do they understand the risks of Folic acid supplementation?
Nick Hunt, Clare Craig, Ros Jones & Liz Evans
On 30th August, the letter below was sent to the following medically qualified MPs and peers:
Baroness Cass, Lord Darzi, Baroness Finlay, Baroness Gerada, Baroness Hollins, Lord Kakkar
Lord McColl, Baroness Nargund, Lord Patel, Baroness Watkins, Lord Winston
Dr Ahmed, MP, Dr Allin-Khan, MP, Dr Cooper, MP, Dr Evans, MP, Dr Johnson, MP
Dr Mullan, MP, Dr Murrison, MP, Dr Opher, MP, Dr Prinsley, MP, Dr Spencer, MP
Dear Dr ……….,
Re: Mandatory Fortification of Flour with Folic Acid
We are a group of medical and safety management professionals with grave concerns about the newly mandated addition of folic acid to flour. We believe that as a Parliamentarian who qualified with a medical degree, you are best placed to understand the issues involved. The claims of benefit are not as clear cut as many of us were taught in medical school and the evidence that risks outweigh benefits has grown to be substantial.
The addition of synthetic folic acid to flour from 13 December 2026 became law in the UK via SI2024/1162, an amendment to the Bread and Flour Regulations 1998. As a Statutory Instrument, there was no parliamentary debate. There was also no full, scientific, Impact Assessment; just a de minimis financial assessment by DEFRA with limited DHSC input. The stated aim of the mandate is to increase blood folate levels in pregnant women in order to reduce the risk of neural tube defects (NTDs). The Government estimates the policy will result in a reduction of about 200 NTD-affected pregnancies annually, approximately 20% of UK cases.
However, behind this headline are some serious risks that were not presented to Parliamentarians when SI2024/1162 was laid. We explain these below and would be grateful to know your views. If you share our concerns about the seriousness of this issue, we ask for your support in ensuring a proper parliamentary discussion and debate.
The Hungarian Folic Acid Trial
The strongest evidence for a reduction in NTDs comes from animal work and randomised controlled trials using high doses of folic acid in high-risk women. However, there was also one randomised controlled trial using moderate doses in healthy women: the Hungarian Periconceptional Supplementation Trial (Czeizel & Dundas, 1992)[1]. In this trial “Women planning a pregnancy (in most cases their first) were randomly assigned to receive a single tablet of a vitamin supplement (containing 12 vitamins, including 0.8 mg of folic acid; 4 minerals; and 3 trace elements) or a trace-element supplement (containing copper, manganese, zinc, and a very low dose of vitamin C) daily for at least one month before conception and until the date of the second missed menstrual period or later.”
The trial found 0 NTDs in the multivitamin (folic acid) arm versus 6 NTDs in the control arm. These results led to public health authorities recommending folic acid for pregnant women and declaring that further research would be unethical.
However, it is less well known that the same researchers published a safety analysis[2] two years later, in 1994, which revealed 70 excess fetal deaths (mainly miscarriages) in the supplemented arm. This paper is behind a paywall, and the abstract does not mention the excess deaths, but Table 2 of the full report shows this data clearly, as shown below:
Therefore, for a pregnant woman, despite the 1 in 450 possibility of NTD benefit, there was also a 1 in 50 risk of pregnancy loss. This translates as 9 pregnancies lost for every 1 NTD prevented. Moreover, the authors noted that all the claimed NTD benefit might have resulted from prenatal death of affected fetuses.
These losses have been explained away as “good deaths” i.e. pregnancies that folic acid sustained just long enough for a loss that would have passed unnoticed to become a recognised miscarriage. This ignores the effect of a pregnancy loss on the parents and does not fit with the data. If folic acid were carrying early conceptions further, the earliest losses (the chemical pregnancies) should have also fallen. However, they rose. This safety analysis has consistently been ignored, and pregnant women have not been informed of the risks of folic acid supplementation, only its claimed benefits.
Risks to Human Health from Synthetic Folic Acid
Synthetic folic acid is not the same as natural folate (found in foods like leafy greens and citrus fruits). It is a manufactured molecule that is converted in the body by an inefficient enzyme into usable folate. This takes many hours and even days at higher doses. The risk to human health arises from circulating, unmetabolised, folic acid, which is associated with a range of harms. For example, it acts as a partial agonist at the folate receptor, blocking actual folate from binding and being absorbed into the cells (including the brain), thereby making any folate deficiency worse.
The NHS has long warned[3] of the risks of folic acid to certain groups; including anyone with cancer, a coronary stent, B12 deficiency (particularly if undiagnosed), or a previous allergic reaction to it, who are all advised by the NHS to completely avoid folic acid supplementation. This fact alone should preclude it from being imposed on the whole public as a mass, uncontrolled medication through fortification of flour. Flour is a staple food which is also hidden in many processed foods, so it will be almost impossible to avoid exposure if you have any of these conditions.
