Folic Acid, Science and the Media

By Michael Edmonds 08/07/2012

This morning on the TV programme Q+A there was a discussion of whether or not folic acid should be added to bread. This is the second time this issue has been raised since it became a political hot potato three years ago, and was put aside. At the time a Folic Acid Working Group was set up, but apparently the members of this group declined to appear on Q+A this morning. Instead, Greg Boyed interviewed Oxford Emeritus Professor of Pharmacology, David Smith, and Dr Andrew Marshall of the Paediatrics Society. The result was embarassing and frustrating to say the least.

Dr Marshall, who supports the addition of folic acid to bread, was dismissive of the evidence provided by Professor Smith to suggest possible risks with folic acid, accusing him of “cherry picking”, while simultaneously appearing to be selective in his own sources of evidence. He also called Professor Smith a “folate hater”, but then swiftly withdrew the comment. I find this type of behaviour appalling – this is the type of rhetoric which taints science and leads to the sorts of non-scientific naming calling “debates” we have seen with climate change.

Personally, I found Professor Smiths’ arguments no more convincing, especially when he emphasised that folate was synthetic and not the same as naturally occurring folic acid. If find the implied “natural is good, synthetic is bad” argument coming from a Professor of Pharmacology extraordinary.

Other frustrating arguments put forward included a big deal being made of some of Professor Smith’s research being funded by bread manufacturers, and Greg Boyed implying that because Professor Smith was an Oxford don that his views held more weight than others. Personally, I would much rather place my faith in the evidence, not rely on an argument from authority.

The panel discussion after the interviews was also annoying. Matt McCarten referred to scientists as “pointy heads”, no doubt frustrated by the conflicting views of the two experts. While I can empathise with his frustration, such insults do nothing and perpetuate the gap between scientists and the general public.

With regards to my own view on folic acid, I think that it’s mandatory addition to bread is not the way to go, primarily because of the variability in its dose. It seems to me that the best way to reduce neural birth defects is to make sure that women who need it receive a known dose of known benefit. Putting it bread just seems such a random way to administer a bioactive substance.

Having said that I am open to being persuaded otherwise, but with evidence, not rhetoric. There appears to be some early suggestions that folic acid may reduce the occurrence of strokes, which might add to the evidence for its addition. However, there are still those who argue that it can increase the risk of some forms of cancer. What really needs to be done is a thorough risk/benefit analysis incorporating ALL existing research.





0 Responses to “Folic Acid, Science and the Media”

  • I always find it interesting in these discussions, they bring in pharma and paediatricians, but where are our nutritionists. MD’s are not the be all and end all of public health nutritional interventions.
    e have a variety of researchers in NZ who have performed research on folic acid. Prof Murray Skeaff from Otago is one, even if we have lost his collaborator Tim Green, who went back to his home country. Lisa Houghton and Bernard Venn are a couple of others with background in the area. – and thats just Otago. Not taking into account the pool of researchers across Massey, both Albany and Palmerston North, plus University of Auckland, Liggins and the likes.

    It is true that we must look at the wider research pool. But, we must also not over strengthen epidemiology to a point it is seen as a replacement for DBRCTs. We already have seen a failure for folic acid against CVD, despite good support from epidemiology. Stroke is another benefit coming from epidemiology, plus country specific rates following incorporation of supplemental folic acid to the food chain. This is not unbiased evidence, and should not be taken as a solid benefit when deciding our own fortification fate.

  • It should be noted, and I’d be interested to know Michael, whether this was disclose on Q&A, that the only reason Professor Smith has popped up in the New Zealand media is because he was commissioned by New Zealand Baking Industry Research Trust and the New Zealand Food and Grocery Council to write a report on folic acid.

    The baking industry was vehemently opposed to folic acid fortification last time and continues to be, which is why Katherine Rich of the Food & Grocery Council sent me the report when the Science Media Centre was preparing a press briefing on folic acid – you can listen back to it here. It included Dr Marshall

    We ran the report past the experts we used including Dr Marshall, who concluded that its findings, at best, cherrypicked the evidence.

    Professor Smith may well have some worthy evidence-based points to make about folic acid, but it should be known why he has entered the debate at this point – basically, the baking industry has scoured the world for alternative views on folic acid and co-opted them into their lobby against fortification.

