Folic acid is a B vitamin. It is called folate when it is found in foods in its natural form. Folic acid is the synthetic form used in supplements or added to food.
Some foods, such as many breakfast cereals and spreads, are already fortified with folic acid and other vitamins and minerals. But recently there have been discussions about whether it should be compulsory to add folic acid to bread or flour in the UK.
Folate (or folic acid) is an important vitamin for everyone. It's essential for many body processes, including the production of red blood cells. Most people can get all the folate they need from a healthy balanced diet and they don't need to take supplements containing folic acid.
But women who are trying to get pregnant, or are pregnant, should take a 400 microgram (mcg) supplement of folic acid every day from the time they stop using contraception until at least the 12th week of pregnancy.
Folate is needed for the rapid cell division and growth that takes place during pregnancy and it has been shown to reduce the chance of neural tube defects, such as spina bifida, in the unborn baby.
Women who have already had a pregnancy affected by a neural tube defect are advised to take a higher dose of folic acid - 5 milligrams (mg) a day - when they are planning to get pregnant again and until the 12th week of pregnancy. Diabetes UK also recommends that all women with diabetes who are planning to get pregnant should take 5mg of folic acid a day for the same period of time.
In December 2006, the Scientific Advisory Committee on Nutrition (SACN) recommended ‘mandatory fortification’ of flour with folic acid in order to reduce the number of pregnancies affected by neural tube defects. This means that it would be compulsory to add folic acid to flour in the UK. This would be flour sold to consumers and flour used by UK-based manufacturers, such as bakers. The Committee estimated that there are between 700 and 900 pregnancies affected by neural tube defects each year in the UK. SACN is an independent scientific committee that advises the Government on nutrition.
In May 2007, the Food Standards Agency Board agreed unanimously that mandatory fortification with folic acid of either bread or flour should be introduced. Alongside mandatory fortification, the FSA Board recommended controls on voluntary fortification (when manufacturers choose to add folic acid to foods) and advice for the public on supplements containing folic acid.
So far, mandatory fortification hasn’t been introduced because, in October 2007, SACN was asked by the Chief Medical Officer to consider some studies that suggested folic acid might increase the risk of colorectal cancer (which affects the large intestine and/or rectum). The Committee also considered the combined results of seven trials that found that folic acid did not increase the risk of cancer. SACN carefully considered the evidence and agreed, in October 2009, to retain its previous recommendation for the introduction of mandatory fortification with folic acid, with controls on voluntary fortification. However, SACN advised that people who might be at more risk of developing colorectal adenomas or colorectal cancer (people over 50 and those who have had colorectal adenomas before) should not take supplements containing more than 200mcg of folic acid a day without medical advice.
The Agency is still recommending mandatory folic acid fortification of either bread or flour. From October 2009, UK Health Ministers will be deciding whether to approve mandatory fortification with folic acid in the UK. If mandatory fortification is approved, the Agency will produce a plan of how it can be implemented, including details of which types of bread or flour would be fortified and how the added folic acid would be labelled.
More information about the evidence on folic acid and cancer risk, and SACN’s updated recommendation, can be found in the ‘Could a high intake of folic acid affect the risk of cancer?’ section below or by following the ‘More about folic acid fortification’ link to the right.
How could folic acid fortification reduce the number of neural tube defects?
If bread or flour were fortified with folic acid, this would increase the folic acid intake of lots of people in the UK, including women with low intakes who may become pregnant. There is strong evidence that the higher a woman’s intake of folic acid before she gets pregnant, and in the first 12 weeks of pregnancy, the lower the risk of her baby developing a neural tube defect.
Even though women are advised to take folic acid supplements when they are trying to get pregnant and in early pregnancy, many women do not take the supplements, or they start taking them too late. This is partly because about half of pregnancies in the UK are not planned.
Are there any other benefits of folic acid?
Some research has suggested that folic acid could help to reduce the risk of cardiovascular disease (heart disease and stroke), reduce the risk of some types of cancer and bone disease and slow down age-related cognitive decline (which is when someone's mental processes become impaired). But at the moment there isn't enough evidence to say if folic acid has a positive effect in these areas.
Could folic acid fortification have a harmful effect on people with vitamin B12 deficiency?
There has previously been some concern that people with vitamin B12 deficiency could be negatively affected by folic acid fortification. Older people are at a greater risk of vitamin B12 deficiency because they are less able to absorb this vitamin from food.
If someone is consuming high levels of folic acid, this could 'mask' a vitamin B12 deficiency by improving one of the symptoms (anaemia), which means it could be difficult for health professionals to spot. If someone has a prolonged B12 deficiency, it can cause damage to the spinal cord and nervous system (neurological damage). If this is left undiagnosed and untreated it can lead to severe disability, though this is not very common (28 cases in 2003).