There is also strong evidence that folic acid increases the risk of cancer[4], with an overall increase of 7% (RR 1.07 [95% CI 1.00 to 1.14]) reported in a meta-analysis of 10 randomised trials. Prostate cancer showed an increase of 24% (RR1.24 [1.03-1.49]).
Folic Acid Fortification is Unethical and Unscientific
Prior to SI2024/1162, the UK had rejected folic acid fortification of flour for nearly 30 years, and it continues to be rejected by nearly every other Western European country. We are gravely concerned that the UK is now speeding, without proper parliamentary scrutiny of serious health risks, towards mandatory folic acid supplementation of flour which will, by implication, be in all food products containing flour (including pasta, cakes, pizza, burgers, battered fish, biscuits, soup, pies, ready meals, baby food, breakfast cereals).
This is unethical mass medication, without consent, of the entire population (including men, postmenopausal women and children who have no possibility of any benefit) for a small potential benefit to reduce NTDs in a very small and specific group. It is not scientific or wise, as it ignores the disproportionately higher risk of fetal death than NTD benefit in pregnant women taking folic acid, as well as the health risks to the wider population from circulating unmetabolised folic acid.
How are those whom the NHS warns about folic acid supposed to avoid it? Or anyone else who does not want to ingest it due to health concerns e.g. its potential for cancer promotion?
Please let us know your views and whether you will press for parliamentary debate about this. If you are willing, we would welcome a meeting or further discussion.
Yours sincerely
Nick Hunt, BSc(Eng), MBA, CEng, Perseus Group
Dr Clare Craig, BMBCh, FRCPath, Pathologist, Co-chair HART group
Dr Rosamond Jones, MBBS, DRCOG, MD, FRCPCH, Paediatrician, Co-chair HART group
Dr Elizabeth Evans, MA(Cantab), MBBS, DRCOG, CEO, UK Medical Freedom Alliance
Professor Angus Dalgleish, MD, FRCP, FRACP, FRCPath, FMed Sci, Emeritus Professor of Oncology, City St Georges, University of London, Principal, Institute for Cancer Vaccines & Immunotherapy
Professor David Paton, Professor of Industrial Economics, Nottingham University Business School
Professor Paul Goddard, MBBS, MD, FRCR, FBIR, retired Professor of Radiology, University of the West of England
Professor Richard Ennos, MA, PhD, Honorary Professorial Fellow, University of Edinburgh
Professor Roger Watson, FRCP Edin, FRCN, FAAN, Saint Francis University, Hong Kong SAR, China
Alex Hicks, MEng, MCIPS, Compliance Director (Supply Chain)
Catherine Cassell, RGN, Practice Nurse
Dr Alan Mordue, MBChB, FFPH. Retired Consultant in Public Health Medicine & Epidemiology
Dr Ali Haggett, Mental health community work, 3rd sector, former lecturer in the history of medicine
Dr Alison Sabine, MBChB, MRCP, Consultant Rheumatologist
Dr Alistair J Montgomery, MBChB, MRCGP, DRCOG, retired General Practitioner
Dr Andrew McHutchon, MBChB, FRCA, retired Consultant Anaesthetist
Dr Angela Musso, MD, MRCGP, DRCOG, FRACGP, General Practitioner, regenerative and longevity medicine
Dr Angharad Powell, MBChB, BSc(Hons), DFSRH, DCP(Ireland), DRCOG, DipOccMed, MRCGP, General Practitioner
Dr Caroline Lapworth, MB ChB, General Practitioner
Dr Charles Forsyth, MBBS, BSEM, retired Independent Medical Practitioner
Dr Chris Newton, PhD, Biochemist working in immuno-metabolism
Dr Christina Peers, MBBS, DRCOG, DFSRH, FFSRH, Naturopathic Holistic Practitioner
Dr Christine Dewbury, MBBS, retired General Practitioner
Dr Christine Suppelt MD FRCS MFHom, Ophthalmic Surgeon & Specialist for Integrated Medicine
Dr Christopher Exley, PhD, FRSB, Bioinorganic Chemist
Dr David Critchley, BSc(Hons), PhD, Clinical Pharmacologist (retired)
Dr David White, MBBCh, retired General Practitioner
Dr Felicity Lillingstone, IMD, DHS, PhD, ANP, Doctor, Urgent Care, Research Fellow
Dr Fiona Martindale, MBChB, MRCGP, GP in out of hours
Dr Francesca Mbow, MD(Italy), MRCGP, DFFP, General Practitioner
