Folic acid fortification and supplementation: further discussion
Holford has e-mailed me about folic acid fortification - objecting to some of the content of this post - and I’d therefore like to explain my position in more detail. I’m grateful to Holford for raising some interesting points, and will take this opportunity to respond to a few of them:
- Holford argues that problems are “already occurring in the US where flour is fortified with folate at half the level proposed for the UK”. This is, technically, correct - the FSA plans to fortify UK bread flour with higher levels of folic acid than is mandatory in the US. However, the FDA insists that a wider range of US staple foods (e.g. rice and grits) are also fortified - meaning that the average folic acid intake in the US increased by 215-240mcg/day following mandatory fortification. It is estimated that fortifying UK bread flour as planned by the FSA will lead to the average folic acid intake by c. 78mcg/day [PDF file, p.7]*.
- Holford argues that there is “no reason for us not to expect [similar problems] in Britain”. However, given that the FSA’s plans will increase UK folic acid consumption by just over 1/3 of what was achieved by compulsory fortification in the US, there is a very good reason to expect that any problems will be less pronounced.
- Holford argues that “[t]he real issue we have to deal with is how to educate and nourish young women.” Certainly, this is important - there have been problems getting across the message that women who are (trying to become) pregnant should generally supplement with folic acid. However, I’m sure that Holford would agree that good nutrition is important for other groups, too. I’d also argue that folate consumption is valuable for the general population, as it may be linked to a reduced risk of cardiovascular disease and cancer (and a good folate intake is definitely important for older women with higher-risk pregnancies). While greens do not oxygenate your blood, the fact that some are a good source of folate is therefore another good reason to eat your greens.
Holford states that “I do not recommend and continue to be opposed to folate supplementation on its own to any individual or group at risk of B12 deficiency”. I’m glad to hear this - it seems a pretty sensible position on folate supplementation. I would, however, suggest that Holford makes the risks of this clear on his website and web-store: I have e-mailed him to advise that he does so.
- Holford argues that I mis-represent Morris et al’s AJCN paper. I fail to see how this is the case: I note, pretty uncontroversially I would think, that the paper finds that “high folic acid intake combined with inadequate B12 intake is related to cognitive impairment in older people”. To be very precise, the Morris et al paper concludes that “In seniors with low vitamin B-12 status, high serum folate was associated with anemia and cognitive impairment.” All the evidence suggests that eating more folate will - at least to a point - increase your serum folate level. An increase of c. 78mcg/day in folic acid consumption (caused by fortification) will not, in itself, lead to high folic acid consumption and will not in itself lead to high serum folate levels. My argument that “it is very unlikely the modest supplementation supported by the FSA is going to be a significant problem in itself” is therefore correct, and is also perfectly compatible with a reasonable interpretation of the Morris et all paper.
- Holford argues that the problems caused by high folic acid consumption have “nothing to do with the source of folate, whether from diet, fortification or supplements, but to blood levels”. I’d note that the Morris et al paper focused on blood levels of folate - and was therefore only likely to show those risks/benefits associated with different blood levels. I’d acknowledge that there are certain risks associated with high serum folate levels - whatever way these are achieved. However, supplement use can play a very significant part in high folate intake levels: for example, Mulligan et al’s recent article has found (albeit in a relatively small sample) that 94% of the over-60s in their sample group with high folate intake used supplements. There’s an obvious link between eating lots of folate and high serum folate levels - supplements provide an easy means of eating lots of folate.
There are a few more issues around this which I might go into later - but this post is already a bit too long. At any rate, I hope it’s clear from the above why I would stand by my criticisms of the Guardian article on folate fortification. As John Nichols of the Royal College of General Practitioners puts it, I would acknowledge that “[t]here may be a case to be made against folic-acid fortification of bread and flour, but the stream of misinformation in [the Guardian] article is not it”.
* I haven’t had time to check these figures, but they seem about right and the FSA is clearly a reliable source.
Categories: B12 · The Guardian · folic acid · health products for life · patrick holford
11 responses so far ↓
Shinga // May 24, 2007 at 3:24 pm
UK Dietitian previously noted that Prof. David Smith is a member of FFTB’s Scientific Advisory Board and the author of an editorial that expresses concern about supplementation.
Associate Prof. Clare Morris has also joined the FFTB Scientific Advisory Board. She is the source of Holford’s own reference and two of the previous references that observe adverse effects that may be linked to high folate status and that a significant number of participants in studies take folate-containing supplements.