There isn't any evidence showing that folic acid can mask vitamin B12 deficiency at doses of 1,000mcg a day or less in the short term. SACN estimated that if mandatory fortification were introduced at 300mcg of folic acid per 100g of flour (as well as controls on voluntary fortification), there would be 900 people aged 65 and over who might have more than 1,000mcg a day of folic acid. This is the same number of people that have more than 1,000mcg a day with the current levels of folic acid added through voluntary fortification. That is why the FSA's Board has agreed to recommend controls on voluntary fortification and advice on supplement use, to accompany mandatory fortification.
Figures from the US, where mandatory fortification of grain was introduced in 1998, show that the number of serious neurological cases associated with vitamin B12 deficiency has remained the same after fortification was introduced, at fewer than 30 cases a year.
The Department of Health is considering better ways of checking for B12 deficiency in older people.
Could a high intake of folic acid affect the risk of cancer?
Some studies have suggested that having a high intake of folate may help protect against cancer, but this may be because of other things in the diet that may also help to protect against cancer, such as fibre.
There is also some evidence from studies using animals that suggests that a high intake of folic acid might protect against the development of cancer. However, if there is already a precancerous growth in the body, a high intake of folic acid might speed up its progression into cancer, though the amounts of folic acid used in the animal studies were much higher than the amounts people would be consuming if mandatory fortification were introduced.
Some evidence from studies in humans suggests that folic acid may increase the risk of colorectal cancer. However, the combined results of seven trials, involving 35,600 people, examined by the Scientific Advisory Committee on Nutrition (SACN) in 2009, found that folic acid did not increase the risk of cancer.
Because the link between folic acid and increased or reduced cancer risk is unclear, SACN thought that it would be best to minimise the chance of people consuming large amounts of folic acid by:
recommending restrictions on voluntary fortification of foods
making it clear that only women of child-bearing age should take folic acid supplements
monitoring any new evidence on negative effects of folic acid fortification
Is there mandatory folic acid fortification in other countries?
Yes. In the US, mandatory fortification of grain with folic acid was introduced in 1998. In Canada, there has been mandatory fortification of white flour and pasta since 1998, and, in Chile, mandatory fortification of flour since 2000. In September 2009, Australia introduced mandatory fortification of flour for bread-making.
In both the US and Canada, the number of pregnancies affected by neural tube defects has fallen since mandatory folic acid fortification was introduced and in Chile the number of live and still births affected by neural tube defects has also fallen.
So far, no European countries have introduced mandatory fortification with folic acid.
Can pregnant women get enough folic acid without supplements or fortified foods?
We can get some folate (the natural form of folic acid) from a healthy balanced diet, but when women are trying to get pregnant, and in the first 12 weeks of pregnancy, they need more folic acid than usual, to reduce the risk of neural tube defects.
It is very difficult to get that amount of folic acid from food alone, which is why women are advised to take 400mcg of folic acid each day when they are trying to conceive and for the first 12 weeks of pregnancy.
Folate is found in small amounts in many foods, including:
yeast extract
green leafy vegetables such as broccoli, spinach and Brussels sprouts
peas and chickpeas
some fruit such as oranges
Women who are pregnant or trying to get pregnant should try to eat plenty of foods containing folate, as well as taking the recommended amount of folic acid as a supplement.
Folate (or folic acid) is an important vitamin for everyone. It's essential for many body processes, including the production of red blood cells. Most people can get all the folate they need from a healthy balanced diet and they don't need to take supplements containing folic acid.
In December 2006, the Scientific Advisory Committee on Nutrition (SACN) recommended ‘mandatory fortification’ of flour with folic acid in order to reduce the number of pregnancies affected by neural tube defects. This means that it would be compulsory to add folic acid to flour in the UK. This would be flour sold to consumers and flour used by UK-based manufacturers, such as bakers. The Committee estimated that there are between 700 and 900 pregnancies affected by neural tube defects each year in the UK. SACN is an independent scientific committee that advises the Government on nutrition.
Yes. In the US, mandatory fortification of grain with folic acid was introduced in 1998. In Canada, there has been mandatory fortification of white flour and pasta since 1998, and, in Chile, mandatory fortification of flour since 2000. In September 2009, Australia introduced mandatory fortification of flour for bread-making.
We can get some folate (the natural form of folic acid) from a healthy balanced diet, but when women are trying to get pregnant, and in the first 12 weeks of pregnancy, they need more folic acid than usual, to reduce the risk of neural tube defects.