Part 1: The Folate Debate- Fortifying Foods with Folic Acid
and what even is it!
I started writing about folate and when it got to over 3,000 words, I thought this probably needs to be in a series so here is part 1!
There are 80 countries in the world that mandate that flour must be fortified with folic acid and the UK government have announced that we will be joining them.
Currently in the UK, brown and white flour must contain calcium, niacin (B3), thiamine (B1) and iron. Whereas wholemeal flour is exempt as the wheat bran and germ contain natural sources of these vitamins and minerals.
I am not sure when the legislation will come into place, but the reason for fortifying flour with folic acid (I enjoy that phrase!) is to reduce the rate of neural tube defects in babies by potentially around 15-22%.1
This sounds reasonable? Folate gets lost in processing flour so all that is happening is a little top-up…?
Well even though I am a nutritional therapist (so I often recommend supplements) this is where it all becomes a bit more nuanced.
I will quickly outline more of my philosophical stance around mandatory fortification of flour but then moving on to the wider picture of what is folate, where we can get it and more!
Ok so quick thoughts on the philosophy of food fortification:
Folic acid is a synthetic version of folate…it is made in a lab, it does not exist in nature so in effect, fortification is mass medication. Now some may argue in favour of that.
My concern is that the measure is entirely justified as a way to reduce neural tube defects in birth. In the UK this affects around 900 pregnancies and 190 babies are born with this per year 23 . If I have my maths right (which I probably have not!) this measure is aimed at preventing a condition that impacts 0.0013% of the population. This seems quite a big public health initiative when children, elderly, men, and women who are not wanting to conceive- (so everyone who eats processed flour products that are not pregnant) are impacted by this. And this when I say impacted, this is because we cannot assume there are no side effects from taking synthetic folic acid…as with everything there are. Some potentially good, some potentially bad.
Plus is it right that we should think the only way to get enough folic acid is by having it added into processed foods? In fact one of the risk factors for neural tube defects is obesity4 so why would you put folic acid in processed foods which contribute to obesity? It’s like putting diabetes medication in chocolate bars (interestingly they do fortify sugar with Vitamin A in Guatemala).
I understand there are many people where their only source of vitamins is from fortified food but surely the better approach is to educate people on how to eat a healthy diet and subsidise better quality foods instead and of course, focus on folic acid where it is needed?
I felt this was well summed up by this blog, where Andrew Whitely discusses theses arguments and how real bread doesn’t need fortification. Sourdough to the rescue!
My whole approach to working with clients is treating them as an individual. No-one gets the same herbal formula, supplement or nutritional recommendations because everyone is different.
This is why mass medication does not work.
For example; we know that people metabolise things differently due to the uniqueness of their gut microbiome, we know that certain stressors can that impact detoxification pathways, we know that our life experiences can even change our DNA!
In fact, 10%-20% of the population have genetic mutations which impacts folic acid metabolism….and this leads me nicely onto the folate debate!
What is folate?
Folate is a B vitamin, specifically B9. It is needed by the body to make red blood cells so a deficiency can result in a form of anaemia. Folate comes from the word foliage which is where you can find it, in our leafy veggies!
There are different forms of folate with names such as dihydrofolate (DHF), tetrahydrofolate (THF) and 5-methyltetrahydrofolate (5-MTHF), folinic acid and the synthetic form of folate is called folic acid.
Check it out: If you have a multi-vitamin or B-complex, look at the ingredients and see what form of folate it has in.
Where is folate?
As well as being rich in green leafy veg, you can find folate in barley, beans, eggs, lentils, liver, organ meats, yeast, sprouts and soybeans.
However, it is unstable when exposed to heat and light. This means that cooking can destroy the folate content in foods (around 65% is lost) and also folate content will be reduced from anything from 20% to 75% when stored.5
Folate is extremely unstable in the freezer so frozen vegetables are not a great source of folate (unless they were fresh-frozen yesterday) although frozen liver seems to retain folate still.6
So when we are eating heavily processed foods, or even just buying vegetables that have been shipped from half-way around the world, we can see how folate deficiency could be a problem in our modern society.
The recommended daily allowance is 400 micrograms (µg) which goes up to 800 µg in pregnancy.
So you can get 100 µg in one cup of spinach, 150 µg in one cup of beetroot, 22 µg in one egg, 134 µg in half a cup of asparagus and 90 µg in one cup of cooked kidney beans! The winner is liver though with 215 µg in one chicken liver!7
The Benefits of Folate
Folate is required for cell division, making DNA and RNA, red blood cell formation and gene expression. It works closely with B12 to metabolise amino acids, synthesise proteins in the body and supports healthy functioning of the nervous system, immune system, and brain.
So it’s a pretty vital vitamin!
Folate deficiency is a common nutrient deficiency and can result in megaloblastic anaemia (also a form of B12 deficiency). Side effects of anaemia include weakness, fatigue, headache, irritability, difficulty concentrating, and shortness of breath
Testing: When running a blood test, an elevated mean corpuscular volume (MCV) of red blood cells can be due to folate deficiency. MCV is the size of the blood cells and if they are bigger it is because the cells unable to divide from folate deficiency.
Folate is especially important for the cells that wear out and divide rapidly which includes red blood cell but also skin cells, the cells that line the small intestine and of course, cell growth in pregnancy!
This is why it’s a big one to consider for those wanting to conceive and having a healthy pregnancy.
We know that folate can help prevent birth defects, heart disease, and even cancer.
A quick rundown of where it could be involved for supporting different conditions:
Acne, ADHD, ageing, anaemia, autism, cervical dysplasia, Crohn’s, type II diabetes, fatigue, gout, lung cancer, memory loss, menstrual problems, mental illness, myopia, neural tubular defects, poor libido, pregnancy, zinc deficiency.
And then more general signs of deficiency, unrelated to a specific condition could include:
Grey hair, fatigue, forgetfulness, cracks on lips, depression, low libido, mental sluggishness, red tongue, weakness, restless legs.
Ok so that is the end of Part 1, coming up next for paid subscribers I’ll be sharing:
the difference between folic acid and folate
methylation and why our genetics could mean that folic acid does more harm than good.
how folate is a key factor in reducing the biggest risk marker for cardiovascular disease
https://www.bda.uk.com/resource/flour-power-folic-acid-fortification.html
https://www.ncl.ac.uk/press/articles/archive/2014/07/possibleriskoffolicacidoverexposure.html
https://action.org.uk/research/preventing-neural-tube-defects
https://www.imrpress.com/journal/CEOG/48/2/10.31083/j.ceog.2021.02.2304
Osiecki, H. (2014) The Nutrient Bible 9th Edition
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7600162/
https://www.unitypoint.org/news-and-articles/18-foods-filled-with-folate-every-woman-should-know-infographic#:~:text=Leafy%20Green%20Vegetables,around%20100%20mcg%20of%20folate.