Flour fortification with folate the Germans' unloved child

by Dr. Lutz Popper and Michael Gusko
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What flour has to do with human dignity

On May 8, 2000 the former Federal Institute for Health Protection of Consumers and Veterinary Medicine (BgVV) organized a public hearing on the fortification of flour with folic acid (folate). Prof. Dr. med. R. Großklaus, head of the Institute’s department for Nutritional Medicine, opened the hearing with the following words: “Human dignity and basic human rights should be granted to the unborn from the beginning of their existence.”

There was no denying the facts: 98% of the women and 95% of the men in Germany had an inadequate intake of the vitamin folate. The associated health risk was pregnancies resulting in severe deformities in the newborn (neural tube defects: spina bifida). At the time there were still 800 – 1,000 neural tube defects every year (1‰ of all pregnancies).

Representatives of four interested groups were asked to give their opinions:

  1. The nutritional physicians felt that fortification of flour with folate would have a beneficial effect on health.
  2. The Association of the German Milling Industry (Verband deutscher Mühlen, VDM) expressed the view that to dose folate at mills would be technically feasible since it was possible to treat flour very precisely with ascorbic acid in any case. The cost of fortifying all basic German flour with folate would be less than one million EUR a year – a fraction of the cost to the economy of treating neural tube defects at that time.
  3. On the other hand, the German Nutrition Society (DGE) had reservations about fortifying staple foods. Its members felt it would be sufficient for all consumers to eat more fruit and vegetables.
  4. The Study Group of the Consumer Associations (AgV) commented that only a minority of pregnant women was affected. It would be better to inform women about the need for folate. The statement was accompanied by an open threat: “We shall take action against any mandatory fortification.”

Fifteen years have passed since this hearing. Fifteen years in which the consumption of fruit and vegetables has not increased. Fifteen years in which women have not been given more information about the preventive consumption of folate as a vitamin. Fifteen years, and over 10,000 severely deformed children. Fifteen years of suffering and grief. And also fifteen years in which a multitude of new data have been collected on the efficacy and safety of fortification with folate. So let us give a current overview of the use of folate in flour.

The present status of flour fortification

The fortification of wheat flour is prescribed by law in 81 countries (FFI, 2014). In most cases the addition of vitamins and minerals is restricted to iron preparations and folate. Numerous scientific studies and epidemiological surveys have demonstrated the benefit of fortifying staple foods even in developed countries. In all cases the few contrary results have been refuted, or considerable systematic shortcomings were found in the studies on which they were based.

In Europe, flour is only fortified (with iron) in the United Kingdom. One argument put forward against fortification in Europe is loss of the consumer’s freedom of choice as a result of mandatory fortification of staple foods. It is also argued that consumers are adequately supplied with nutrients, or that there is even a risk of overdosing if food supplements are consumed at the same time. A vitamin B12 deficiency is often accompanied by an undersupply of folate; some 30 percent of all elderly people have an inadequate intake of vitamin B12. The increased administration of folate through a basic food may conceal a vitamin B12 deficiency; this can only be prevented by simultaneously fortifying foods with vitamin B12. One argument in favour of fortifying staple foods is that this is the only reliable way to reach financially weak or poorly educated sections of the population.

Effects of folate deficiency

Folic acid and its salts, the folates, are involved in cell division, growth processes and protein metabolism. A lack of folate in the blood of expectant mothers can lead to severe developmental anomalies in the foetus, which may result in reduced intellectual ability or even neural tube defects (NTDs, e.g. an open spinal canal [Spina bifida], Hydrocephalus, Anencephalus etc.) or death of the unborn or newborn child. In Europe, about one neonate in 1,000 births is affected. That does not include prematurely aborted foetuses. About two-thirds of the babies survive, but a quarter of these are so severely disabled that they die within a month (Fig. 1). The remaining half of the newborn children with neural tube defects are affected to different degrees. In some cases their life expectancy and quality of life are drastically impaired (Tab. 1).

Fig. 1: Progression tree for neural tube defects (data from the Netherlands; modified from Jentink et al., 2008, with permission)

Tab. 1: Life expectancy and quality of life with NTD (modified from Jentink et al., 2008.
1.0 = full quality of life)

Besides the negative effects of folate deficiency in mothers on the development of the unborn child there are indications that the quality of the sperm is impaired too. The effects of folate deficiency presumably include changes in the number of chromosomes. That mayresult in sterility, miscarriages or developmental anomalies caused by the Down syndrome, Turner syndrome or Klinefelter syndrome.

To those who are not affected, these phenomena may seem very abstract and distant. But for the many victims of folate insufficiency in food they mean a drastic impairment of their quality of life – and one that need not have happened, because it could have been prevented by simple means.

But as we will explain below, our society as a whole is affected – if not because of the sympathy we feel obliged to show, then at least because of the considerable cost of making survival possible or easier for the disabled sufferers.