11Joanna Blythman was writing in Friday’s Guardian, discussing concerns about plans FDA to fortify UK bread with folic acid11. Discussing it badly. Really, really badly. And – to add to the excitement – using Patrick Holford as a source. I’m going to look at the article – and Holford’s contribution here.
I thought the article was so bad that I wrote a letter to the Guardian criticising it. And – credit where credit’s due – the Guardian has published the letter today. Read my letter here22 (along with an excellent letter from John Nichols of the Royal College of General Practitioners).
Naturally, I’m grateful that the Guardian published the letter – but there are more problems with the article than I could fit into a single letter to the paper (and – while whoever was editing the letter did a good job on it – they did edit out a little of what I had to say). I’ve also been in touch with Holford since the publication of the article (and since after I wrote the letter) and he’s kindly clarified a few of his points. I’m therefore going to use this post to outline some of the problems with Holford’s position, and to go into more detail about some of the points raised in my letter.
Firstly, if the Guardian wants to run an article on adding ‘chemicals’ to our food, it might help if they made sure that their writers know what a ‘chemical’ is. The article certainly appears confused about this (rather central) point: for example, Blythman refers to adding the “controversial chemical” flouride to our water supply.
My God! Chemicals in water! Next you’ll be telling me that there’s hydrogen in there, or even – shudder – dihydrogen monoxide33. One would hope that someone writing for The Guardian would know that water is a chemical (H2O) and that without access to such chemicals we would all die pretty quickly. We need chemicals all the time, not just daily.
Looking for a good source to quote on folic acid and fortification, Blythman chose to quote Holford – listing him as a “nutritionist”. I know Holford doesn’t have any accredited university degrees in nutrition – but ‘nutritionist’ isn’t a accredited title (I could quite legally market the duck in my local park as a ‘nutritionist’) so I’ll let that pass. However, Holford does have a number of competing interests in this area and it would have been appropriate to at least mention this – so that readers could take this into account when judging Holford’s statements. Especially given that Blythman has written at length44 about the distorting effects of the commercial interests of the supermarkets, it’s surprising that she doesn’t think that Holford’s commercial interests are worth mentioning.
Of course, if Holford’s science was sound then his commercial interests wouldn’t be so…well…interesting. However, I’ve got real problems with his arguments – problems which are exacerbated by the fact the Holford’s Health Products for Life makes money from selling folic acid supplements.
In the article, Holford argues that “We already know that folic acid, given without B12, is creating problems for the elderly…And that’s at half the amount that the FSA is proposing to add to British flour.” However, the FSA is proposing55 [PDF file; see p7] to add folic acid to our flour at pretty low levels: 300mcg/100g of flour; after the cooking of bread is taken into account, this “will increase the average folic acid intake of the population by about 78[mcg/day]”.
A high folic acid intake can mask the symptoms of B12 deficiency – something which, as Holford is right to note, is a particular problem for older people. However, the Scientific Advisory Committee on Nutrition has found that66 [PDF file; see p.53] “folic acid intakes up to 1mg/day are not associated with delayed diagnosis of vitamin B12 deficiency in older people.” The American Journal of Clinical Nutrition has found77 that high folic acid intake combined with inadequate B12 intake is related to cognitive impairment in older people (although good folic acid intake, alongside good B12 intake, brings cognitive benefits). However, although David Smith (writing in the same journal) urges caution88, it is very unlikely the modest supplementation supported by the FSA is going to be a significant problem in itself.
This is where Holford’s commercial interests become interesting. The SACN report99 argues that, at current levels of consumption, fortification of bread will increase “the number of people aged 65 years and over with low vitamin B12 status consuming more than 1mg/day of folic acid.” Supplement pills will play a key role here – anyone who wanted to shovel down enough (unfortified) food to eat 1mg of folic acid every day would need the constitution of an ox and a freakish love of spinach. An obvious way to avoid this risk is therefore for people to take fewer supplements. One likely consequence of the move to fortify bread flour is thus more prominent warnings about the need to avoid over-supplementation.
Holford’s Health Products for Life sells1010 folic acid pills (without B12). Holford advises that some people seeking to reduce their risk of Alzheimer’s should supplement with 2mg of folic acid per day1111. This is despite the fact that the Expert Group on Vitamins and Minerals has set1212 [PDF file] a safe Upper Limit (UL) for folic acid supplementation of 1mg/day (though a few groups – e.g. women with high risk pregnancies – may be advised to take more). 2mg/day is, however, not advisable for most of us.
So – Holford is quoted in a Guardian article emphasising the dangers of bread fortification (which could have a negative impact on Health Products for Life sales) but not even mentioning the much more significant risks from folic acid supplementation (Holford has a commercial interest in selling folic acid). Of course, one can’t know why Holford gives the advice he does – and had he given a balanced assessment of the evidence, I would not even need to be asking about him making money from pill sales. However, the rather skewed advice he was quoted giving does appear to serve his commercial interests surprisingly well – and I would therefore argue that the Guardian article should have made his commercial interests clear, in order to allow readers to decide for themselves whether they are relevant.
A note on measurement
1g = 1000 mg (milligrams) = 1,000,000 mcg (micrograms)