    • Peter,
      There was a mention of some of Professor Smith’s “research” being sponsored by those interests but from what I can remember it wasn’t identified as being related to the current NZ debate directly, that is very interesting to know.
      Greg Boyed (I think) mentioned during the programme that the baking interesting was no longer strongly opposed to the introduction of folic acid, which seems curious.
      I do worry that science may end up taking a back seat in this argument. Perhaps it is up to scientists, especially nutritionists and medical researchers to make sure it stays at the front.
      I agree that it is reasonable to know how someone entered such a debate, but this shouldn’t be used to automatically dismiss Prof Smith’s position.

  • JC Carter, that is a very interesting point. It seems to me that a pediatrician would have a strong bias towards the addition of folic acid and therefore may unconsciously rate evidence in support of addition of folic acid higher than contrary evidence.
    A nutritionist might provide a much much broader perspective.

  • How about this as a solution – folic acid is added to some breads, and the consumer can buy either the fortified or unfortified depending on what they think they need?
    Any extra cost for fortification (which the programme this morning ompled was minimal anyway) could be spread across the cost of all breads in recognition of the value of fortification for pregnant women (though still have to wonder if this will ensure an effective dosage).

  • The reason why only fortifying some bread isn’t a good solution was summed up by Tim Watkin in his column on

    “The reality is that many women get pregnant without planning to — especially those who are young, can’t afford many GP visits for “education” and are most resistant to public health campaigns. Even those planning a pregnancy might take a long time to strike oil. And for folic acid to work for those extra 24 kids each year, their mums have to be taking it before they get pregnant.”

  • Michal, if it was widely advertised that women would benefit from loaves containing folic acid and there was no cost difference, then surely it would be fairly straightforward for all women who have the potential to fall pregnant to buy such bread?

    Also it still bothers me that putting folic acid in bread is a very hit and miss approach. It will not help women who eat very little bread (a common diet approach at the moment is to eat little or no bread), and dose will vary depending on how much bread and other food containing folate are consumed. Tim’s comment does not address this point.
    I think it would be far more reliable to put more funding into educating women regarding the importance on folic acid if there is any chance they could fall pregnant.

  • >The reality is that many women get pregnant without planning to

    Can we fortify alcohol, beer and mixers, with folic acid then?

  • Can we fortify alcohol, beer and mixers, with folic acid then?

    Ha, on the right track though perhaps. I’m sure there’s an energy drink manufacturer out there who’d love to stick in an extra vitamin.

  • The MPI report and associated documents are a good place to start to get a more balanced overview than any media ‘duelling experts and discussion panel of conflicting opinions’ will provide.

    There is an interesting perspective here that I believe Michael hit upon in his initial post:

    • Gary,

      Thanks for the links, I look forward to reading them.

  • I received the following information from Professor Helga Refsum on behalf of herlsef and Professor Smith. I find the suggestion at the end, on an alternative way to provide women with folic acid supplementation, most interesting.

    “We welcome Michael Edmonds comments on the Q+A interviews and support his plea “What really needs to be done is a thorough risk/benefit analysis incorporating ALL existing research.” We tried to do this in our recent report, available on-line: together with the supplementary tables:

    May we reply to some of the comments and concerns raised in the blog.
    First of all: Yes, we were commissioned by the Baking Industry Research Trust to write a report about folic acid fortification. Why should not the Baking Trust get advice from scientists that are very familiar with the topic, together having some 50 years experience in the field? We imagine that our Commentary on folic acid published in the American Journal of Clinical Nutrition in 2008 may have drawn attention to our expertise. However, the Trust does not support our research.

    Smith is a Pharmacologist, Refsum a professor of Nutrition. Using folic acid to prevent NTD is a pharmacological as much as a nutritional intervention. As a pharmacologist, Smith pointed out that folic acid is a synthetic compound that does not occur in significant amounts in natural foods simply to correct claims that it is normally in the diet, not to imply that ‘”natural is good, synthetic is bad”. In fact, humans metabolise folic acid rather poorly and there is a 5-fold variation in the rate of its conversion to reduced folates. This means that a proportion of the population in countries that have fortified has significant amounts of unmetabolized folic acid in their blood, which may not be a good thing, as we have discussed in our report.

    In our report, we discuss both potential beneficial (many) and possible harmful effects of folic acid. We have not cherry picked. As we state in our report: “the Trust had no influence on its content or the conclusions drawn, for which the authors are entirely responsible.”

