Lord Rooker (Lab)
My Lords, I am very pleased to have the opportunity to raise the subject of fortifying white flour with folic acid in the interests of public health.
Deficiencies in folic acid have been found to lead to neural tube birth defects, including spina bifida and hydrocephalus. It is both a national and an international issue. Public health policy has been to encourage those planning to become pregnant to ensure a voluntary input of folates, either by supplement or by folate-rich foods, in that crucial period covering conception and the first 12 weeks. However, this policy is known to fall on deaf ears in some socioeconomic groups, and does not cover the issue of unplanned or unintended pregnancies. In some countries, where bread is part of the staple diet, it has been found that fortifying bread flour with folic acid can cover both the issues of the target group and unplanned pregnancy.
Bread has been a staple food in the UK for centuries. Consumption has fallen a little but it still contains more than 10% of our daily intake of key nutrients and remains a major source of them. Since the 1940s, just after the war, most of our bread flour has been fortified with four added nutrients, and that is still the case today. On 5 August this year, at the start of the Recess, Defra announced the result of the consultation on the bread and flour regulations, which was that the mandatory fortification of flour will continue on health and scientific grounds.
The idea of folic acid fortification has been around for many years. I can confirm from my own personal experience that in 1999, as Minister for food safety—before my Food Standards Agency days—I was lobbied on the issue by a leading scientist during a journey to a food conference. My initial reaction was, “It’s mass medication”. But I soon realised it was not then, and it is not now. By 2007, Her Majesty’s Government had been advised by the independent Scientific Advisory Committee on Nutrition and the Food Standards Agency to go down the route of mandatory fortification. This advice was reinforced in 2009-10, during my term as chair of the Food Standards Agency.
Scientists involved in the research, such as Professor Nicholas Wald of the Wolfson Institute of Preventive Medicine, have chased the issue up over the years. Others, such as Professor Colin Blakemore, have raised more generally the issue of the lack of feedback from government on advice from scientists, where there seems to be no clear decision on policy or action to be taken, or not taken, on the basis of the advice. He cited folic fortification as a recent example.
Delay has been caused by some scientific doubts regarding the effect of too much folate in the diet, which might be the cause of some rare cancers. Justifiably, Ministers and Chief Medical Officers required reassurance on this aspect. I believe—and this is why I am raising the issue now, after leaving the FSA—that the publication in March this year of the paper by Vollset et al in the Lancet puts the concerns to rest. The study analysed data on 49,621 individuals in 13 evenly randomised trials and found that there was no significant effect of folic acid supplementation on the incidence of cancer of the large intestine, prostate, lung, breast or any specific site. Furthermore, in interpretation, the scientists pointed out that the fortification of flour and cereal products involves doses of folic acid that are on average an order of magnitude smaller than the doses used in the trials they examined.
On 1 July the noble Earl, Lord Howe, the Health Minister for England, told Parliament that Ministers were “taking stock”. Has that included talking to Ministers in the other three countries of the UK? More than 50 countries are fortifying flour with folic acid, including the United States, Canada, Iran, Argentina and South Africa. So far, none in Europe are, due to the concerns I have mentioned, which are no longer justified.
Australia introduced mandatory folic fortification in September 2009. It has been found, in a paper by Brown et al in the Medical Journal of Australia in January 2011, that,
“the introduction of mandatory fortification with folic acid has significantly reduced the prevalence of folate deficiency in Australia, including in woman of childbearing age”.
A study in the American Journal of Medical Genetics in 2010 found that food fortification with folic acid prevents neural tube defects but not other types of congenital abnormalities. The study covered more than 3 million births in Chile, Argentina and Brazil over a 25-year period, according to the authors, Lopez-Camelo et al. The paper by Blencowe et al in 2010 in the International Journal of Epidemiology concluded:
“The evidence supports both folic acid supplementation and fortification as effective in reducing neonatal mortality from NTDs”.
So it works.
The latest study, published earlier in the year in the Lancet, clears the way to vastly improve the health position in the UK. We start from a low position. England has the highest rate of unintended or unplanned pregnancies after the USA—well in excess of 200,000. As such, the women concerned will see no need for supplementation. So far as the pregnancies that are affected by neural tube defects are concerned, there are hidden and avoidable family tragedies involved.
The best figures I have—they are a little old but I am advised they are the best—are those used by SACN, the Scientific Advisory Committee on Nutrition, in its report, drawn to my attention by the Shine charity. In England and Wales, there were 178 neural tube defect-affected births from 853 neural tube defect-affected pregnancies. That means that there were 675 terminations. In Northern Ireland, there were 11 affected births and no terminations. In Scotland, there were 49 affected pregnancies with 50% terminations. That means that there were more or less 238 neural tube defect-affected births and 913 affected pregnancies, with around 700 terminations. These will be late, following the 20-week scan, when neural tube defects show. In summary, therefore, there are 150 to 200 babies born with neural tube defects leading to spina bifida and other conditions, with a total of 750 to 1,000 pregnancies. Eighty per cent of the neural tube defect-affected pregnancies are terminated.
Nothing I say diminishes my life-long support for a woman's right to chose, but it is self-evident that decisions for termination based on neural tube defect-affected pregnancies would decline with folate increases. More than one in 1,000 pregnancies in the UK is affected each year. Folic fortification has been shown in the countries that have a mandatory policy to have prevented between 27% and 50% of cases of neural tube defects. Based on these figures, we have a potential to save 100-plus neural tube defect-affected births per year in UK; and significantly we could prevent hundreds of late terminations every year. Putting it crudely, the current reduction in the number of babies born with neural tube defects is actually brought about by the termination of pregnancies. I do not like the idea that in the past some DoH officials have claimed that NTD is well managed.
The Prime Minister said at PMQs on 27 February that,
“conditions such as spina bifida have come down and that folic acid has an important role to play”.—[Official Report, Commons, 27/2/13; col. 311.]
They have “come down” as terminations go up, due to the rate of diagnosis getting more accurate. What we need is primary prevention. Putting folic acid in white bread flour is not mass medication. Those who wish to avoid it just avoid white sliced bread. It gets to the groups of women most difficult to get to.
I want to hear what assessment the Government have made of the impact over the past seven months while they have been taking stock of the operation in England and what discussions have taken place with the devolved Administrations and their Chief Medical Officers. It is better to have a UK solution, as I know that flour mills are not always in the most convenient locations for four separate policies.
The science policy advice to government is to do it. Scientific concerns have been raised and cleared. It is not mass medication; it saves lives and misery, and it saves money. It reduces the hidden cost of the present policy, namely the costs of terminations as a management tool. It produces more healthy babies and improves public health.
Lord Wallace of Saltaire (LD)
My Lords, one speaker has scratched. That will allow us to stretch speaking times from seven to nine minutes, provided that the next four speakers all observe that when 9 comes up on the clock, they stop.