Question to the Department of Health and Social Care:

To ask the Secretary of State for Health and Social Care, what assessment his Department has made of the potential impact of the mandatory fortification of non-wholemeal wheat flour with folic acid on people with pernicious anaemia and other medical conditions for whom folic acid supplementation may not be appropriate.

Folic acid fortification was recommended by the Committee on Medical Aspects of Food and Nutrition Policy in 2000 and by its successor the Scientific Advisory Committee on Nutrition (SACN) in 2006, after an extensive review of the evidence on folate and health. The SACN has further considered the evidence in its 2009 report to the Chief Medical Officer on folic acid and colorectal cancer risk and its 2017 update on folic acid. The tolerable upper limit was also re-considered by the Committee on Toxicity (COT) in 2018.

In its 2006 report on folate and disease prevention, the SACN considered data from hospital discharge surveys in the United States of America, where mandatory fortification of enriched cereal grain products with folic acid was authorised in 1996 and fully implemented in 1998. The data suggested that the number of cases of pernicious anaemia or subacute combined degeneration of the spinal cord had not increased post-fortification. This suggests that mandatory fortification had not led to a delay in the detection of vitamin B12 deficiency by masking the diagnosis of pernicious anaemia.

In the SACN’s extensive review of the evidence on folate and health it considered other medical conditions for whom folic acid supplementation may not be appropriate including epileptic patients on phenytoin, an epileptic drug, pregnant women in the context of multiple births and embryo selection and anti-folate chemotherapy. For each, the SACN noted that there is no evidence or no substantive evidence to suggest that folic acid fortification would cause adverse health outcomes.

The policy was developed with Government’s public consultations on both the impact assessment and legislation. This issue was considered as part of the consultation and impact assessment process.

The level of folic acid chosen for fortification, 250 micro grams per 100 grams of flour, was based on modelling carried out by Food Standards Scotland. The level of fortification has been chosen in order to minimise the risk of the population exceeding the tolerable upper intake level and therefore the risk of masking the diagnosis of pernicious anaemia. COT concluded in 2018 that “Further work is needed to identify the maximum level of folic acid intake at which masking would not occur. However, it is very unlikely that this would be such that the [upper limit] for intake would be less than 1 mg/day, as at present.”

The Government is planning an evaluation on the impact of the policy to assess the effectiveness of the level of mandatory folic acid fortification for both the prevention of neural tube defect affected pregnancies but also to check that the population are not routinely exceeding a tolerable intake and identify any further unintended consequences.