“Folic acid is to be added to UK flour to help prevent spinal birth defects in babies”
BBC News 20 Sept 2021
A personal view by Andrew Whitley, author of Bread Matters and co-founder of Scotland The Bread
Quick wins and white lies
Adulterating all the UK’s wheat flour except wholemeal with synthetic folic acid – as we are told will now happen – continues a long and disastrous tradition of food adulteration, stretching back at least 250 years, when a contemporary observer described London bread as “a deleterious paste, mixed up with chalk, alum and bone-ashes; insipid to the taste and destructive to the constitution”. One of those ‘ingredients’ is still being used in Britain’s loaves along with several more modern additions. If Hippocrates ever said ‘let food be thy medicine’, he surely didn’t have folic acid-medicated refined flour in mind.
Since 1953 all non-wholemeal flour in the UK has, by law, been ‘fortified’ (the sanitised term) with chalk, iron and two synthetic B vitamins. This is a de facto admission that white flour, as it comes off the roller mills that have supplied almost all our flour since the 1870s, has been so denuded of its food value – so ‘ultra-processed’ – that it can’t be recommended as a staple food without partial replacement of a few of the many depleted nutrients. Now we will be forced to swallow another synthetic ‘additive’ in what must go down as one of the most illogical public health interventions of all time.
Putting folic acid in all non-wholemeal flour is designed to reach women of child-bearing age so that they get enough even if they don’t plan a pregnancy or eat an appropriate diet (or take supplements) before and after conception. Medicating men and older women in this way is obviously irrelevant to the issue of spina bifida births. And it’s behind the curve. So many people have reduced their bread consumption or have turned to gluten-free alternatives that medicating non-wholemeal wheat flour alone seems oddly inconsistent if the aim is to reach all at-risk women (without them needing to do anything about their food choices).
The Prime Minister is quoted as saying this would be a “quick, simple win to enhance a baby’s development, as well as helping to boost the health of UK adults”. This highly refined blend of spin and mission creep (with the Health Secretary left to justify the original purpose of folic acid flour fortification as leading to “fewer people needing hospital treatment” – what? 200, maybe, compared to how many with seasonal flu, Covid-19, or diet-related conditions untouched by folic acid?) suggests the ‘quick win’ in question has more to do with diverting attention from current political embarrassments than addressing public health nutrition. Or was the day the PM flew out to address the UN a good day to bury bad food policy?
A real quick win would be simply to get British bakers to ferment their dough for longer: slow rising, as in traditional ‘overnight’ processes and especially sourdough, allows time for yeasts to generate at least double the amount of natural folate compared to high-speed industrial ‘no time’ doughs.
The longer-term answer to making more natural folate (and many other important vitamins and minerals) available to everyone in appropriate amounts is to grow more nutrient-dense wheat, leave more goodness in it when it is milled to flour and take time to ferment the bread sufficiently to achieve greater digestibility and nutrient bioaccessibility. Such an approach, unlike mandatory fortification, is consistent with official dietary policy and supports, rather than undermines, better consumer choices by encouraging producers and processors to build on natural capital not replace it with synthetic analogues.
Mass medication also seems to be at odds with the current government’s general aversion to ‘regulation’ and its slogans about ‘taking back control’. It locks people into a deeply unequal food system under the disempowering mantra of ‘health by stealth’, designed to keep us in a state of ignorance about the overall damaging effects of ultra-processed foods of which industrial white flour is a pernicious constituent.
What can we do (to avoid adulterated flour and bread)?
- Choose wholemeal flour, preferably organic – to avoid residues of agrochemicals in your bread and to support biodiversity
- When making your own bread, be sure to ferment the dough well – prolonged yeast fermentation at least doubles the amount of naturally occurring folate (Vitamin B9) in wholemeal flour/bread
- Since B vitamins are largely present in the bran layers of wheat grain, it makes sense to use wholemeal anyway – but it also needs to be fermented well to allow naturally occurring lactic acid bacteria to make the important minerals (iron, zinc, magnesium, calcium etc) available to our digestive systems
- Sourdough bacteria also generate important short chain fatty acids (ferulate, butyrate etc) from wholemeal flour. Ferulate alone “can be antioxidant, acting on cell signalling, antidiabetic, anti-inflammatory, anticarcinogenic, antiapoptotic, hepatoprotective, neuroprotective, hypotensive, and even antiatherogenic” (Anthony Fardet and Edmond Rock 2018, Perspective: Reductionist Nutrition Research Has Meaning Only within the Framework of Holistic and Ethical Thinking)
- Always choose Real Bread. Industrial wholemeal bread is made so fast that most of the minerals in the bran are poorly assimilated by our guts. And it’s made with a long list of synthetic additives and processing aids, which do nothing – as the Government appears to hope folic acid adulteration will do – to “boost the health of UK adults”
- Support initiatives such as Scotland The Bread and its Flour to the People project – a slow win for people and health. Flour to the People is a finalist in the BBC Food & Farming Awards, due to be revealed on November 24th.
Other reasons why medication of all UK flour – other than wholemeal – with synthetic folic acid is a bad idea
1. It limits choice and responsibility
Increasing numbers of people choose food that they believe and wish to be wholesome and additive-free. Successive governments, recognising the growing cost of diet-related ill-health, have supported such trends, ‘nudging’ people to exercise personal responsibility and make better food choices.