    In relation to the cancer question: there are two large meta-analyses available. They show essentially the same. Some people who are not scientists do not understand that. The meta-analysis by Clarke et al, with 35,000 subjects showed a 5% increased risk in cancer in those receiving folic acid (non-significant, but close), the study by Wien et al including 38,000 subjects showed a 7% increased risk, significant (just). The difference is minute. Clarke’s meta-analyses did not show a lack of association. A better description of the result would be: ‘There was no significant association’. Scientists who see the whole picture, all the evidence, from cell studies, animal experiments, human epidemiological and clinical studies and trials, in relation to cancer, express their concern. To this day, you will not give a patient with active cancer folic acid, for a very particular reason. Folic acid stimulates cancer growth. In line with this, some of our best anticancer drugs are anti-folates.

    In relation to stroke: we discuss this at length in our report. Marshall was selective in his citing of the Clarke meta-analysis when he only mentioned that the association of folic acid with increased cancer was not significant; Clarke also reported that the association with a decrease in stroke was not significant.

    A more important finding reported by the Wien meta-analysis, and in several other studies, is that there are groups that may be particularly sensitive to the folic acid effect. For instance, Wien et al reported a 24% higher risk of prostate cancer. In our Norwegian trials, we found that people with MTHFR TT genotype (10% of the population) had higher risk of cancer. So, is it right to expose these people to high folic acid, against their will? Notably, all the evidence suggests that folic acid may only accelerate growth of an existing cancer/preclinical cancer, not cause cancer itself. Experimental studies suggest that good folate status before cancer has developed, may protect against later cancer development. Thus, some people may benefit, others may suffer. We discuss this issue in detail in our report.

    Folate status in New Zealand women: It is excellent, indeed better than in USA that has mandatory folic acid fortification. Since it has been shown in the USA that adding folic acid supplements does not further decrease the incidence of NTDs, we suggest that, based on the present folate status in New Zealand, further fortification may not reduce NTDs, only increase risk.

    Marshall’s ‘Folate hater’: Both of us are strongly in favour of folic acid, but used the right way. For example, in our own research we have shown that a combination of folic acid and other B vitamins may be one approach to preventing Alzheimer’s disease.

    European countries: European Food Safety Authority recently had a major assessment of the potential risks of folic acid, in which we participated. No countries in EU have so far continued with the intention to fortify for two reasons. The NTD rate is already low, and there is significant concern about risk.

    Lack of data for New Zealand: Do please demand an update of data on NTD incidence, if possible including terminations, for the last 3 years. If the incidence is low, which it should be, given the very good folate status after voluntary fortification was introduced, then consider whether you need further fortification.

    Too much folic acid is not good. Everyone agrees that there is an upper limit. By the way, it is mainly children and older people that tend to have too high intake of folic acid in countries that have fortified. We are concerned about folic acid and cancer, cancer being commoner in the older population. But if high folic acid has other effects, not yet identified, it is the young, the children that are most exposed.

    If you want our personal view about how to get folic acid to young women who may become pregnant: Add folic acid supplements to packages with sanitary pads/tampons: You then reach the target population.”

  • Between 2002 and 2004 the government sprayed the insecticide Foray 48b on parts of Auckland.
    During the spraying I developed a range of medical conditions including leukemia. My research into why I got the conditions revealed that the manufacturers of Foray 48b were adding the genotoxin chloramphenicol to the nutrient broth that formed the basis of the insecticide to genetically modify the active ingredient.
    When I researched my leukemia, I found medical research showing that the mutant cells that characterize my leukemia have high levels of folic acid. The chloramphenicol that poisoned me has an affinity for the bone marrow where the mutant cells are made. It would appear that chloramphenicol has ruined my ability to conjugate folic acid. Further evidence of that, are anomolies in my thyroid, pituitary and prostate glands. All these conditions are normally prevented by PABA- a compound linked to folic acid.
    To keep my leukemia under control I have a low folic acid diet.
    My daughter in law’s first baby had to be terminated in the womb as it was oversize and had no heart-a neural tube defect? She had also been poisoned by chloramphenicol just like me. After the abortion I ensured she took vitamin D to detoxify the chloramphenicol in her body. Her next baby was normal and her latest pregnancy is going fine.
    Putting folic acid in bread is simplistic and dangerous, especially to people like me.
    As I found out after being poisoned, most doctors have limited understanding of medicine and their actions are characterised by corruption, lies and deceipt all designed to massage their ego and line their pockets.
    I recently(March) had a hollow victory against the ACC in court over my poisoning. Their so called Toxicology Panel now has to look at chloramphenicol as the cause of my poisoning. Of course no doctor on the panel is actually qualified in toxicology so I should see a vague, inadequate, false report from them as they try to mitigate the ACC’s liability.