There is currently no warning that if your child is taking the FFTB-recommended Dinochews then it may be unwise to combine this with other supplements such as the Holford-approved Advanced Brain Food Formula(ABFF) because it would be easy to exceed the RDA. E.g., a 9 year-old child would take 3 Dinochews which provide a total of 45µg Folic Acid; the ABFF would provide another 67µg for a supplementation total of 112µg Folic Acid. The European RDA is 200µg. A banana sandwich plus a glass of orange juice would easily provide around 100µg so it is quite easy for children to exceed the RDA for folic acid/folate is they are taking the ‘recommended’ supplements.
Regards - Shinga
Jon // May 24, 2007 at 7:08 pm
thanks Shinga, all interesting info. One thing I should note - I think you may be talking about a different Morris? I think the Morris involved in this paper is Martha Savaria Morris at Tufts; as far as I can tell, the Morris who’s on the Food for the Brain scientific advisory board is Martha Clare Morris at Rush University.
Frankly, I find it hard to see why well-qualified academic nutritionists would be happy to be associated with Food for the Brain. Take their online mental health questionnaire for example. This uses a bizarre-looking methodology, and gives ‘interesting’ results: it will diagnose a 0% chance of food allergy based only on an online questionnaire, and will diagnose healthy people with a range of rare conditions. This is the type of thing that normally annoys the heck out of academics - haven’t Food for the Brain’s scientific advisors objected to this?
Shinga // May 24, 2007 at 10:51 pm
Thanks, Jon. A brace of Morris’ have declared that there may be benefits or harmful effects from supplementation. It’s nice that they are in accord on this matter.
Maybe there will be a modification to some of the recommendations with the latest arrivals to the Scientific Advisory Board?
I’ve just noticed that (amongst others) your questionnaire results suggested that you should consider a histamine blood test.
I notice that Holford recommends a histamine status check for people with schizophrenia or who are experiencing “chronic or severe depression”.
This is a record year for people developing hayfever symptoms. Without knowing the absolute numbers that the lab uses, it wouldn’t be that hard to achieve a high histamine level.
Given how easy it is to have an environmental influence on your histamine levels (e.g., pollen, foods associated with histamine or vaso-active amines, use of antihistamines), I’m a little disturbed to read about how important it is to distinguish high and low levels of histamine in schizophrenia: “Since Folic acid and B12 stimulate the production of histamine, these supplements may be helpful for individuals who are low histamine, but should be avoided by those with a high histamine status”.
It is looking a tad difficult to recommend supplementation to people when it might make such a dramatic difference. “High histamine levels in these people can lead to compulsive and obsessive behaviour and pits of depression. The other side of the coin is that low levels of histamine are associated with anxiety, paranoia and hallucinations.”
I must write this up.
Regards - Shinga
Jon // May 26, 2007 at 11:32 pm
Thanks for the comment, Shinga. I’ve also had an e-mail from Patrick Holford, which he’s asked me to post on the blog: the text he sent me is pasted below.
Jon - I wish I could share your optimism about folate levels not rising above 59 nmol/l as a consequence of folate fortification which, according to Morris et al, was enough to increase cognitive decline risk in those B12 deficient elderly. Recent research in the US has found that, post fortification, 10% of children have a level of folate of above 77.3 nmol/l. We’ll have to wait and see what really happens in the UK with the elderly. Personally, if fortification is the answer, I’d recommend fortifying with B12 as well, or a B complex since other nutrients, such as B6, are also important.
The difference between recommending supplementation and fortification is that the former is optional and the latter is mandatory. If your concern is that supplementation may contribute to the higher folate levels that, only if accompanied by B12 deficiency, may make matters worse, then the only point of concern is individual folic acid supplements without any, or sufficient B12. I agree that it is therefore important for individual folic acid supplements to make this clear. I have asked Health Products for Life to add the following statement to their website: “Folic acid is recommended to be taken alongside a B complex or multivitamin providing 10mcg or more of B12. This is because folic acid can mask the symptoms of B12 deficiency. The elderly may need more than this level – best determined by a homocysteine or B12 blood test.”
By the way, I note you still haven’t revealed your qualifications. Is there a reason for this non-disclosure?
