The most at risk women eat flour that has been exempted from fortification
Dr Clare Craig
| Key points Neural tube defect risk is highest among women of Indian and Bangladeshi origin. They are also the least likely to take a folic acid supplement before pregnancy. Despite their higher risk these groups only account for about one in fourteen affected pregnancies. Around seven in eight are to White mothers. The mandate is justified partly as a way to reach women who do not supplement. That description fits these women on both risk and uptake. Peers raised chapatti flour, the atta most South Asian families use, as the way to reach them, in 2016 and again in 2024. The mandate fortifies non-wholemeal flour only. Chapatti flour is wholemeal, so it is exempt. The whole population is exposed to folic acid while the group named as highest-risk is not reached by the mandate. |
The clearest recent estimate of how neural tube defect risk varies by ethnicity in Britain comes from a study of congenital anomaly registers in England and Wales. After adjustment for deprivation and maternal age, mothers of Indian ethnicity were 1.84 times as likely as White mothers to carry a pregnancy affected by a neural tube defect, and Bangladeshi mothers 2.86 times as likely. The excess among Indian mothers was concentrated in anencephaly and in cases occurring alongside other anomalies, which the authors linked to possible genetic factors rather than to folate intake. Findings for Pakistani mothers have varied between regions.
These same groups take folic acid before pregnancy least often. Among nearly half a million women screened in London, 35 per cent of White women reported taking a supplement before conception, against 20 per cent of South Asian women.
It is important to note that the elevated rate translates into a small number of cases. In the register data used for the ethnicity analysis, 52 of 748 affected pregnancies were to mothers of Indian, Pakistani or Bangladeshi ethnicity, about one in fourteen, with roughly seven in eight to white mothers.
The justification for a mandate in food has been based on the claim that is what is required to reach women at risk who do not take supplements. During the Lords stages of the private member’s bill that preceded the mandate, Baroness Flather argued that if folic acid were not added to all flour, it should be added to chapatti flour, the atta most Asian families use. The point returned in December 2024, when a peer asked that folic acid reach chapatti flour so the policy did not widen inequalities. The minister replied that fortification applied to non-wholemeal products, that wholemeal was already a higher source of folate, and that chapattis would be considered along with all other products.
After all that the fortification policy has exempted chapatti flour. The Bread and Flour (Amendment) Regulations 2024 require folic acid in non-wholemeal wheat flour only. Chapatti flour is the wholemeal atta used in most South Asian households, and wholemeal flour sits outside the mandate. Much wholemeal bread contains folic acid because it is made with white flour as one of the ingredients.
A blanket policy of mass medication is going to fail to reach the group with the highest recorded risk and lowest supplement use.
