What You Need to Know About Folic Acid: The Deficiency That Wasn’t

What you need to know about Folic Acid Part One: The Deficiency That Wasn’t

No one needs folic acid fortification

HART

Dr Clare Craig

In 1875, Parliament made it a criminal offence to adulterate flour.

The Sale of Food and Drugs Act of that year was written in answer to a scandal that had been building for decades. Bakers bulked out their flour with alum, chalk and plaster of Paris, and on occasion with sawdust. In 1861 Dr Edward Lankester told the Royal Society of Arts that 87 per cent of the bread and 74 per cent of the milk sold in London was adulterated. The Act was intended to end all adulteration; its long title promised “better provision for the Sale of Food and Drugs in a pure state”. Section 3 made it an offence to “mix… any article of food with any ingredient or material so as to render the article injurious to health”, with a second conviction punishable by being “imprisoned for a period not exceeding six months with hard labour”. Section 6 forbade selling any food “not of the nature, substance, and quality of the article demanded”. The principle was that you do not tamper with the staple food of the nation.

One hundred and fifty-one years later, the British government is about to add a substance known to be injurious to health – folic acid – to our flour.

From 13 December 2026, under the Bread and Flour (Amendment) Regulations 2024, it will be mandated that any white flour sold in the UK contains synthetic folic acid. The mandate includes imported flour and even organic flour. The stated aim is to ensure that women in the first trimester of pregnancy have adequate intake in order to reduce neural tube defects such as spina bifida and anencephaly (the absence of a brain). The policy has been presented as a straightforward public health benefit but like many such claims the risks have not been properly measured and the benefits have been massively exaggerated (with nine dead babies – mostly miscarroages – for every neural tube defect ‘prevented’) – if they exist at all.

The assumption is that there is a group of women who are short of folate. Therefore folic acid in the food will reduce the size of the group with inadequate levels. But this story is not like other stories of deficiencies. With rickets from too little vitamin D, scurvy from too little vitamin C, or goitre from too little iodine there is a genuine missing nutrient and a direct measurable and predictable consequence of that.

There is no deficiency like that regarding folates.

Today we are told folic acid fortification is obviously necessary. However, forty years ago, Britain’s own expert committee was adamant that it was not. What changed between then and now is worth following carefully, because it was not the evidence.

Is anyone deficient?

If you measure folate levels across a population the result is a bell curve. There is no point below which deficiency suddenly begins. There is no level that predicts neural tube defects. For decades this problem perplexed the medical profession. Then Irish data, published by Daly and colleagues in 1995, did link folate levels to neural tube defects. They showed that at every level of folate stores there was a risk of a neural tube defect but the lower the stores the higher the relative risk. Women with higher folate had lower risk than women with lower folate, but the risk never reached zero, not even at the very top of the distribution. Nor was there a deficient subgroup sitting below a threshold, waiting to be fed up to normal.

When you give an undernourished person more food, they reach a normal level and stop; the surplus is dealt with and excreted. Folic acid does not behave that way. Add it to the food supply and folate rises across the entire population, including in the great majority who had perfectly adequate levels to start with. That is not the correction of a deficiency. It is what a drug does.

What happened in Chile

Chile mandated folic acid fortification of flour in 2000, and the levels of folate stores increased across the whole population. Serum folate rose almost fourfold and red blood cell folate rose 2.4-fold, for everyone. The before-and-after curves barely overlapped. Almost nobody in fortified Chile had a folate level that would have counted as normal in the Chile of the year before. Only levels that had once belonged only to the extreme high end of the bell curve saw any overlap with the earlier measures.

Figure 1: Serum folate (A) and red blood cell folate stores (B) in women of reproductive age in Chile before and after folic acid fortification of their flour

Shifting an entire population along a distribution is a pharmaceutical effect, and the long-term consequences of doing it to every person of every age, sex and health risk is simply not known. The assumption that having higher levels can only be good is wild. We do not know under what circumstances lower folate stores may be of overall benefit. There may be perfectly good reasons why folate stores are sometimes lower in some people. For a start, folate fuels cell division, which is precisely why fast-growing tumours depend on it too. It is an astonishing act of hubris to assume that we know better than human physiology what a “healthy” folate store should be.

Why does the government want to add it to flour?

The claim the government makes is that folic acid supplementation reduces neural tube defects. There is some evidence of that from animal studies showing that folate deficiency in brain cells is the cause of these defects and giving very high doses to women at high risk does reduce that risk in trials. However, the only trial of a reasonable dose in low risk women showed an illusory benefit with nine dead babies for every claimed prevented defect.

