Folic acid fortification of wheat flour: A cost-effective public health intervention to prevent birth defects in Europe

Neural tube defects (NTDs) annually affect an estimated 320 000 newborns worldwide. Folic acid (FA), provided through supplementation and fortification, is an effective primary-prevention strategy for NTDs if consumed in the periconceptional period. However, the potential impact of FA supplementation is tempered by low compliance. Countries that mandate FA fortification of wheat flour report an average reduction of 46% in NTD birth prevalence and favourable benefit : cost ratios of 12-48:1. Despite the well-documented benefits of fortification and the new evidence that provides a better understanding of purported risks associated with FA, European countries have yet to embrace this public health initiative. Viable primary-prevention strategies are needed given that an estimated 4500 NTDs occur in the 27 countries of the European Union annually, of which 72% end in terminations. Many existing factors will facilitate the success of FA flour fortification programs in the region: widespread consumption of wheat-based products, a technologically advanced milling industry, experience adhering to and monitoring food safety measures, and familiarity with mandatory food fortification.