PHOTO: PETER SANDGROUND/SBH SCOTLAND518 29 OCTOBER 2021 • VOL 374 ISSUE 6567 science.org SCIENCEI
n 2013 at the Scottish Parliament in
Edinburgh, 9-year-old Ella Chambers
of Glasgow spoke to politicians from
her wheelchair. Ella has spina bifida,
a birth defect that occurs when the
embryonic neural tube does not close
properly during the first month of preg-
nancy. She and her family were campaign-
ing for the U.K. government to mandate
fortification of flour with folic acid, a syn-
thetic form of the B vitamin folate that can
prevent many such defects. Ella’s mother
had taken folic acid supplements—but not
until she knew she was pregnant, by which
point the damage was done.
The United Kingdom studied and wran-
gled over the issue for another 8 years. Fi-
nally, last month, the country announced
it would begin the mandatory addition
of folic acid to white flour. New Zealand
made a similar announcement in July. The
U.K. decision, the culmination of a long
campaign that included pro-fortifica tionrecommendations by government science
advi sers in 2006 and again in 2017, puts
the country in line with 80 or so others,
including the United States, Canada, and
Australia, many of which made the change
decades ago.
“I couldn’t believe they had actually
done it,” says Ella, now 17, of the U.K. move.
“It was a bit of a shock—in a good way.”
“There’s nothing that can help Ella,”
who is paralyzed from her chest down and
has learning difficulties, says her mother,
Melanie Chambers. The family has worked
with Spina Bifida Hydrocephalus Scotland
to promote fortification. “But other fami-
lies hopefully won’t have to go through
what we have.”
Yet the nations of the European Union
are not following suit. For reasons that in-
clude a wariness about unnatural ingredi-
ents in food, they have steadfastly declined
to mandate flour fortification. The average
prevalence of neural tube defects (NTDs) in
19 European countries is about 10 for every
10,000 pregnancies, notably higher than inothers where fortification is required. (The
figure is seven per 10,000 pregnancies in
the United States [see graph, p. 519].)
“Europe is really dragging the chain,” says
Lyall Thurston, a veteran New Zealand activ-
ist whose 38-year-old son has spina bifida.
“It’s incredibly sad. Because the science and
the research is there.”
Babies with NTDs are born without brains
or with their spinal cords protruding from
their backs, the former killing them and the
latter often causing lifelong disability. Many
pregnancies are terminated when an NTD is
diagnosed. An estimated 70% to 80% of cases
are due to inadequate folate, an essential
nutrient that promotes DNA synthesis and
is present in leafy greens, liver, lentils, and
other dietary sources.
Back in 1991, Nicholas Wald, now a pro-
fessor of preventive medicine at University
College London, and colleagues showed that
folic acid supplements taken before and dur-
ing early pregnancy substantially reduced
NTDs. Folic acid is a synthetic form of folate
that is better absorbed than the natural form
and more effective in preventing NTDs. Be-
cause the neural tube closes by 28 days after
conception, before most women know they
are pregnant, starting in the 1990s many
countries aimed to boost the nutrient value
for everyone. They required companies to
add folic acid to white flour. (In the United
States, “enriched” rice, pasta, and cornmeal
are also fortified.) The numbers of pregnan-
cies affected by NTDs dropped in every coun-
try studied.
But no EU nation joined them. Fortifica-
tion “has not been considered justified” by
the scientific evidence, says an official of the
European Commission. Even targeted sup-
plementation isn’t uniformly urged by Euro-
p e a n p o l i c i e s , m o s t o f w h i c h d a t e t o t h e 1 9 9 0 s.
In a survey published in 2016, only three of
20 countries recommended that all women of
childbearing age take a daily folic acid pill. Al-
though 11 countries recommended folic acid
supplementation by women planning a preg-
nancy, none specified that they should start
12 weeks before conceiving, the time needed
to attain optimal protective levels, according
to work published since 2000.
Such measures are inadequate in any case,
fortification advocates say. They note that
about 50% of pregnancies are unplanned and
many women, particularly disadvantaged
ones, don’t know they need supplements.
The result is an elevated rate of NTDs in
much of Europe—in Bulgaria, for example,
22 of every 10,000 pregnancies are affected.
The rate is lower in a few countries such asMelanie Chambers (right) and her daughter
Ella, 17, who has spina bifida. They helped push the
United Kingdom to fortify flour with folic acid.By Meredith WadmanIN DEPTH
United Kingdom moves to
prevent birth defects
European Union countries are holdouts against widespread
practice of adding folic acid to flour
PUBLIC HEALTH