The deficiency argument runs into a second, more awkward fact. The great fall in neural tube defects in Britain happened before any folic acid campaign began.

A retrospective study by Kadir and colleagues, published in the BMJ, tracked neural tube defects in England and Wales from 1972 to 1996 using national data on live births, stillbirths and terminations. The figures are striking. Spina bifida fell from 215 per 100,000 births in 1972 to 38 per 100,000 by 1991, a fall of 82 per cent. Anencephaly fell by 81 per cent and encephalocele by 77 per cent over the same years.

The official recommendation that women take 400 micrograms of folic acid a day in the first trimester or when trying for a baby did not arrive until 1992. That was after almost all of that decline had already happened. None of the reduction can be credited to folic acid.

What is more, the authors looked at what happened next and found that the rate of decline slowed after 1992, significantly so. As folic acid prescriptions and over-the-counter sales climbed through the decade, the fall in neural tube defects decelerated rather than accelerated. That is the opposite of what the policy predicts, and there is a biological reason for it that I take up in the third article of this series. For now it is enough to note the shape of the thing: the decline came first, and the intervention arrived to take the credit.

What Britain decided in 1981

Earlier policymakers understood all of this. When they examined the same question they reached the opposite conclusion to today’s public health officials.

In 1981, the Department of Health published Nutritional Aspects of Bread and Flour, the report of an expert panel of the Committee on Medical Aspects of Food Policy. The panel — chaired in turn by Sir Frank Young and Dr John Cummings, and including Dr Elsie Widdowson, co-author of the foundational wartime bread studies — reviewed every additive then required in British flour and recommended, unanimously, that ALL of them be removed. The Chief Medical Officer, Sir Henry Yellowlees, set out the conclusion in the preface, “The Panel concluded unanimously that there is no nutritional reason for continuing to add calcium carbonate compulsorily to flour or to restore thiamin, nicotinic acid and iron to flour.”

On folate the panel could hardly have been plainer. In the absence of any public health problem of deficiency, it found, “there is no evidence of a public health problem arising from folate deficiency in the general population…. The Panel considered whether there was any nutritional justification for the addition of folic acid to flour and concluded that there was not.” Its reasoning on iron reads now like a direct answer to the argument being used today: “The fact that some individuals become iron-deficient due to clinical disease is not a basis for a national policy of adding iron to flour.”

At the time this was not thought controversial. It was simply the reasonable reading of the evidence. Today it has been almost entirely forgotten.

Something changed, but not the evidence

Between 1981 and 2024 there was no new evidence that British folate intakes had fallen. If anything the diet had improved: more fruit and vegetables, higher living standards, no return of any deficiency disease. There was no public health problem of folate deficiency then, and there is none now.

What changed was the momentum behind the public health greater good policy. In 1998 the United States produced a new and much larger folate recommendation, and in the same year mandated the fortification of American flour. For the next twenty-five years British advisory bodies were under steady pressure to fall into line. In November 2024 they did.

The stated case for the policy is the prevention of neural tube defects. Even if that benefit were achievable, this would be a sledgehammer to crack a nut. Tens of millions are exposed every year with no possibility of benefit, so any risk at all must outweigh it for them. The NHS lists large numbers of people who are told to avoid folic acid for their health including those with cancer, B12 deficiency, stents and kidney disease. Most of them have no idea that this will mean avoiding all flour. In addition there are numerous other risks including a doubling of the risk of prostate cancer in men and inhibition of immune response in women.

Please sign this petition to stop the addition of folic acid to UK flour: https://petition.parliament.uk/petitions/769589

To find out more about folic acid:
Read this website:

https://fauxlate.org/

or listen to these interviews:

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This article (What you need to know about Folic Acid Part One: The Deficiency That Wasn’t) was created and published by HART and is republished here under “Fair Use” with attribution to the author Dr Clare Craig

What you need to know about Folic Acid Part Two: How 100 Micrograms Became 400

The dose that was doubled, and then doubled again

HART

Dr Clare Craig

Ask almost any doctor how much folate an adult needs to eat and the answer will be four hundred micrograms per day. That figure is printed on supplement bottles, prenatal tablets, cereal boxes and government leaflets the world over, and it is repeated so reliably that it has taken on the authority of a biological fact.

The body does not need 400 micrograms of folate a day. The real figure is almost exactly four times smaller, and the story of how the smaller number became the larger is a story of double-counting and industry influence on decision making.