Patrick Holford
Jon // May 26, 2007 at 11:37 pm
Right, a few responses - written in haste - to Holford’s points:
- I think that, by relying on US data, Patrick is probably being too pessimistic about the problems which will be caused by compulsory UK fortification: as argued in the post, this is at just over 1/3 of US levels and should therefore be expected to have a smaller effect. The very modest fortification planned in the UK is unlikely to lead - in itself - to high folate status (although it may contribute to such status). When people achieve high folate status, supplementation and consumption of optionally fortified foods (e.g. cereal) is likely to play a role (although eating lots of ‘naturally’ high-folate foods could also have this effect). That’s not to say that introducing fortification in the UK won’t have any attendant risks or negative effects - it will do - but I think we should be careful not to over-exaggerate these (or, as John Nichols argues, to understate the likely benefits).
- The Mulligan et al article cited in the post found that 94% of subjects with high folate consumption took a supplement, and that cereal fortification was also an important source of folate. It is thus important that the move to fortify UK bread is accompanied by an education campaign, and by appropriate warnings about the potential risks of supplementation and eating optionally fortified foods. I’m therefore glad that Health Products for Life will be adding a suitable warning to their folic acid pills - naturally, I would welcome this move.
- re. the mandatory nature of fortification - I’d agree that this does raise ethical issues. However, in order to discuss these properly it’s important to have accurate information about the benefits and disbenefits of mandatory fortification. We should also contextualise the discussion of mandatory fortification: this should be discussed in the context of ethical issues around the sale of dietary supplements and the voluntary fortification of foods (e.g. cereals).
Right, that’s enough for tonight. A few more issues I may return to if I get round to it, but it’s late…
Anonymous // May 28, 2007 at 6:04 pm
Patrick - What qualifications do people need in order to be able to point out obvious mistakes?
You can’t seriously believe the people who post here haven’t got 2 brain cells to share.
AFAIK you need to be able to read and do mental arithmetic to see the problem with some of your claims.
Anonymous // May 28, 2007 at 6:37 pm
I agree with much on this site.
But compulsory folic acid fortification I cannot support.
I am a middle aged male, only getting older! I have no plans on getting pregnant. I am also a vegetarian, and eat quite a lot of greens. Another love of mine is good bread.
I can quite easily foresee my own intake being significantly higher than the average intake of ~70mcg/day you mention here - perhaps leading to some of the problems identified with high intake in older people (I do not use vitamin tablets), as I get older.
Surely we should have a choice? The money could be spent on better dietary education - especially in schools. This has greater benefits than just folic acid fortification and can take in other things such as fat and calorie intake.
There is a dangerous element lurking in society that is telling us what we can eat and making us eat certain things based on the “average”. This is not an avenue we should be going down.
By all means offer fortified bread, and perhaps encourage it to be in many of the standard brands (and not an extra cost option). But let those of us who know what we’re doing have a choice too.
Keep up the good work otherwise!
Shinga // May 28, 2007 at 8:19 pm
Splendid news on the amendment to Health Products for Life - as such as significant shareholder, I hope that the web editor listens to PH on this matter.
I’ve Googled and PubMeded but can’t find the recent research about the post-fortification folate levels in children- is there any chance of a reference, please?
Regards - Shinga
Jon // May 28, 2007 at 10:25 pm
Anonymous- thanks for the kind words about the site. Sorry if I wasn’t clear - I’m not trying to make the case for compulsory fortification, but rather to criticise some bad arguments against it. To repeat the John Nichols quote I end the post with: “[t]here may be a case to be made against folic acid fortification of bread and flour, but the stream of misinformation in [the Guardian] article is not it”.
I’d actually be fairly sympathetic to a principled opposition to type of compulsion proposed here. Pragmatically, I’d argue that there are much more worrying threats to our civil liberties, and the outcomes generated by fortification are likely to be more positive than negative, but I can certainly see why some would want to oppose compulsory fortification.
The fact that there are good reasons to disagree on this issue is all the more reason why we should criticise sloppy arguments on both ’sides’ of the debate.
Shinga- it definitely is good news. I’m afraid I couldn’t find the reference in question either - maybe Patrick Holford could oblige?
Anonymous // June 3, 2007 at 1:33 pm
Interesting that in medicine the usual dose of folic acid supplementation to correct a deficiency is 5mg - that is 5000 micrograms.
Not entirely clear to me how the many many people who have been on this dose - presumably with normal B12 levels - still retain any cognition!
Bizarre confluence of vitamins, histamine and mental illness - just think that those pesky antihistamines I take for hayfever are helping my sanity - no, wait,…..
banshee
Jon // June 4, 2007 at 10:38 am
thanks anonymous - yeah, I never knew that changes in histamine level could be such a threat to my mental health…
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