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Healthy Evidence
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Why didn't the UK fortify flour with folic acid

Was doing research today into the following story - dailymail.co.uk/news/articl... - and the one thing that puzzles me is why the UK didn't choose to fortify flour with folic acid like most other developed nations in the late 1990s; once the evidence became available that such a move would prevent birth defects.

There doesn't seem to have been any industry objections - reportedly the food industry are happy to comply.

Was there some sort of weird - Daily Mail / Daily Express -esque - "hands of our bread" campaign?

"Fury at secret EU plan to add dangerous supplements to our bread!" ?

Or did the politicians just never got around to doing it?

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There has been debate over many years on whether or not this is a good idea:

should everyone be 'medicated' via bread?

is the added folic acid in a form that the body can metabolise?

Is there a link to an increased risk of cancer for some people?

This is one past paper from the NHS


Some thirty years ago, two of my friends had babies with a severe neural tube defect, both were anencephalic. It was a truly terrible experience for them and their families, and anything that prevents this happening would be welcomed.


Doesn't folic acid mask B12 deficiency?


It can and does.

Perhaps the problem is that B12 deficiency is often picked up by high MCV. Iron deficiency also contributes to masking that. If B12 deficiency were better identified by other techniques, the folate/folic acid masking might become very much less important. Hopefully, there could even be an improvement in B12 deficiency identification.

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We have seen a massive rise in the numbers of people avoiding gluten and/or wheat over the past few years. Not only the well-known coeliac sufferers but also non-celiac gluten sensitivity, wheat allergy, autism, ADHD, multiple sclerosis and irritable bowel syndrome (IBS) – and, my niche, those suffering from thyroid disease believed to have at least some autoimmune component. As well, of course, as the paleo and other diet followers who positively avoid carbohydrate foods.

Is there any sense in now implementing folic acid fortified wheat flour? A possibly important subset will not benefit because of their non-consumption of wheat flour. With most of these widespread fortification programs, once implemented it tends to be assumed that no-one will ever again suffer from a lack of the fortification agent. Which leads to those who do suffer being even more out on a limb and marginalised.

We need to appreciate that many of these issues merely need to be suspected. They don’t need to be “scientifically” proved. After all, if your thyroid disorder seems to have less of an impact on you by avoiding gluten and dairy, wouldn’t you consider following such an elimination diet? Certainly seems more appealing than staying put, not trying, and feeling dreadful.

We already have mandatory addition of iron, thiamin, nicotinic acid or nicotinamide and calcium carbonate (with various detailed exceptions) to flour. How much more do we expect to deliver via wheat flour?

When it comes to the extremely important issue of neural tube defects, I see it is often claimed that fortification alone is inadequate – and direct supplementation is necessary. If that is indeed the case, perhaps the concentration should be on delivering those supplements?


In the age of 'evidence-based medicine', this is an example of non-action, despite solid gold data proving protective effects on NTD developments in the foetus, if mothers-to-be have a higher folic acid intake before or very very early in pregnancy.

However concerns over the 'mass medication' of the population have been possible delayed diagnosis of B12 deficiency in elderly, and possible cancer acceleration (cancer cells develop faster with more folate).

However (part 2) is that folic acid in now added by law to flour in more than 80 countries: the USA, who possibly have the best data collection, confirm a halving of NTD occurrence and public health savings of more the 500 million US dollars. They also report no observations of changes to population cancer patterns that could be attributable to folic acid fortification.

However this is not (just) about science - it is about food policy and philosophies which always makes decisions more messy and complicated. Also of note, is that there are no folic acid policies in any EU countries (although it could also be argued, that any company is free to fortify foods on a voluntary basis, and reading breakfast cereal labels shows that this indeed happens). So perhaps the EU wide position of all-or-nothing, i.e. 'level playing field' is the hinderance?

But the Scientific Advisory Committee on Nutrition (SACN) have now written to Health Ministers in the UK saying "why are we waiting?" Some pronouncement is awaited.


No downsides then?


You say: "once the evidence became available that such a move would prevent birth defects.".

This is a simple answer. However, it does not consider the complications if such an action was taken. Would the lifetime of the bread be reduced because a better growth medium is provided to bacteria and fungi. Some bread moulds are poisonousness. Quite a number of people are unaware of this issue. Which leads to the question how much of the problem was due to eating poorly stored bread? I do not think that this was ever investigated.

I read somewhere that B vitamins need to be taken as a complex as an overdose of one B vitamin would wash out the other B vitamins which would not be a good thing. So lots of folic acid in bread could mean a reduction of other B vitamins.

B vitamins if I recall correctly can be produced by bacteria in the gut. Some people can lose this bacteria as a result of antibiotics etc or never had them in the first place. My understanding is that it would not be possible to determine who would have a shortage of B vitamins and who would have a reasonable supply. I do not know what the up to-date research on this matter is. Could someone enlighten me?

Some people do not absorb B vitamins from the diet very well. These people would need to be made aware of their poor absorption. Was this ever done? Not sure if vitamin B absorption is a variable and if it is how do you check for this?

Answers are never simple.

Just some food for thought.


Back in 1972, when pregnant, I was accused by my doctor of not taking my iron pills because I was anaemic. Not once, but twice. After which he gave me Folic Acid supplement which solved the problem.

I'm therefore surprised that folic acid alone is thought to be responsible for babies with severe neural tube defects.


Folic acid is prescribed to pregnant women. There is no need to fortify flour.


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