Fortified Flour

Owen Smith Excerpts

Wednesday 16th May 2018 Westminster Hall

[Owen Smith (Pontypridd) (Lab)]

I beg to move,

That this House has considered the mandatory fortification of flour with folic acid to prevent spina bifida and anencephaly.

I am delighted to serve under your chairmanship, Mr Hanson, in this important debate on the potential for the mandatory fortification of flour with folic acid to prevent neural tube defects. Every week in this country two children are born with a neural tube defect, most commonly spina bifida and anencephaly, and every day two pregnancies are terminated as a result of the diagnosis of such conditions in the womb.

The neural tube is the structure in the embryo that becomes the brain and the spinal cord. It should close between the 18th and 28th days after conception. Failure of the neural tube to close completely and properly leads to conditions such as spina bifida, affecting brain development, mobility, and bladder and bowel dysfunction—other right hon. and hon. Members have personal experience of that and will talk with great knowledge about it—and anencephaly, a fatal condition in which the brain does not develop.

In 1991 a seminal piece of research on prevention of neural tube defects for the vitamin study group of the Medical Research Council by Professor Sir Nicholas Wald showed conclusively that supplementing the diets of women with folic acid, a naturally occurring nutrient found in spinach, liver or Marmite, prior to conception and during the first trimester of pregnancy could reduce the incidence of NTDs by up to 70%. In response to the data, the Conservative Government at the time introduced new guidelines that recommended that all women should take supplements of folic acid prior to conception and during the first 12 weeks of pregnancy.

Eighty-one other countries around the world, however, including the United States, Brazil, Australia, South Africa, Nigeria, Indonesia, Argentina and Canada, took a far bolder position, mandating the fortification of flour and flour-based products in their countries with folic acid as a public health intervention for whole societies. They did so having recognised the data and the long-established fact that at least 40% of pregnancies are unplanned, so NTDs might develop in the womb often even before those women realise that they are pregnant.

The recommendation of voluntary supplementation in our country led to an initial increase in the number of women taking folic acid before conception. The proportion went up to 35% in 1999,but by 2012 it had started to fall back, to just 31%, with much lower numbers seen in the more deprived socioeconomic sectors of society and in black and minority ethnic communities. Among pregnant women aged less than 20, on average just 6% supplement their diet before conception.

In short, the position that we have taken in our country under successive Governments has led to increasing health inequalities, with poorer, more marginalised and younger women having greater risk of their children being born with spina bifida or other conditions. By contrast, in the United States, which in 1998 started mandatory fortification of rye and wheat flour, and in 2016 introduced a new programme to fortify corn flour so as to target the Hispanic population, we have seen a reduction in NTD pregnancies of almost 30%. In Canada, one study of the prevalence of NTDs showed a drop from 4.56 births per 1,000 to 0.76 per 1,000 after fortification. Had we in this country followed the same route as Canada or the US, we would have seen 2,000 fewer pregnancies with a neural tube defect between 1998 and 2012. That is a sobering thought for the advisory committee in the UK to consider.

In fact, the scientific evidence in the case for fortification is not really contested. That is why the Scientific Advisory Committee on Nutrition to this Government and previous ones—it used to be called COMA, the Committee on the Medical Aspects of Food Policy, but understandably changed its name—back in 2000 responded to the evidence and to the US move by recommending that our country should go down the route of mandatory fortification. SACN repeated that recommendation in 2006, in 2009 and in July of last year.

The most recent SACN report, surveying all the evidence available around the world about the benefits and the possible adverse consequences of folic acid fortification, stated:

“Conclusive evidence from randomised controlled trials…has shown that folic acid supplementation during the early stages of pregnancy can reduce the risk of the fetus developing neural tube defects”.

It goes on to maintain its view, expressed consistently by scores of scientific advisers to the committee over the years, that Britain should be fortifying our flour to prevent NTDs. The key question as far as I am concerned—not as a clinician or expert, but as someone who understands the value of evidence-based policy making—is this: why have this Government and previous Governments not acted on the advice and the evidence to take similar steps in our country?

The principal excuse offered by Ministers is that the evidence is mixed and that some studies have shown some possible risks associated with having higher levels of folic acid or folates in our bodies. In particular, two risks have been talked about: first, that higher levels of folates may mask vitamin B12 deficiencies in individuals, possibly leading to anaemia and neurological damage; and secondly, that higher doses of folic acid might run the risk of increasing the likelihood of certain cancers. As far as I can see, however, all the evidence and the science produced over the intervening 25 years have largely debunked such concerns.

The SACN has looked at all the evidence in last year’s review and previous ones and stated, on the issue of B12, that folic acid intakes up to 1 mg per day are not associated with neurological impairment in older people with low vitamin B12 status. The most recent SACN review stated that

“studies of folic acid supplementation and observational studies, indicate either no relationship with cognitive decline or a lower risk associated with higher folate status.”

