Health: Birth Defects

Countess of Mar Excerpts

Wednesday 6th November 2013 Lords Chamber

[The Countess of Mar (CB)]

My Lords, I do not think I am likely to get to nine minutes. I am very grateful to the noble Lord, Lord Rooker, for bringing this subject to our attention this evening.

Under normal circumstances, I would prefer that young women should all have a good balanced diet with plenty of fresh fruit and leafy vegetables, regardless of whether or not they were considering pregnancy, to give them sufficient folic acid to prevent neural tube defects and, come to that, a very large number of other subclinical conditions linked with folic acid deficiency. Unfortunately, life does not work like that. Many young people—women and girls in particular—lead rather frenetic lives and tend to eat on the hoof. Food which takes little preparation and cooking is the easiest way for them to get their calories. Many have little idea of the nutritional values of the food they eat and cooking a good, balanced meal comes very low in their order of priorities. Others simply cannot afford to buy fresh green vegetables and fruit on a regular basis. While some cereal and snack manufacturers fortify their products with folic acid, these too might be out of range for those on benefits. No amount of education or health promotion material can overcome these problems.

As a mother and grandmother of healthy girls, I find it hard to imagine the anguish and grief that a pregnant woman suffers when told that she is bearing a baby with neural tube defects. The noble Lord, Lord Rooker, has pointed out the abortion rates for this condition. She and her partner have to decide whether they wish to continue with the pregnancy. She has the added knowledge, and the guilt that would accompany it, that if she had taken folic acid before she became pregnant, or immediately she knew that there was a possibility that she was pregnant, she might have prevented potential disaster.

There are people who object on principle to what they regard as mass medication. The noble Lord, Lord Rooker, again has made very clear that it is not without consent. We are all aware of the objections to fluoridation of drinking water. I know that there have been discussions about removing calcium fortification in flour, although these seem to have stalled. Few people realise that, as well as calcium, our white flour is already fortified with thiamine, iron and niacin. They also ask why they should have to have their products made with flour fortified to prevent disease in a very small minority. I believe very strongly that, in the case of folic acid, flour should be fortified. This belief is endorsed by researchers at the Institute for Science and Society at the University of Nottingham in their 2007 report The Ethical Implications of Options for Improving the Folate Intake of Women of Reproductive Age.

The prevalence of neural tube defects started to fall before folic acid supplementation was introduced in the 1970s. Perhaps the abortion laws that came in around that time had some effect. When I was newly married I was told to avoid eating green potatoes because these were seen as the cause of spina bifida. The prevalence fell quite steeply for about 20 years but it has remained stubbornly at between eight and 15 per 10,000 pregnancies since the 1990s. One possible reason could be that nearly half of pregnancies are unplanned; by the time a woman finds she is pregnant it is too late for the supplements to have the greatest benefit.

Most of the UK population eats white flour in some form or another as part of their staple diet, although we must not forget those who are gluten sensitive and do not eat wheat for medical or other reasons. A standard loaf of bread is relatively cheap and filling. It tends to be a substantial part of the diet of those who cannot afford fresh fruit and vegetables or other foods rich in folic acid, such as offal and pulses. It seems likely that fortified bread has a better chance of reaching the target than education or promotional campaigns to encourage this group of women to take folic acid as a precautionary measure. It would also catch those who have unplanned pregnancies.

As well as preventing neural tube defects, folic acid may have a role in reducing congenital heart defects, cleft lips, limb defects and urinary tract abnormalities. It may also help to protect the unborn infant from disease in the mother. It seems to be important that vitamin B12 levels are checked as there is concern that high prenatal levels of folic acid combined with low B12 may cause epigenetic changes. There is a complex interaction between B12, folic acid and iron. As our flour is already fortified with iron we would need to ensure that B12 deficiency would not be masked by the other two.

As the noble Lord, Lord Rooker, has already said, concerns have been voiced about the possibility that folic acid fortification might mask vitamin B12 deficiencies in the elderly and that it might cause bowel cancer, but recent research would appear to negate both these concerns, particularly for the elderly. There would appear to be very little, if any, risk from fortified bread to the general population—indeed, it might even prevent a number of subclinical conditions which could become serious, particularly in the elderly.

The one small concern that I have is that, if white flour is fortified, it will be difficult to determine the folic acid status of women who want to become pregnant or who are pregnant because we will not know their average daily intake. The Department of Health recommends that,

“‘all women who could become pregnant should take 400 microgrammes”—

that is, 0.4 milligrams—

“of folic acid per day as a medicinal or food supplement prior to conception until the twelfth week of pregnancy”.

The RDA for folate equivalents is 600 micrograms. The BMA suggests that the guidance level set for the UK of 1 milligram a day is satisfactory,

“provided there are appropriate controls on mandatory fortification to ensure that individuals do not exceed the upper intake level of 1mg per day”.

There must be huge variations in the amount of white bread and other white flour products that UK consumers eat on an average daily basis. How are we to ensure that young women get enough folic acid to protect their unborn children, or that the elderly do not get too much? What advice about additional supplements will be given to women of child-bearing age who do not eat a lot of bread and to those who have had a previous pregnancy with neural tube defects or who have a genetic risk? We need to be cautious about depending too much upon fortification of white flour with folic acid to solve all the problem of neural tube defects. Nevertheless, that is not an excuse for not doing it.

I support the noble Lord, Lord Rooker, who is himself supported by the BMA, the Scientific Advisory Committee on Nutrition, the Department of Health’s Committee on Medical Aspects of Food and Nutrition Policy and the Food Standards Agency. I hope that the Government will listen to him.