Dr Jonathan Sher
If you can read this article, then thank your ‘neural tube’ (as well as your primary school teacher). This tiny, but mighty, tube became your brain, central nervous system and spinal cord. Astonishingly, everyone’s neural tube is completely formed (or malformed) by the end of the fourth week of pregnancy.
If that crucial facet of fetal development is incomplete or inadequate, then it is known as a Neural Tube Defect. NTDs matter. They are the cause of many miscarriages, stillbirths, therapeutic terminations (when revealed in pregnancy screening), neonatal deaths, as well as such lifelong conditions as Spina Bifida and Hydrocephalus.
Neural Tube Defects are not rare. The human and financial costs are high, as are the burdens on an already over-stretched NHS. Wouldn’t it be great if NTDs could be prevented?
Happily, up to 80% of NTDs can be prevented. And yet, the UK Government has proposed a policy that (by its own estimates) would prevent only between 15-22% of NTDs. Better than nothing, of course, but why settle for an inequitable, inadequate 15-22% when up to 80% prevention can be achieved just as safely, easily and inexpensively?
The ‘secret’ is to have enough folic acid (Vitamin B9) early enough; that is, pre-pregnancy. Starting to take folic acid supplements once pregnancy is known cannot prevent NTDs. That ship already sailed by Week 5.
A sufficient amount of folic acid, taken regularly during preconception, raises blood folate levels to the point at which NTD prevention can occur. Eating foods rich in folate (the natural form of Vitamin B9) is healthy. Yet, even Popeye could not eat enough spinach to protect against NTDs.
So, what is the solution? Is the UK Government heading toward a major ‘own goal’ here?
Preventing up to 80% of NTDs is entirely within reach through Fully Effective Fortification. The key is adding a high enough level of folic acid to multiple grains, such as wheat and rice. Unfortunately, the UK Government is proposing adding a minimal level of folic acid to only one type of flour. Too little plus too narrow equals less than 22% prevention. Own goal!
The reality that Vitamin B9 can prevent most NTDs is not new news. Nearly 90 countries across the globe have routinely been fortifying foods with folic acid. All have lowered NTDs, without any credible evidence of ill effects. Experience has demonstrated it is both effective and safe. No country has ever renounced or discontinued its fortification policy.
Two ironies abound in the case of the UK.
First, adding Vitamin B9 to grains would not be blazing new territory. There have been four vitamins and minerals automatically added to flour in the UK for more than sixty years to promote public health – Calcium, Iron, Niacin and Thiamin. Thiamin is Vitamin B1, while Niacin is Vitamin B3. Vitamin B9 was not included because, back then, its preventative benefits were not yet known.
Second, the scientist leading the landmark, international MRC Vitamin Study in 1991 was Nicholas Wald. This research proved the power of folic acid to prevent NTDs. He is now world-renowned Professor Sir Nicholas Wald. He was honoured with a knighthood, but not heeded in practice in the UK for more than thirty years. He firmly recommends UK-wide Fully Effective Fortification.
The UK is finally catching on and catching up. In 2019, the UK Government held a public consultation on folic acid fortification. The positive response led to an announcement in 2021 that this public health measure would be implemented. So far, so good.
However, in September 2022, another UK-wide public consultation was launched. This very technical, 46-page document is most relevant to the food industry, not the public or public health.
It has two flagrant flaws. First, it proposes a low level of fortification of only one type of wheat flour. The government itself admits this is only sufficient to avoid less than 22% of Neural Tube Defects.
Second, the lengthy and numerous questions in the consultation focus on technical details, but avoid the fundamental issues about the level and breadth of fortification. The sole opportunity to encourage Fully Effective Fortification is by adding it to the marginal ‘Other comments’. A fair and balanced consultation would allow everyone to express support for either the UK Government’s proposal, or a much more meaningful public health policy to prevent NTDs.
Inequality is also an (unnecessary) weakness in the government’s proposal. The longstanding policy of encouraging (and sometimes subsidising) voluntary folic acid supplementation by women of reproductive age was well-intentioned. But it ultimately failed.
Taking folic acid benefited those who regularly took enough, early enough. However, that did not include two-thirds of all women. It largely missed those in the lower half of the socioeconomic spectrum and those whose pregnancies were unintentional or mistimed. Thus, the policy of voluntary Vitamin B9 supplementation inadvertently increased health inequalities.
The UK’s current policy proposal would exacerbate health inequalities in a new way. By narrowly restricting the level and scope of folic acid fortification, ‘collateral damage’ will be experienced by those who don’t regularly (or ever) consume bread made with a single type of wheat flour. What justification can there be for discriminating against, for example, people who have medically-necessary dietary restrictions or different, culturally-influenced food preferences? Shouldn’t they have an equal right to be protected from Neural Tube Defects?
The UK Government’s consultation ends on 23 November 2022.
This is the moment to advocate for Fully Effective Fortification, instead of allowing the ‘half-baked’ current proposal to slip through unchallenged. The prospective parents of today and the next generation of our children deserve better.
Dr Jonathan Sher is a Senior Fellow at the Queen’s Nursing Institute Scotland (QNIS) and the Lead for Healthier Pregnancies, Better Lives. Further background information is available free at: https://www.qnis.org.uk/wp-content/uploads/2022/10/HPBL-Key-Points-About-Folic-Acid-Fortification-and-Prevention-of-Neural-Tube-Defects-NTDs.pdf
The consultation document is here: https://consult.defra.gov.uk/food-compositional-standards/bread-and-flour-consultation-2022/consultation/intro/ Only questions 11, 13, 14 and 35 are directly relevant to Fully Effective Fortification. The rest can be skipped.
firstname.lastname@example.org November 2022