This year, legislation came into place requiring that folic acid be added to most non-wholemeal flours in the UK, a move that’s been standard practice in the US, Canada, and over 80 other countries for years. The goal is to help prevent neural tube defects (NTDs) such as spina bifida and anencephaly in babies, which develop in the first few weeks of pregnancy, often before a woman even knows she’s pregnant and certainly before she may have started taking a folic acid supplement.
It’s estimated around 200 cases of debilitating brain and spine defects will be prevented every year in the UK as a result. And the need to increase folate levels for this purpose is real, a 2023 study found that 89% of females of reproductive age had folate levels below the threshold associated with increased NTD risk.
This is alarming, but not surprising: we know that folate-rich foods like leafy greens, legumes and liver just aren’t making up a large part of many peoples’ diets today.
What is folic acid?
Folic acid is the synthetic form of Vitamin B9. It’s essential for DNA synthesis and cell division. Folate, the form we get from food, is found in dark green leafy veg, legumes, citrus fruits and liver. Grains contain it too, but folate is concentrated in the nutrient-dense outer layer, which is stripped away when flour is refined. Since white flour products including bread, pastry, biscuits, and cakes, are consumed so widely across society, fortification is a practical way to prevent widespread deficiency.
It’s worth noting that this isn’t new territory for UK flour which has been required to contain added iron, calcium, and Vitamins B1 and B3 for years. Folic acid is simply the latest addition to that list.
The case for fortification
Ursula Arens, nutrition writer and former dietician, is delighted with the introduction of fortification and feels it’s long overdue.
“It’s already government policy in over 80 countries. And every time a government makes that decision, they obviously have a group of scientists who spend thousands of hours checking and debating the research. And they’ve all made this decision.”
In countries with long-established fortification programmes, rates of NTDs have fallen. The intervention works.
What are people worried about?
Concerns fall into two broad camps: a general unease about fortification, and specific questions about folic acid itself.
The Soil Association opposed the change, arguing in their response to the government consultation that ‘the priority instead should be an environment in which healthy diets, based around minimally processed foods are affordable and available to everyone.’
However, they do recognise ‘that in the absence of a cohesive food strategy, and in the context of folate deficiencies, fortification of non-wholemeal wheat flour might provide benefit for vulnerable groups. But we don’t see fortification as the ideal long-term solution.’
Instead, the Soil Association is calling on the government to reduce the risk for those in vulnerable groups through dietary interventions, including secondary school age girls, by supporting their consumption of folate-rich foods. They are also requesting that any potential adverse effects be closely monitored.
In New Zealand, organic flour is exempt from mandatory folic acid fortification to preserve organic certification standards and to guarantee consumer choice for those wishing to avoid synthetic additives.
Some people have specific concerns about folic acid, which is a synthetic form of folate. Unlike the folate found naturally in food, it must be converted by the body into its active form – and not everyone does this equally well.
Lucinda Miller, Naturopath and Clinical Lead at NatureDoc, explains the distinction: ‘There are thought to be around a dozen naturally occurring folate compounds found in food that benefit human health. The one to know about is methyl folate, which is the main form naturally found in food and the active type that is most bioavailable in the body. This type of folate is essential for a process called methylation and for making the master antioxidant glutathione, which helps our cells to stay healthy, calms inflammation and supports our nervous systems. If methylation and glutathione production are compromised, this is linked to higher likelihood of developing autoimmune, inflammatory and neurological problems, as well as cancers.’
The complication? A gene variant called MTHFR.
‘The folic acid added to white flour is the synthetic form, usually made by industrial chemical synthesis in China, which the body has to convert into the methyl form. It is thought that up to 60% of the population carry a variant of a gene called MTHFR which means that this conversion from synthetic folic acid into methyl folate can be trickier to do. The outcome can mean that the synthetic folic acid builds up in the bloodstream and does not get methylated. And so, our blood might look like it has plenty of folic acid, but our cells are actually deficient in the active methyl folate which is so essential for making this vital glutathione.’
It’s worth being clear though: carrying a variant of the MTHFR gene doesn’t mean the body can’t convert folic acid, it just means the process is less efficient. Arens understands the concerns over this, but for her, it’s not an issue in practice.
‘The bottom line is that even in people with this variant, they still have the intended outcome which is reduced risk of NTDs. In fact, studies showed that in people who did have the generic variant, folic acid had a greater protective effect than on people who didn’t have this metabolic variant.’
What about Vitamin B12?
Nutrients don’t act in isolation, they interact in our bodies. Folate and Vitamin B12 work as a team. Folate helps cells make new DNA, essential for healthy red blood cells and tissue repair. B12 helps unlock and recycle folate so that it can keep doing its job. A deficiency in either can undermine the other. This is the root of another concern. High doses of folic acid can ‘mask’ a B12 deficiency, making a blood count appear normal, potentially delaying diagnosis. This is serious, as left untreated B12 deficiency can cause neurological damage.
It’s a legitimate worry, but evidence has shown that this hasn’t been a problem in the US since fortification became mandatory. Available data suggests that the levels used in fortification are not high enough to cause this ‘masking’ effect.
Still, the concern carries more weight for older people, who are already at higher risk of B12 deficiency due to reduced stomach acid and declining absorption with age. As Arens puts it: “Older people are even more at risk of low B12 levels than vegans, as their absorption rate crashes.”
There is some evidence that low levels of B12 combined with a high folic acid status may be associated with cognitive impairment in some older adult populations, but the evidence is observational, and mixed. Still, it’s important that those at higher risk of low B12 get their levels checked and supplement where appropriate.
The bottom line
Evidence suggests folic acid fortification is safe at the levels used, and effective at reducing NTDs, which can have a profound effect on those affected, and their families. That doesn’t mean that concerns are unfounded, but on balance, the risks appear manageable.
For some, this ‘mass supplementation’ will still not be desirable. If you’d prefer to avoid fortified flour, options exist. Wholemeal, spelt, and rye flours and breads provide an alternative. Smaller mills, that produce no more than 5000 tonnes of flour a year, are also exempt from mandatory fortification. The Real Bread campaign has a list of where you can buy unfortified flour.
And the truth remains, that eating naturally folate rich foods is as important as ever.
As Miller puts it: “Flour is not the best source of folate even when it is made from whole or ancient grains. Folate is more abundant in green vegetables, salad leaves, avocados, beans, pulses, liver and eggs, so we can get folate from other food sources.”
But for those in our society who aren’t eating enough of these foods – for the many complex reasons rooted in our unequal, broken food system – fortification does fill a gap.
Hannah Neville-Green is a nutritional therapist and part of the Food Team at Riverford.
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