Folic Acid: How Much Is Enough?
Article by Leonie Jones, ANutr
Folic acid (vitamin B9) is being proposed as a mandatory fortification in non-wholemeal wheat flour. This has sparked a discussion on whether the proposed amount is too low, or just enough!
What is folic acid?
Folic acid is the synthetic version of the naturally occurring vitamin - folate (found in many foods), also known as B9 (1). Folate is important as it can assist in the production of red blood cells in the body (2), as well as an array of other benefits, especially within the development of a foetus (3). Folic acid is used in the fortification of certain foods, as well as in supplements.
Can you get enough folic acid from food alone?
The Association of UK Dietitians suggest ways in which folate can be implemented into our diets, this includes eating certain cruciferous vegetables such as spinach and cabbage as well as beans and legumes, citrus fruits and meats such as poultry, pork and liver (1). Although these are all good sources of folate, it is challenging for women to get enough folate from food alone (4), and different types of cooking methods can destroy natural folate levels (5,6).
The Scientific Advisory Committee on Nutrition (SACN) also highlights how the levels of folate from foods alone are relatively low, as well as absorption rates of folate being 50% lower than that of folic acid (4). This is why if you are expecting to become pregnant, or in the early stages of pregnancy it is important to focus on the supplementation of folic acid (7).
Why Fortify With Folic Acid?
The current reference nutrient intake (RNI) (the estimated amount of a nutrient needed within populations to be healthy) of folic acid is 0.2mg (200mcg) every day (8). A study done in 1991 by the Medical Research Council (MRC) Vitamin Research Group found evidence for Neural tube defects (a developmental condition) to have been significantly minimised (72%) when 0.4mg (400mcg) folic acid was supplemented prior to and during early pregnancy (9). The Scientific Advisory Committee on Nutrition (SACN) (UK) endorsed these guidelines of 0.4mg of folic acid for pregnant women in 2006 and are remaining unchanged (4). This is now the standard recommendation within the NHS, with supplementation starting every day before pregnancy and every day afterwards until the 12th week (7).
Despite these precautions, around 1000 pregnancies are affected each year within the UK by neural tube defects, which can be prevented through increased folic acid intake (10). The issue is still very much present, as not every mother will undergo supplementation (11) and unplanned pregnancies are common in the UK (45%) (12). This is where the fortification of folic acid in food comes in.
The Proposal
Recent implementation proposals have been issued as of late 2022 which discussed the update of ‘The Bread and Flour Regulations’ (which specify the rules of the composition and labelling of bread and flour). The regulations exist in order to ensure the fortification of milled white and brown non-wholemeal wheat flour in the UK with added vitamins and minerals within the public. The proposals made to alter these regulations within the UK were to now also introduce folic acid fortification in non-wholemeal flour to prevent foetal neural tube defects (NTDs) (13).
The Debate: Not enough or too much?
The UK Government recently proposed to add 0.25mg of folic acid per 100g of non-wholemeal wheat flour. They also stated that adding folic acid to flour and foods which include flour will “help to avoid around 200 neural tube defects each year - around 20% of the annual UK total” (14). Neena Modi, professor of neonatal medicine at Imperial College London said that the proposed amount was too little and that there should be “four times this amount”, 1mg per 100g of flour (15). Scientists have also made arguments against the estimated amount of a 20% NTD risk reduction being too low (16). An article published in The Journal of Medical Screening claimed that by increasing the proposed dose of fortification, the reduction of neural tube defects would increase to about 80% (17).
There's some debate around whether the UK’s current tolerable upper intake limit (UL) of 1 milligram per day of Folic acid is too low. A UL is essentially the maximum daily amount of a nutrient you can safely consume without harming your health (18). A study in 2018 argued that this UL on folic acid in the UK is based on a flawed analysis of evidence (19). They pointed out that over 80 countries fortify flour with folic acid and have not reported any negative effects (19). The UK Committee on Toxicity (CoT) has said that the UL exists because there isn't enough data on the long-term effects of exceeding it, so more research is needed (20).
Other concerns scientists have include the limitations of folic acid only being fortified in non-wholemeal flour. They suggest that folic acid should be added to all flour/flour-containing products (15). An independent charity that focuses on research for coeliac disease has also said that gluten-free products should be covered by this legislation (26). There is a general argument that those allergic to gluten, as well as those who do not eat wheat-based foods, will get no benefit, and that other products such as rice should also be fortified with folic acid (15).
Many are critical of the delay in this process of implementing folic acid into wheat-based foods due to the fact other countries have been undergoing this process for years (16). The Department for Environment, Food and Rural Affairs (DEFRA) stated their reasoning for choosing to fortify only non-wholemeal wheat flour is due to providing the consumer with a choice (21).
Supplementation vs fortification
Jonathan Bestwick, from Queen Mary University of London, originally co-authored a study which discovered that amongst nearly 500,000 women, fewer than 1 in 3 underwent folic acid supplementation prior to pregnancy (11). Bestwick said that supplementation of folic acid has “failed’’, and the fortification of flour with folic acid should be implemented as an alternative measure in order to save lives (22). It has been shown in various studies that compliance with folic acid supplementation within pregnant women falls short (23,24, 17). This highlights the reason as to why many are urging for folic acid to be fortified to a degree which will carry out the prevention of devastating birth defects.
Summary
It is clear that many experts within the nutrition field are in favour of ‘The Bread and Flour Regulations’ being amended to a higher level of folic acid fortification in flour than what is currently being proposed. Charities such as Shine stand in support of those affected by neural tube defects, Shine Chief Kate Steele said “After more than 25 years of campaigning for this, we look forward to the day that mandatory fortification with folic acid finally becomes a reality” (25). It was found that when mandatory folic acid fortification in bread was introduced in Australia, neural tube defects decreased by 14% (25).