It goes on to note:

“The prevalence of vitamin B12 deficiency with or without anaemia did not increase after mandatory fortification in the USA.”

Since the SACN provided that evidence, a further, critical study has been done by Professor Sir Nicholas Wald, who produced the original research suggesting the use of folic acid in flour, and Professor Sir Colin Blakemore, who is well known to right hon. and hon. Members. The study shows definitively that there is no evidential base for the suggestion of a maximum tolerable level for folic acid. The question of it masking vitamin B12 is therefore no longer taken seriously by the scientific community in our country or overseas as a reason for not introducing folic acid into flour.

On the potential connection between high folate levels and overall cancer risk, again I quote the SACN’s latest review:

“Findings from the different study types are inconsistent but overall do not suggest an adverse association. RCTs”—

randomised controlled trials—

“show no effect of folic acid supplementation on overall cancer risk. The MTHFR genetic studies suggest higher folate concentrations reduce overall cancer risk.”

Again, observed data from America, Canada and other societies do not show any adverse effects of increased cancer risk.

Support for the notion of mandatory fortification comes not just from our country or the SACN, but from a volume of organisations that I shall reference at some length: Shine, the brilliant spina bifida and hydrocephalus charity in this country; the Royal College of Obstetricians and Gynaecologists; the Royal College of Paediatrics and Child Health; the Royal College of Midwives; the British Maternal and Fetal Medicine Society; the Faculty of Sexual and Reproductive Healthcare; the British Dietetic Association; the Governments in Wales, Northern Ireland and Scotland, where only last year the Scottish Government said that they wished to introduce mandatory fortification but were unable to do so on a Scotland-only basis; the chief medical officers in England, Wales, Northern Ireland and Scotland; Public Health England; Public Health Wales; NHS Health Scotland; Health and Social Care in Northern Ireland; the Faculty of Public Health; the Food Standards Agency; Food Standards Scotland; Colin Blakemore; Nick Wald; Jeff Rooker; and me.

There are many people who think this is a very clear case where the evidence should lead to a policy change. Why do the Government not agree with their own advisers and with the overwhelming majority of scientific opinion? Why, in the light of the evidence, do they appear to have dragged their feet—not just this Government, but the previous Labour Government and, indeed, the Conservative Administration before that?

On 2 May, in response to a written question from my hon. Friend the Member for Coventry South (Mr Cunningham) on the case of mandatory fortification, the Minister said:

“No assessment has been made of potential merits of adding folic acid to flour on pregnant women or children.”

That seems to be slightly at odds with what I have been saying for the past 10 minutes—that there seems to be a lot of evidence in support of it. He went on to say that the recent SACN report, which was published in July 2017,

“made recommendations in respect of folate levels and developing foetuses. Ministers are currently considering the issue of mandatory fortification and will set out their position in due course.”

We find ourselves here because I am looking for the Minister to set out the Government’s position in due course. They have had a quarter of a century to mull over the position, in the light of the evidence. I know the Minister, who I have great regard for, is a man of action. I look forward to him setting out the Government’s case and getting on with it.

--- Later in debate ---

[Owen Smith]

I thank the Minister for his response, but I have to say that I am disappointed by it. I am disappointed principally because I do not think he has taken the action that he could have on the basis of the evidence that has been presented both today and, more importantly, by the scientific community in our country and around the world over the past 25 years, as well as the lived experience of the 80-odd communities, societies and Governments around the world that have undertaken mandatory fortification with no evidence recorded in any studies of any of the potential adverse events in their populations that have been referred to in a few scientific papers.

The Minister concedes that the current process is not working because of low uptake of the advice and because so many pregnancies are unplanned. I am pleased that COT is looking at the Wald paper on tolerable upper limits and the evidence it presents that there is not one, because excess folic acid is excreted. However, I am intrigued to know—I will write to the Minister on this—whether COT has advised the Government not to introduce mandatory fortification and not to follow the advice from their other advisory body, SACN, formerly known as COMA. If it has not offered advice to that effect, I cannot understand where Ministers are getting the advice that tells them not to introduce mandatory fortification.

The only formal advice that Ministers have had from 2000 to 2017 is to do what all Members here and the scientific community have recommended and to get on with mandatory fortification. It is a mystery to me why the Government continue to suggest that there are serious scientific reasons for not doing it. I do not believe that the Government have illustrated that and I do not think that the Minister illustrated that today; unfortunately, I do not think successive Ministers in all Governments have illustrated that.

Today has been a missed opportunity. However, I leave the Minister under no illusion that we will continue to raise this issue and to push for mandatory fortification. I look forward to debating it with him again in the future.

Question put and agreed to.

Resolved,

That this House has considered the mandatory fortification of flour with folic acid to prevent spina bifida and anencephaly.