By contrast, mandatory food fortification is an admission of defeat. It implies that there is no way to get women of child-bearing age to consume enough folate other than by sneaking it synthetically into the flour they eat. It would limit choice (‘untreated’ flour would be illegal) and discourage personal responsibility. It might even perversely bolster the health image of otherwise nutritionally poor ultra-processed foods, many of which are based on white wheat flour.
2. Collateral damage
When a nutrient, in synthetic form and uncertain dosage, is forced upon an entire population, more than half of whom do not need it, there are bound to be risks. Most of these arise from differences in the way that synthetic folic acid and natural folate (from things like green leafy vegetables and well-fermented wholemeal flour and bread) are metabolised by the human body. In countries such as the USA where folic acid has been added to white flour and cereal products since 1998, the level of unmetabolised folic acid in people’s blood has risen. In the words of Dr Siân Astley of the Institute of Food Research, writing in 2007*,
“This can cause problems for people being treated for leukaemia and arthritis, women being treated for ectopic pregnancies, men with a family history of bowel cancer, people with blocked arteries being treated with a stent and elderly people with poor vitamin B status.…It could take 20 years for any potential harmful effects of unmetabolised folic acid to become apparent.”
A 2017 study** in Brazil, where mandatory fortification of wheat and maize flour was implemented in 2004, pointed to the complicated relationship between folic acid and other nutrients, suggesting that vitamins B6 and B12 are needed to metabolise natural folate and folic acid efficiently. Unsurprisingly perhaps, in this study, people consuming the most processed and fortified foods tended to have lower levels of unmetabolised folic acid than those who consumed higher amounts of natural dietary folate – which, if mandatory folic acid fortification is implemented in the UK might result in an unintended ‘penalty’ for people who adhere to national dietary guidelines (e.g. the NHS Eatwell Guide).
In its assessment of the potential risks associated with sustained high doses of folic acid, the Scientific Advisory Committee on Nutrition (SACN) concludes that uncertainty in, or current limitations of, data do not justify a conclusion other than support for mandatory fortification. I argue that these very uncertainties, coupled with the contradiction between fortification and the main thrust of official dietary policy, should dictate a precautionary approach to this issue and the adoption of other, focussed measures to achieve the desired improvement in ‘the folate status of women most at risk of Neural Tube Defect-affected pregnancies’.
*British Journal of Nutrition (2007), October, 98.4 “Folic acid metabolism in human subjects revisited: potential implications for proposed mandatory folic acid fortification in the UK”
**Journal of the American College of Nutrition, (2017), Sep-Oct;36(7):572-578 “Association between Serum Unmetabolized Folic Acid Concentrations and Folic Acid from Fortified Foods”
3. There are alternatives
The most logical way of reducing the number of NTD-affected pregnancies is to make sure that all women who are likely to get pregnant get sufficient folate, preferably from a good diet but aided by appropriate supplements if necessary. Some would argue that it is not easy to get enough natural folate (vitamin B9), even if you have a reasonable diet. But this has much to do with the underlying quality of our basic foods and the way that processing depletes their potential vitality.
Over the past 50 years or more, there has also been a gradual decline in the quantity of minerals and vitamins in bread wheat and we don’t make best use of those that remain. Roller-milled white flour, as used in the vast majority of UK bread, rolls, pizzas etc, is so deficient in key nutrients that since 1953 it has been fortified with synthetic iron, calcium, and two B vitamins (thiamin and nicotinic acid). B vitamins such as folate are present in larger amounts in the bran and germ of the wheat grain. 41% of the folate in whole wheat is removed by milling to white flour.
Yeast also contains folate, so bread should be a good source. But there can be two or three times more folate in bread if it is fermented properly – the one thing that cannot be said for over 90% of UK bread since the adoption of the ‘no-time’ Chorleywood Bread Process in 1961.
4. Avoidance and exclusion
The number of people who avoid wheat has risen in recent years, so fortification of non-wholemeal wheat flour alone runs the risk of excluding a small but significant number of people from any presumed benefits. At the same time, increasing numbers of people are choosing less-processed, including organically grown, grains, flour and Real Bread precisely because they wish to avoid synthetic additives and adulterants of all kinds. Mandatory fortification might be seen as discriminating against those who take most responsibility for the impact of their diet on personal and community health.
Mass intervention with synthetic additions to food is clearly a hopelessly blunt instrument and the only way to make sure that certain groups and individuals are not negatively affected is by providing for exceptions, e.g. for organic flour and bread. However, this risks undermining the integrity of the organic market by offering its competitors a spurious opportunity to characterise organic flour and bread as ‘less nutritious’ by virtue of the absence of mandatory fortificants. Such an outcome is at odds both with the bulk of evidence for the benefits of organic food and the clear thrust of official dietary advice with its emphasis on personal choice.
5. Net zero obligations and incoherence in government policy
This kind of policy proposal, i.e. the compulsory fortification of a primary ingredient (flour), is only possible because of the high degree of concentration in the flour milling and baking industries in the UK. It also appears to assume that most people neither know nor seemingly care about what goes into (or has been removed from) their staple foodstuffs. However, official policy, animated increasingly by the urgent need to address climate breakdown, is to encourage de-centralisation and diversity of provision accompanied by consumer responsibility and choice. Mass fortification seems at odds with the overall direction of travel required to deal with diet-related ill-health in the context of national commitments to achieve net zero climate-heating emissions.
© Andrew Whitley 2021