The Department for the Environment, Food and Rural Affairs (DEFRA) are still considering fortifying flour with Folic Acid. There has been some developments in this area. Niacin, Thiamin, Iron and Calcium are all added to bread. This practice began in 1940 when millers were required to extract 80% of flour from grain. This was reduced to 70% in 1954 but it was considered wise to keep adding the nutrients to compensate for any dietary deficiency. Calcium was added to flour to compensate for the lack of dairy products in the diet of the population due to strict rationing of dairy products. All milled flour (with the exception of wholemeal) is required to have Niacin, Thiamin, Iron and Calcium added to it.
The Scientific Advisory Committee on Nutrition (SACN) were asked to look at whether this practice should be continued and they concluded:
“In order of public health nutrition importance, the case for maintaining the mandatory addition of calcium to wheat flour (other than wholemeal flour) is strongest, followed by iron. Evidence to continue the mandatory addition of niacin and thiamin to wheat flour (other than wholemeal flour) is much weaker”.
So it could be that the mandatory fortification of flour with Niacin and Thiamin may be discontinued though Iron and Calcium will remain. Thiamin is also known as Vitamin B1; Niacin is also known as Vitamin B3.
And that brings me back to the issue of fortifying flour with Folic Acid. No decision has yet been taken – here’s what the SACN have to say:
In 2006 SACN concluded that mandatory fortification of flour with folic acid would reduce the risk of inadequate folate status in women most at risk of neural tube defect-affected pregnancies. The decision whether to introduce mandatory fortification of flour with folic acid is with government Ministers.
So they have simply stated that adding folic acid to flour would “reduce the risk of inadequate folate status” in pregnant women – thereby reducing, quite significantly, the risk of the foetus developing neural tube defects (such as spina bifida). So why the delay? There have been significant reductions in the number of babies being born with neural tube defects where folic acid is added to flour (both Canada and the USA have been fortifying their flour for years with an accompanying decrease in the number of neural tube defect births) and so really it should be a no-brainier.
Well there is a drawback – high levels of Folic Acid can mask one of the indicators of B12 Deficiency – enlarged red blood cells. When a Full Blood Count is conducted B12 is not analysed; instead doctors will look for enlarged red blood cells (macrocytosis) as an indicator of either alcohol abuse or low B12. So does that mean we shouldn’t be fortifying flour? Well, if all patients with low B12 status had macrocytosis then there would be a case for not fortifying flour. The fact is that only around 60% of patients with low B12 levels will display any macrocytosis. So should the Pernicious Anaemia Society be against of for folic acid fortification? This has been a question that we haven’t really answered for many years. I think I now know the answer.
The evidence that folic acid fortification causes a decrease in the number of babies born with Neural Tube Defects is compelling. Over fifty countries in the world now have mandatory fortification of flour. And according to the Flour Fortification Initiative those countries that have introduced folic acid fortification have seen Neural Tube Defects fall by between 30% and 60% and this fall not only leads to healthier babies but also reduces the cost of healthcare in dealing with the consequences of Neural Tube Defects.
So what should we be doing? I believe, and this is my own personal opinion and not that of the PA Society, I believe we should support folic acid fortification with one proviso. The serum B12 test – although the current test is flawed and not really fit for purpose – should be made part of the Full Blood Count. Something will have to be done about the current test and a replacement introduced which should, hopefully provide doctors with a more accurate picture of the patient’s B12 status.
Fortify flour with folic acid but introduce a better test for serum B12 and make that test part of the Full Blood Count – a win win situation.
Dear Martin,
I think it doesn’t work this way.. In politics it works like this: your words become twisted around and they will say: sure PS soc is also in favor.
My personal opinion is: Say NO, not before all B12 problems are recognized, well educated in Med school etc. People are sloppy and don’t read very close (sorry for my english)
SAY NO to this otherwise to many will suffer to much
There are numerous problems with folic acid fortification – not least in that Folic Acid is not folate.
Secondly, and I discussed this last year with several food standard authorities, there could well be a problem with the interpretation of underlying studies leading to the current daily amounts of voluntary and/or mandatory supplementation.
When it comes to folic acid masking b12 deficiency and the subsequent serum b12 levels being raised – well, again numerous arguments. However, since they haven’t raised the lower end range and even if they do we don’t know to what, then the argument, at the present time, is academic. From a purely personal perspective, I do not want to see folic acid supplementation.
Hi Martyn,
I am against folic acid (and or B12) being added to food products purely as there is still conflicting research data implying to much folic acid (and or other B vits) stays unmetabolised in the body and some research data suggesting this may cause harm (cancer),see topic on forum:http://www.pernicious-anaemia-society.org/phpbb/viewtopic.php?f=6&t=11493
I personally do not believe its good to mess with food, keep it as natural as you can and at least give the consumer a chance to keep their food intake natural..If one wants to add folic acid then one can buy a supplement..if one does not want to add arteficial supplements to their diet then that should at least be an option,
Kind regards,
Marre.
Hi Martyn,
Please see second para of this new paper.
Jan 2014
http://www.ncbi.nlm.nih.gov/m/pubmed/24445402/?i=3&from=folate
Autism has rocketed in the States. I feel a decision on FA fortification should not be made until we know if MTHFR patients & B12ds have been harmed by FA in the US. Docs still can’t tell us if MTHFR patients need the active form of folate. Alternative med sites say MTHFRs are harmed by FA. Also very small study in Irish children showed 10% had unmetabolised Folic Acid in their systems following fortification. 10% equates to the percentage of the US population who are homozygous MTHFR 677T.
Drs also need to make a firm decision on whether or not to include B12d in pre-pregnancy work up before prescribing FA /folate in my opinion.
Hi Martin, I have just been watching “Diagnosing and Treating B12 Deficiency” on YouTube which runs for 51.46 minutes. Its an American documentary that discusses 4 cases of B12 deficiency. It raises the folic acid fortification issues discussed but also advises that testing for B12 deficiency should include the following tests: Serum B12; HoloTranscobalamin; Homocysteine; Methylmalonic Acid; and Unsaturated b12 Binding Capacity. I wonder if any of these tests are available over here in the UK. I know a test for Intrinsic Factor is available, but have never heard of any of these others before. Although I am currently having monthly injections of cyanocobalamin and my serum B12 levels seem to be high as a result I’m not feeling the full benefit of the injections and wonder whether I would benefit from the American methylcobalamin instead. Hope you find the above of interest.
Yes I’ve seen the video. New guidelines (draft) on cobalamin by the British Committee for Standards in Haematology mention the MMA test as being a second line test. It’s a myth that once B12 levels are back to ‘normal’ or above normal then the symptoms disappear. See my second book ‘Living with Pernicious Anaemia and B12 Deficiency’ published by Hammersmith Books