The first panel

In 1989 the United States National Research Council published the tenth edition of its Recommended Dietary Allowances. Before then the estimate of folate required had not been evidence based but now there was funding to carry out the work to measure what the requirement was. The body loses about 50 micrograms a day. That is what we need. The evidence base suggested that 100 μg/day provided a substantial margin above deficiency. The eventual recommendation of 180–200 μg/day therefore represented not a demonstrated biological need for that quantity of folate, but a precautionary adjustment for the assumed incomplete absorption of naturally occurring food folates.

However, while folate from animal sources is fully absorbed, folate from fruit and vegetables was reckoned at the time to only be about 50 per cent absorbed. On that basis the panel set the allowance at 200 micrograms for adult men and 180 for women. This doubling was to allow for the lower availability of the plant folate that made up most of the diet. Given that meat, eggs and dairy all contain folate that is fully available it would be hard to find any diet that did not contain sufficient folate.

The hundred-microgram body

Folate is essential to life. Every cell uses it to build RNA and DNA and to switch genes on and off, and rapidly dividing tissues depend on it utterly. In those with a severe deficiency the result can be severe anaemia and worse. Because it is so essential to every cell, the body is built to hold on tightly to the folate we have. It is not built to be at risk if we do not eat a predictable diet.

The liver alone stores somewhere between 10,000 and 30,000 micrograms. Against a daily loss of around 100 micrograms, that is months of reserve with no intake at all. The kidneys have receptors to actively reclaim folate to stop it being lost in the urine. When folate runs short those receptors increase in number so that even less escapes. In pregnancy urinary loss also falls. The body keeps back what the baby, the placenta and the mother will need to grow. A nutrient this fundamental to cell function would be a reckless thing to waste and it is not wasted.

The consequence is that reaching a deficient state is a challenge. It generally takes prolonged poor intake, malabsorption, or alcohol dependency to produce it.

So how did we go from the 100 micrograms that we need each day to replace losses to the claim that we need 400 micrograms a day – an amount that no diet could ever achieve.

The second panel

Nine years after the first panel, in 1998, the Institute of Medicine produced the successor report. Alongside the usual US federal agencies, the 1998 panel was underwritten by a new source – the Dietary Reference Intakes Corporate Donors’ Fund. The donors were listed beneath it: Roche Vitamins, Mead Johnson Nutrition Group, Daiichi Fine Chemicals, Kemin Foods, M&M Mars, Weider Nutrition Group, and the Natural Source Vitamin E Association. Three of the seven had a direct commercial interest in the answer. Roche Vitamins was at the time the largest manufacturer of synthetic folic acid in the world. Daiichi Fine Chemicals also made it. Mead Johnson made infant formula, fortified with it.

In 1989 the folate allowance had been set by an independent panel of government-funded scientists. In 1998 this panel part-funded by the manufacturers of synthetic folic acid doubled it. They used the same reasoning that the 1989 panel had used to double the requirement from 100 micrograms of absorbed folate to 200 micrograms from fruits and vegetables. Only this time they took the 200 micrograms as if that is what the body required and doubled it to 400 micrograms. The dose printed on every supplement bottle, every prenatal tablet, every box of fortified cereal and from December 2026, every sack of British white flour, descends from that 1998 number.

Worse, the 400 number has been translated into 400 micrograms of folic acid which is all bioavailable. The consequence is that the daily dosing is four times higher than what the body requires and is on top of the 100 micrograms which any diet already contains. Put plainly, the recommended dose is not topping up a small shortfall; it is the body’s entire daily requirement delivered four times over, on top of the folate already coming from ordinary food.

A 2006 study actually measured the folate absorbed from food. Their result put the figure for how much folate is absorbed from fruit and vegetables closer to 80 per cent. What we take from our food has been underestimated.

Industry had managed to hoodwink everyone to suggest that we needed an amount four times higher than we need and importantly an amount that could never be achieved from any diet. The official recommended daily allowance made it look like we could not be healthy without eating industry’s supplements.

How much folate is in food

The simplest test of a recommendation is to hold it up against an ordinary plate of food. A serving of chicken liver carries 500 to 600 micrograms of folate. A cup of cooked lentils, around 350. A cup of cooked spinach, more than 250. Asparagus, broccoli and beans all add their share. Even on the pessimistic absorption figures, a normal mixed diet routinely supplies far more folate than the body actually requires.

This is exactly why the 1981 Committee on Medical Aspects of Food Policy concluded that there was no public health problem of folate deficiency to solve. The panel argued correctly that food already supplied plenty of folate. Nobody needs a supplement.

Please sign this petition to stop the addition of folic acid to UK flour: https://petition.parliament.uk/petitions/769589

To find out more about folic acid:
Read this website: https://fauxlate.org/

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