For now, we are awaiting the final adaptation of future Bread and Flour Regulations. The question that is on everyone's mind is; how much folic acid will be fortified into our products, and will the decided amount prevent as many birth defects as possible?
This blog post was written by Leonie Jones, a Registered Associate Nutritionist (ANutr), who studied BSc (Hons) Nutrition and Health with First Class Honours. Leonie has had a passion for nutrition from a young age and enjoys deep diving into different aspects that can influence health such as diet, exercise and sleep. Leonie volunteers at FoodCycle and Hammersmith hospital in order to provide healthy meals for the community. She has an Instagram page where she shares her journey uncovering methods of nutrition and holistic healthcare, you can find her at @wavesandgainsx.
References:
(1) BDA (2019). Folic Acid Food Fact Sheet. [online] www.bda.uk.com. https://www.bda.uk.com/resource/folic-acid.html
(2) NHS (2022). About folic acid. [online] nhs.uk. https://www.nhs.uk/medicines/folic-acid/about-folic-acid/
(3) Sijilmassi, O. (2019). Folic acid deficiency and vision: a review. Graefe’s Archive for Clinical and Experimental Ophthalmology = Albrecht Von Graefes Archiv Fur Klinische Und Experimentelle Ophthalmologie, [online] 257(8), pp.1573–1580. doi: https://doi.org/10.1007/s00417-019-04304-3.
(4) SACN (2017). Update on folic acid. [online] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/637111/SACN_Update_on_folic_acid.pdf.
(5) Banjari, I., Matoković, V. and Škoro, V. (2014). The question is whether intake of folic acid from diet alone during pregnancy is sufficient. Medicinski Pregled, [online] 67(9-10), pp.313–321.
(6) Czarnowska-Kujawska, M., Draszanowska, A. and Gujska, E. (2020). Effect of Different Cooking Methods on Folate Content in Chicken Liver. Foods, 9(10), p.1431. doi:https://doi.org/10.3390/foods9101431.
(7) NHS (2020). Planning your pregnancy. [online] nhs.uk. https://www.nhs.uk/pregnancy/trying-for-a-baby/planning-your-pregnancy/.
(8) NHS Choices (2020). B vitamins and folic acid - Vitamins and minerals. [online] Nhs. Available at: https://www.nhs.uk/conditions/vitamins-and-minerals/vitamin-b/.
(9) Wald NJ, Sneddon J, Densem J, et al.(1991). Prevention of Neural Tube Defects: Results of the Medical Research Council Vitamin Study. MRC Vitamin Study Research Group. [online] Lancet (London, England).
(10) GOV.UK (2022). Folic acid added to flour to prevent brain and spinal conditions in foetuses. [online] GOV.UK.
(11) Bestwick, J.P., Huttly, W.J., Morris, J.K. and Wald, N.J. (2014). Prevention of Neural Tube Defects: A Cross-Sectional Study of the Uptake of Folic Acid Supplementation in Nearly Half a Million Women. PLoS ONE, 9(2), p.e89354. doi: https://doi.org/10.1371/journal.pone.0089354.
(12) Public Health England (2018). Health matters: reproductive health and pregnancy planning. [online] GOV.UK..
(13) DEFRA (2022). Amending the Bread and Flour Regulations 1998 and the Bread and Flour Regulations (Northern Ireland) 1998 - Defra - Citizen Space. [online] consult.defra.gov.uk.
(14) GOV.UK (2021). Folic acid added to flour to prevent spinal conditions in babies. [online] GOV.UK.
(15) BBC.UK (2023). Folic acid in flour to prevent birth defects is too low, scientists say. BBC News. [online] 2 Feb.
(16) Wald, N.J. and Hoffbrand, A.V. (2021). Mandatory UK folic acid fortification. The Lancet, 398(10315), pp.1961–1962. doi: https://doi.org/10.1016/s0140-6736(21)02447-8.
(17) Wald, N.J. (2022). Folic acid and neural tube defects: Discovery, debate and the need for policy change. Journal of Medical Screening, 19(3), p.096914132211023. doi: https://doi.org/10.1177/09691413221102321.
(18) Folate, I. of M. (US) S.C. on the S.E. of D.R.I. and its P. on, Vitamins, O.B. and Choline, A. (1998). A Model for the Development of Tolerable Upper Intake Levels. [online] www.ncbi.nlm.nih.gov. National Academies Press (US).
(19) Wald, N.J., Morris, J.K. and Blakemore, C. (2018). Public health failure in the prevention of neural tube defects: time to abandon the tolerable upper intake level of folate. Public Health Reviews, 39(1). doi: https://doi.org/10.1186/s40985-018-0079-6.
(20) https://cot.food.gov.uk/sites/default/files/cotfolatepositionpaper.pdf
(22) Queen Mary University of London (2014). Two-thirds of women in the U.K. not taking folic acid before pregnancy to prevent spina bifida. [online] ScienceDaily.
(23) Linnell, A., Murphy, N., Godwin, J. and Cremona, A. (2022). An evaluation of adherence to folic acid supplementation in pregnant women during early gestation for the prevention of Neural Tube Defects. Public Health Nutrition, pp.1–27. doi: https://doi.org/10.1017/s1368980022001574.
(24) McNulty, B., McNulty, H., Pentieva, K., Marshall, B., Ward, M., Molloy, A.M. and Scott, J.M. (2023). Women’s compliance with current folic acid recommendations and achievement of optimal vitamin status for preventing neural tube defects. [online] Oup.com. Available at: https://academic.oup.com/humrep/article/26/6/1530/2914587 [Accessed 7 Mar. 2023].