Dr Gary Sidley, PhD, retired NHS Consultant Psychologist
Dr Geoffrey Maidment, MBBS, DRCOG, MD, FRCP, retired Consultant Physician
Dr Gerry Quinn, PhD, Postdoctoral researcher in Microbiology and Immunology
Dr Gillian Breese, BSc, MB ChB, DFFP, DTM&H, retired General Practitioner
Dr Greta Mushet, MBChB, MRCPsych, retired Consultant Psychiatrist in Psychotherapy
Dr Helen Westwood, MBChB, MRCGP, DCH, DRCOG, General Practitioner
Dr James Dyson, MRCS LRCP, MA, retired Medical Practitioner
Dr Janet Menage, MA, MBChB, retired General Practitioner
Dr Jayne LM Donegan, MBBS, DRCOG, DCH, DFFP, MRCGP, Naturopathic Practitioner
Dr Jenny Goodman, MA, MBChB, Ecological Medicine
Dr Jessica Robinson, BSc(Hons), MBBS, MRCPsych, MFHom, Psychiatrist and Integrative Medicine Doctor
Dr John Flack, BPharm, PhD, Retired Director of Safety Evaluation, Beecham Pharmaceuticals and Senior Vice-president for Drug Discovery SmithKline Beecham
Dr Jon Rogers, MBChB(Bristol), MRCGP, DRCOG, retired General Practitioner
Dr Jonathan Eastwood, BSc, MBChB, MRCGP, retired General Practitioner
Dr Julia Piper, FRCGP, BM BS, BMedSci, DFFP, AFMCP, DipOccMed, DipMedAcc, Naturopathic Medicine Practitioner
Dr Keith Dewbury, MBBS, FRCR, retired Consultant Radiologist
Dr Livia Tossici-Bolt, PhD, retired Clinical Scientist
Dr Lucie Wilk, MD, MRCP, Rheumatologist
Dr Mark A Bell, MBChB, MRCP(UK), FRCEM, Consultant in Emergency Medicine
Dr Matthew Hicks, MBChB, NHS Specialty doctor
Dr Michael Bazlinton, MBCHB, MRCGP, DCH, General Practitioner
Dr Michael D Bell, MBChB, MRCGP, retired General Practitioner
Dr Noel Thomas, MA, MBChB, DObsRCOG, DTM&H, MFHom, retired Doctor
Dr Pauline Jones, MB BS, retired General Practitioner
Dr Peter Chan, BM, MRCS, MRCGP, NLP, General Practitioner, Functional Medicine Practitioner
Dr Rachel Nicoll, PhD, Medical researcher
Dr Renee Hoenderkampf, MBBS, MRCGP, DFSHRH, General Practitioner
Dr Richard House, PhD, CPsychol, AFBPsS, CertCouns, Chartered Psychologist, former senior lecturer in Psychology (Roehampton) and Early Childhood (Winchester), retired Psychotherapist
Dr Ruth Wilde, MBBCh, MRCEM, AFMCP, Integrative & Functional Medicine Doctor
Dr Sarah Myhill, MBBS, retired General Practitioner
Dr Sheena Fraser, MBChB, MRCGP(2003), Dip BSLM, General Practitioner
Dr Tanya Klymenko, PhD, FHEA, FIBMS, Senior lecturer in Biomedical Sciences
Dr Theresa Lawrie, MBBCh, PhD, Director, Evidence-Based Medicine Consultancy Ltd, Bath
Dr Thomas Carnwath, MBBCh, MA, FRCPsych, FRCGP, retired Consultant Psychiatrist
Fiona Jones, BScHons, DipPreSci, PgCert MEd, MFRPSII, FRPharmS, retired Clinical Lead Pharmacist
Helen Auburn, Dip ION, MBANT, CNHC, Registered Nutritional Therapist
Ian Humphreys, UKMFA Programme Director
James Cook, NHS Registered Nurse, Bachelor of Nursing (Hons), Master of Public Health (MPH)
Kaira McCallum, BSc, retired Pharmacist, Director of strategy UKMFA
Katherine MacGilchrist, BSc(Hons), MSc(Epidemiology), former CEO/Systematic Review Director, Epidemica Ltd.
Marco Tullio Suadoni, RN, BSc(Hons) Adult Nursing, MSc, retired Specialist Palliative Care Lead
Michael Cockayne, MSc, PGDip, SCPHNOH, BA, RN, previous Occupational Health Practitioner
Mr Anthony Hinton, MBChB, FRCS, Consultant ENT surgeon, London
Mr Ian F Comaish, MA, BMBCh, FRCOphth, FRANZCO, Consultant ophthalmologist
Mr Ian McDermott, MBBS, MS, FRCS(Tr&Orth), FFSEM(UK), Consultant Orthopaedic Surgeon
Mr John Bunni, MBChB (Hons), DipLapSurg, FRCS [ASGBI Medal], Consultant Colorectal and General Surgeon
Mr T James Royle, MBChB, FRCS(Ed), MMedEd, Consultant Colorectal Surgeon
Rev Dr William J U Philip, MBChB, MRCP, BD, Senior Minister, The Tron Church, Glasgow, formerly physician specialising in cardiology
Sarah Waters, BA (Hons), Dip Counselling & Therapy, MBACP, Psychotherapist, Therapeutic Parenting Practitioner
Sophie Gidet, RM, Midwife
Sorrel Scott, Grad Dip Phys, Specialist Physiotherapist in Neurology, 30 years in NHS
Wendy Armstrong, Practice Nurse
[1] https://www.nejm.org/doi/10.1056/NEJM199212243272602
[2] https://pubmed.ncbi.nlm.nih.gov/7979565/