    • Grant, you make a number of assertions in your post, it would be great if you could include any literature references which support these.
      Also, I consider it unacceptable to make comments such as “most doctors have a limited understanding of medicine and their actions are characterized by corruptions, lies and deceit..” It is a broad generalization, which is patently untrue. At sciblogs the focus is on evidence and not personal attacks.

  • It turns out that after mandatory folic acid fortification in the United States we learned it was a very effective way to get a rather uniform amount of folic acid to the population. Dr. RJ Berry and his colleagues at the Centers for Disease Control and Prevention showed in a national population based nutritional study that the average consumption of folic acid from mandatory sources was approximately 140 micrograms in each quintile of serum folate concentrations. (Yeung L, Yang Q, and Berry RJ. JAMA 2008;300(21):2486-2487.) (Yang Q et al. Am J Clin Nur doi: 10.3945/ajcn.2009.28401). I think this is pretty good evidence that mandatory folic acid gets a consistent amount across the population. It is also worth noting that the 140 micrograms that mandatiory fortification added to most American’s diet is less than the RDA and is highly effective in preventing folic acid preventable spina bifida. Recent case control studies are consistent with the interpretation that most of folic acid preventable spina bifdia has been prevented. Let me end by noting that people in the upper two quintiles of serum folate arrived there by voluntarily consuming vitamin supplement pills with folic acid and/or eating breakfast cereals voluntarily fortified by manufacturers and of course eaten voluntarily. Mandatory folic acid fortification is an excellent public health program that is safe and prevents most of folic acid preventable spina bifida and folate deficiency anemia. Australians, Americans and Canadians are all benefiting from mandatory folic acid programs. Let’s hope that the existing regulations for fortification in New Zealand are allowed to go forward by the Minster so that the population of New Zealand can enjoy the benefits that these same regulations have for 3 years already provided to Australians…

  • Thanks for your post Godfrey.
    According to US research into neural tube defects after fortification of enriched cereal grain products in 1998 the rate of neural tube defects reduced from 7.64 per 10,000 births to 5.31 per 10,000 births. Rates of NDS in Australia where fortification also occurs is also around 5 per 10,000
    In New Zealand in 2000, the rate of neural birth defects was around 10 per 10,000 births. So assuming similarity between the two populations, then this certainly supports folic acid fortification as a way to reduce NTD’s.

    However, is fortification of bread the best way to do this? Could fortifying something else better achieve the goal of increasing folic acid levels in women who may fall pregnant?
    With the popularity of low carbohydrates, it seems to me there is still a risk that a proportion of women who need to get folic acid will not get it through bread supplementation. An earlier post from Helga Refsum suggested that adding folic acid supplements to feminine products might provide a more targeted approach.

    In terms of benefit vs risk, as far as I can see there is no reliable evidence to show that folic acid fortification of bread would increase rates of cancer so until further evidence comes along I don’t have any major concerns about fortification of cereals/bread.
    I just wonder if there is a better more targeted way of doing it? What if another way of providing women with folic acid could drop it even lower than 5 per 10,000?

  • For the record, Godfrey Oakley is a Research Professor of Epidemiology, Rollins School of Public Health, Emory University,
    Atlanta, GA, USA.

    A useful review of his regarding the addition of folic acid and vitamin B12 to flour can be found at

    I did a thorough review back about 1999 when some in the dietary supplement industry were concerned about policy discouraging the use of folic acid supplements and also concerned about fortification of bread being ‘unnatural’ as well as fearing loss of market share. Apart from the irony that there is nothing natural about consuming a pill, the only scientifically proven means of reducing NTDs is via folic acid supplementation; the rationale and epidemiological evidence for fortifying flour are compelling; the risks at a population level are de minimis.

    I reached the conclusion that much of the argument regarding adverse effects are a beat-up. The argument a decade ago was about masking the neurological effects of pernicious anaemia. An analysis of the literature showed that the argument stemmed from the late 1940’s early 50’s when the then treatment of pernicious anaemia, beef extracts, was unfortunately replaced by the newly discovered folic acid. B12 was discovered later.

    Oakley rightly argues that B12 should also be added to flour, along with several other vitamins and minerals that have fortified flour for quite some time.

    The key policy decision is one of increasing micronutrient content in the food chain. Flour was chosen because it is the most commonly consumed single food.

    The arguments regarding increased cancer is a late comer raised after the previous missive, masking of B12 deficiency, was successfully debunked.