatment of «pernicious anaemia of pregnancy» and «tropical anaemia» with special reference to yeast extract as a curative agent. BMJ. 1931;1:1059–64.

  2. 2.

    MRC Vitamin Study Research Group. Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. MRC Vitamin Study Research Group. Lancet. 1991;338:131–7.

  3. 3.

    Food and Drug Administration. Food standards: amendment of standards of identity for enriched grain products to require addition of folic acid. Fed Regist. 1996;61:8781–807.

  4. 4.

    Food and Drug Administration. Food labelling: health claims and label statements; folate and neural tube defects. Fed Regist. 1996;61:8752–81.

  5. 5.

    Berry RJ, Mulinare J, Hamner HC. Folic acid fortification: neural tube defect risk reduction–a global perspective. In: Bailey LB, editor. Folate in health and disease. Boca Raton, (FL): CRC Press; 2010.

  6. 6.

    De Wals P, Tairou F, Van Allen MI, Uh SH, Lowry RB, Sibbald B, et al. Reduction in neural tube defects after folic acid fortification in Canada. N Engl J Med. 2007;357:135–42.

  7. 7.

    Honein MA, Paulozzi LJ, Mathews TJ, Erickson JD, Wong LY. Impact of folic acid fortification of the US food supply on the occurrence of neural tube defects. JAMA. 2001;285:2981–6.

  8. 8.

    Pfeiffer CM, Caudill SP, Gunter EW, Osterloh J, Sampson EJ. Biochemical indicators of B vitamin status in the US population after folic acid fortification: results from the National Health and Nutrition Examination Survey 1999–2000 (and supplemental tables). Am J Clin Nutr. 2005;82:442–50; S1-S4.

  9. 9.

    Rosenberg IH. Science-based micronutrient fortification: which nutrients, how much, and how to know? Am J Clin Nutr. 2005;82:279–80.

  10. 10.

    Yang Q, Botto LD, Erickson JD, Berry RJ, Sambell C, Johansen H, Friedman JM. Improvement in stroke mortality in Canada and the United States, 1990 to 2002. Circulation 2006;113:1335–43.

  11. 11.

    Bailey LB, editor. Folate in health and disease. Second ed. Boca Raton: CRC Press; 2010.

  12. 12.

    Folic Acid Working Group: Berry RJ, Bailey L, Bower C. Fortification of flour with folic acid. Food Nutr Bull. 2010;31:S22–S35.

  13. 13.

    Allen LH, Rosenberg IH, Oakley GP, Omenn GS. Considering the case for vitamin B12 fortification. Food Nutr Bull. 2010;31:S36–S46.

  14. 14.

    World Health Organization and Food and Agriculture Organization. Guidelines on Food Fortification with Micronutrients. Geneva: World Health Organization and Food and Agriculture Organization of the United Nations; 2006.

  15. 15.

    Leck I. Causation of neural tube defects: clues from epidemiology. Br Med Bull.;30:158–63.

  16. 16.

    Hibbard ED, Smithells RW. Folic acid metabolism and human embryopathy. Lancet. 1965;285:1254.

  17. 17.

    Smithells RW, Sheppard S, Schorah CJ, Seller MJ, Nevin NC, Harris R, et al. Possible prevention of neural-tube defects by periconceptional vitamin supplementation. Lancet. 1980;315:339–40.

  18. 18.

    Oakley GP, Adams MJ, James LM, Smithells RW, Seller MJ, Fielding DW, et al. Vitamins and neural tube defects. Lancet. 1983;322:798–9.

  19. 19.

    Czeizel AE, Dudas I. Prevention of the first occurrence of neural-tube defects by periconceptional vitamin supplementation. N Engl J Med. 1992;327:1832–5.

  20. 20.

    Centers for Disease Control and Prevention. Use of folic acid for prevention of spina bifida and other neural tube defects–1983–1991. MMWR Morb Mortal Wkly Rep. 1991;40:513–6.

  21. 21.

    Centers for Disease Control and Prevention. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR Morb Mortal Wkly Rep. 1992;41:1–7.

  22. 22.

    Botto LD, Lisi A, Robert-Gnansia E, Erickson JD, Vollset SE, Mastroiacovo P et al. International retrospective cohort study of neural tube defects in relation to folic acid recommendations: are the recommendations working? BMJ. 2005;330:571.

  23. 23.

    Shojania AM, von Kuster K. Ordering folate assays is no longer justified for investigation of anemias, in folic acid fortified countries. BMC Research Notes 2010;3.

  24. 24.

    Berry RJ, Li Z, Erickson JD, Li S, Moore CA, Wang H, et al. Prevention of neural-tube defects with folic acid in China. China-U.S. collaborative project for neural tube defect prevention [corrected; erratum published 341:1864]. N Engl J Med. 1999;341:1485–90.

  25. 25.

    Morris MS, Jacques PF, Rosenberg IH, Selhub J. Folate and vitamin B-12 status in relation to anemia, macrocytosis, and cognitive impairment in older Americans in the age of folic acid fortification. Am J Clin Nutr. 2007;85:193–200.

  26. 26.

    Yang Q, Cogswell ME, Hamner HC, Carriquiry A, Bailey LB, Pfeiffer CM, et al. Folic acid source, usual intake, and folate and vitamin B-12 status in US adults: National Health and Nutrition Examination Survey (NHANES) 2003–2006._Am J Clin Nutr. 2010;91:64–72.

  27. 27.

    Bell, KN and Oakley, GP, Jr. Update on prevention of folic acid-preventable spina bifida and anencephaly. Birth Defects Res Part A 2009;85:102–7.

  28. 28.

    Lindenbaum J, Rosenberg IH, Wilson PW, Stabler SP, Allen RH. Prevalence of cobalamin deficiency in the Framingham elderly population. Am J Clin Nutr.1994;60:2–11.

  29. 29.

    Winkels RM, Brouwer IA, Clarke R, Katan MB, Verhoef P. Bread cofortified with folic acid and vitamin B-12 improves folate and vitamin B-12 status of health older people: a randomized controlled trial. Am J Clin Nutr. 2008;88:348–55.

  30. 30.

    Institute of Medicine. Dietary reference intake: thiamin, riboflavin, niacin, vitamin B6, folate, p antothenic acid, biotin, and choline. Institute of Medicine: Washington (DC): National Academy Press 1998.

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Correspondence to Godfrey P. Oakley Jr. MD, MSPM.

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Key Words

  • folic acid
  • vitamin B12
  • food fortification
  • micronutrients
  • birth defects
  • spina bifida
  • neural tube defects
  • anemia
  • homocysteine
  • stroke
  • nutrition