Scotland has provided a timely reminder of why the debate raging worldwide over the fortification of flour with folic acid is of such consequence.
On 2 September, the Scottish Spina Bifida Association revealed that 15 babies had been born in Scotland with the condition since January — twice the normal number. The charity said it was possible the rise was a result of women failing to take folic acid supplements, which research suggests can prevent many cases, at the right time to prevent the condition.
Dr Margo Whiteford, consultant geneticist and chair of the Scottish Spina Bifida Association, told the BBC: "This year we've had as many contacts from families in the first half of the year as we'd expect to see for the full year. We don't know if this is down to folic acid but we do know that most women don't take enough folic acid at the right time.
"Ladies do know about folic acid preventing spina bifida but they wait until they've missed a period before they start taking it. The spinal cord develops within the first four weeks of pregnancy so by that stage it's too late. If the baby's going to have spina bifida it will already have developed it."
The charity did not call for mandatory fortification of flour with folic acid — instead it urges all sexually active women of child bearing age to take it regularly in the form of supplement to prevent neural tube defects such as spina bifida. But Whitehead's comments could easily be used by some as a strong case for fortification on the basis that not all women can be trusted to take the B vitamin.
But widespread fortification is controversial because of the effect it could have on those who do not need to consume more folic acid. High intakes of folic acid have been linked with an increased risk of certain cancers, as well as with the masking of a vitamin B12 deficiency in the elderly. Concerns about this have led governments to think twice about mandatory fortification of flour. The UK's Food Standards Agency was all set to rubber-stamp fortification in 2007, but held back at the last minute to examine the health implications of such a move in more detail. The issue is still under review.
In Ireland, regulators decided in March 2009 not to introduce mandatory fortification. This was principally because it believed women already had enough folic acid in their diets through the voluntary fortification of food and drink, a verdict that was supported in research published by Dublin University just a month ago. But concerns about the health risks were a factor too.
A fierce debate raged in New Zealand earlier this year when the bakery industry called for the government to abandon planned mandatory fortification of flour on the basis it would add to production costs, would have little impact on reducing neural tube defects and could damage some people's health. Official research also indicated an overwhelming lack of public support for the initiative.>
Mandatory fortification was due to begin in New Zealand this month, but in July the government agreed to delay any such move until 2012 while more research was conducted. Subsequently, the New Zealand bakery sector indicated it would be willing to work towards voluntary fortification as that date approaches.
New Zealand had been due to introduce mandatory fortification alongside Australia, with which it shares a food regulator in the form of Food Standards Australia and New Zealand. But Australia will now go it alone.
It will join the US, Canada and Chile, all of which have had mandatory fortification of flour for 10 years now. But for women of child bearing age in New Zealand, and the increasing number of other countries where opponents of fortification have won the day, the advice will continue to echo that of the Scottish Spina Bifida Association: "Keep taking the pills."